Master's degree in sexual and reproductive health: enhancing career development opportunities for midwives in Mali.

BACKGROUND: Midwives' contribution to improving outcomes for women and newborns depends on factors such as quality of pre-service training, access to continuing professional development, and the presence of an enabling work environment. The absence of opportunities for career development increases the likelihood that health professionals, including midwives, will consider leaving the profession due to a lack of incentives to sustain and increase motivation to remain in the field. It also limits the opportunities to better contribute to policy, training, and research. This study aimed to assess the influence of a Master in Sexual and Reproductive Health (SRH) at the INFSS on midwives' career progression in Mali. METHODS: This mixed methods study was conducted using an online questionnaire, semi-structured interviews, and a document review. The study participants included graduates from two cohorts (N = 22) as well as employers, managers, and teachers of the graduates (N = 20). Data were analysed according to research questions, comparing, and contrasting answers between different groups of respondents. RESULTS: The study revealed that graduates enrolled in the programme primarily to improve their knowledge and skills in management and public health. The graduates' expected roles are those of programme and health project manager and participation in planning and monitoring activities at national or sub-national level. The managers expected the programme to reflect the needs of the health system and equip midwives with skills in management and planning. The Master enhanced opportunities for graduates to advance their career in fields they are not usually working in such as management, research, and supervision. However, the recognition of the master's degree and of the graduates' profile is not yet fully effective. CONCLUSION: The master's degree in SRH is a capacity building programme. Graduates developed skills and acquired advanced knowledge in research and management, as well as a postgraduate degree. However, the master programme needs to be better aligned with health system needs to increase the recognition of graduates' skills and have a more positive impact on graduates' careers.

Participation in primary health care through community-level health committees in Sub-Saharan Africa: a qualitative synthesis.

BACKGROUND: Health committees are key mechanisms for enabling participation of community members in decision-making on matters related to their health. This paper aims to establish an in-depth understanding of how community members participate in primary health care through health committees in sub-Saharan Africa (SSA). METHODS: We searched peer-reviewed English articles published between 2010 and 2019 in MEDLINE, Popline and CINAHL databases. Articles were eligible if they involved health committees in SSA. Our search yielded 279 articles and 7 duplicates were removed. We further excluded 255 articles following a review of titles and abstracts by two authors. Seventeen abstracts were eligible for full text review. After reviewing the full-text, we further excluded two articles that did not explicitly describe the role of health committees in community participation. We therefore included 15 articles in this review. Two authors extracted data on how health committees contributed to community participation in SSA using a conceptual framework for assessing community participation in health. We derived our themes from five process indicators in this framework, namely, leadership, management and planning, resource mobilization from external sources, monitoring and evaluation and women involvement. FINDINGS: We found that health committees work well in voicing communities' concerns about the quality of care provided by health facility staff, day-to-day management of health facilities and mobilizing financial and non-financial resources for health activities and projects. Health committees held health workers accountable by monitoring absenteeism, quality of services and expenditures in health facilities. Health committees lacked legitimacy because selection procedures were often not transparent and participatory. Committee members were left out in planning and budgeting processes by health workers, who perceived them as insufficiently educated and trained to take part in planning. Most health committees were male-dominated, thus limiting participation by women. CONCLUSION: Health committees contribute to community participation through holding primary health workers accountable, voicing their communities' concern and mobilizing resources for health activities and projects. Decision makers, health managers and advocates need to fundamentally rethink how health committees are selected, empowered and supported to implement their roles and responsibilities.

Systematic review: a systems innovation perspective on barriers and facilitators for the implementation of healthy food-store interventions.

BACKGROUND: Due to their central position in the modern food system, food stores present a unique opportunity to promote healthy dietary behaviour. However, there is a lack of insight into the factors that impede or enhance the implementation of nutritional interventions in food stores. We applied a systems innovation and implementation science framework to the identification of such barriers and facilitators. METHODS: We conducted a systematic literature review. A search string was developed to identify qualitative and quantitative articles on environmental nutritional interventions in the food store. Four databases were systematically searched for studies published between 2000 and 2018. Eligible publications described study designs or original studies, focused on stimulating healthier dietary behaviour through environmental changes in retail settings and contained information on the perceptions or experiences of retailers or interventionists regarding the implementation process of the intervention. Context-descriptive data was extracted and a quality assessment was performed. RESULTS: We included 41 articles, of which the majority was conducted in the USA and involved single stores or a mix of single and multi-store organisations. We categorized barriers and facilitators into 18 themes, under five domains. In the 'outer setting' domain, most factors related to consumers' preferences and demands, and the challenge of establishing a supply of healthy products. In the 'inner setting' domain, these related to conflicting values regarding health promotion and commercial viability, store lay-out, (insufficient) knowledge and work capacity, and routines regarding waste avoidance and product stocking. In the 'actors' domain, no major themes were found. For the 'intervention 'domain', most related to intervention-context fit, money and resource provision, material quality, and the trade-offs between commercial costs and risks versus commercial and health benefits. For the 'process' domain, most factors related to continuous engagement and strong relationships. CONCLUSIONS: This review provides a comprehensive overview of barriers and facilitators to be taken into account when implementing nutritional interventions in food stores. Furthermore, we propose a novel perspective on implementation as the alignment of intervention and retail interests, and a corresponding approach to intervention design which may help avoid barriers, and leverage facilitators. TRIAL REGISTRATION: PROSPERO; CRD42018095317.

"We come as friends": approaches to social accountability by health committees in Northern Malawi.

BACKGROUND: In Malawi, as in many low-and middle-income countries, health facility committees (HFCs) are involved in the governance of health services. Little is known about the approaches they use and the challenges they face. This study explores how HFCs monitor the quality of health services and how they demand accountability of health workers for their performance. METHODS: Documentary analysis and key informant interviews (7) were complemented by interviews with purposefully selected HFC members (22) and health workers (40) regarding their experiences with HFCs. Data analysis was guided by a coding scheme informed by social accountability concepts complemented by inductive analysis to identify participants' perceptions and meanings of processes of social accountability facilitated by HFCs. RESULTS: The results suggest that HFCs address poor health worker performance (such as absenteeism, poor treatments and informal payments), and report severe misconduct to health authorities. The informal and constructive approach that most HFCs use is shaped by formal definitions and common expectations of the role of HFCs in service delivery as well as resource constraints. The primary function of social accountability through HFCs appears to be co-production: the management of social relations around the health facility and the promotion of a minimum level of access and quality of services. CONCLUSIONS: Policymakers and HFC support programs should take into account the broad task description of HFCs and integrate social accountability approaches in existing quality of care programs. The study also underscores the need to clarify accountability arrangements and linkages with upward accountability approaches in the system.

Performance of community health workers: situating their intermediary position within complex adaptive health systems.

Health systems are social institutions, in which health worker performance is shaped by transactional processes between different actors.This analytical assessment unravels the complex web of factors that influence the performance of community health workers (CHWs) in low- and middle-income countries. It examines their unique intermediary position between the communities they serve and actors in the health sector, and the complexity of the health systems in which they operate. The assessment combines evidence from the international literature on CHW programmes with research outcomes from the 5-year REACHOUT consortium, undertaking implementation research to improve CHW performance in six contexts (two in Asia and four in Africa). A conceptual framework on CHW performance, which explicitly conceptualizes the interface role of CHWs, is presented. Various categories of factors influencing CHW performance are distinguished in the framework: the context, the health system and intervention hardware and the health system and intervention software. Hardware elements of CHW interventions comprise the supervision systems, training, accountability and communication structures, incentives, supplies and logistics. Software elements relate to the ideas, interests, relationships, power, values and norms of the health system actors. They influence CHWs' feelings of connectedness, familiarity, self-fulfilment and serving the same goals and CHWs' perceptions of support received, respect, competence, honesty, fairness and recognition.The framework shines a spotlight on the need for programmes to pay more attention to ideas, interests, relationships, power, values and norms of CHWs, communities, health professionals and other actors in the health system, if CHW performance is to improve.

Comparing patients' perspectives of "good care" in Dutch outpatient psychiatric services with academic perspectives of patient-centred care.

BACKGROUND: Over the past six decades, the concept of patient-centred care (PCC) has been discussed in health research, policy and practice. However, research on PCC from a patients' perspective is sparse and particularly absent in outpatient psychiatric services. AIM: to gain insight into what patients with bipolar disorder and ADHD consider "good care" and what this implies for the conceptualisation of PCC. METHOD: A literature review on the different conceptualisations of PCC was complemented with qualitative explorative research on the experiences and needs of adults with ADHD and with bipolar disorder with mental healthcare in the Netherlands using focus group discussions and interviews. RESULTS: The elements addressed in literature are clustered into four dimensions: "patient", "health professional", "patient-professional interaction" and "healthcare organisation". What is considered "good care" by patients coincided with the four dimensions of PCC found in literature and provided refinement of, and preferred emphasis within, the dimensions of PCC. CONCLUSIONS: This study shows the value of including patients' perspectives in the conceptualisation of PCC, adding elements, such as "professionals listen without judgment", "professionals (re)act on the fluctuating course of the disorder and changing needs of patients" and "patients are seen as persons with positive sides and strengths".

A qualitative assessment of health extension workers' relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance.

BACKGROUND: Health extension workers (HEWs) in Ethiopia have a unique position, connecting communities to the health sector. This intermediary position requires strong interpersonal relationships with actors in both the community and health sector, in order to enhance HEW performance. This study aimed to understand how relationships between HEWs, the community and health sector were shaped, in order to inform policy on optimizing HEW performance in providing maternal health services. METHODS: We conducted a qualitative study in six districts in the Sidama zone, which included focus group discussions (FGDs) with HEWs, women and men from the community and semi-structured interviews with HEWs; key informants working in programme management, health service delivery and supervision of HEWs; mothers; and traditional birth attendants. Respondents were asked about facilitators and barriers regarding HEWs' relationships with the community and health sector. Interviews and FGDs were recorded, transcribed, translated, coded and thematically analysed. RESULTS: HEWs were selected by their communities, which enhanced trust and engagement between them. Relationships were facilitated by programme design elements related to support, referral, supervision, training, monitoring and accountability. Trust, communication and dialogue and expectations influenced the strength of relationships. From the community side, the health development army supported HEWs in liaising with community members. From the health sector side, top-down supervision and inadequate training possibilities hampered relationships and demotivated HEWs. Health professionals, administrators, HEWs and communities occasionally met to monitor HEW and programme performance. Expectations from the community and health sector regarding HEWs' tasks sometimes differed, negatively affecting motivation and satisfaction of HEWs. CONCLUSION: HEWs' relationships with the community and health sector can be constrained as a result of inadequate support systems, lack of trust, communication and dialogue and differing expectations. Clearly defined roles at all levels and standardized support, monitoring and accountability, referral, supervision and training, which are executed regularly with clear communication lines, could improve dialogue and trust between HEWs and actors from the community and health sector. This is important to increase HEW performance and maximize the value of HEWs' unique position.

How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature.

BACKGROUND: 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 intersect to influence CHW performance. A systematic review with a narrative analysis was conducted to identify contextual factors influencing performance of CHWs. METHODS: We searched six databases for quantitative, qualitative, and mixed-methods studies that included CHWs working in promotional, preventive or curative primary health care services in LMICs. We differentiated CHW performance outcome measures at two levels: CHW level and end-user level. Ninety-four studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programmes. Thematic coding was conducted and evidence on five main categories of contextual factors influencing CHW performance was synthesized. RESULTS: Few studies had the influence of contextual factors on CHW performance as their primary research focus. Contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were community factors that influenced CHW performance. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes. CONCLUSIONS: Research on CHW programmes often does not capture or explicitly discuss the context in which CHW interventions take place. This synthesis situates and discusses the influence of context on CHW and programme performance. Future health policy and systems research should better address the complexity of contextual influences on programmes. This insight can help policy makers and programme managers to develop CHW interventions that adequately address and respond to context to optimise performance.

A System-Oriented Dialogue Model to Design Community Partnerships for More Effective Sars-Cov-2 Prevention in Schools: The Case of Spain.

Objectives: The European Centre for Disease Control (ECDC) COVID-19 guidelines for non-pharmaceutical interventions (NPI) identify safety, hygiene and physical distancing measures to control SARS-Cov-2 transmission in schools. Because their implementation requires complicated changes, the guidelines also include "accompanying measures" of risk communication, health literacy and community engagement. Although these are considered crucial, their implementation is complex. This study aimed to co-define a community partnership that a) identifies systemic barriers and b) designs recommendations on how to implement the NPI to improve SARS-Cov-2 prevention in schools. Methods: We designed and piloted a System-Oriented Dialogue Model with the participation of 44 teachers and 868 students and their parents from six Spanish schools during 2021. The results were analysed using thematic analysis. Results: Participants identified 406 items addressing issues related to system characteristics, which is indicative of the complexity of the challenge. Using a thematic analysis, we defined 14 recommendations covering five categories. Conclusion: These findings could help in developing guidelines for initiating community engagement partnerships in schools to provide more integrated prevention interventions.

Community participation in the health system: analyzing the implementation of community health committee policies in Kenya.

BACKGROUND: Community health committees (CHCs) are a mechanism for communities to voluntarily participate in making decisions and providing oversight of the delivery of community health services. For CHCs to succeed, governments need to implement policies that promote community participation. Our research aimed to analyze factors influencing the implementation of CHC-related policies in Kenya. METHODS: Using a qualitative study design, we extracted data from policy documents and conducted 12 key informant interviews with health workers and health managers in two counties (rural and urban) and the national Ministry of Health. We applied content analysis for both the policy documents and interview transcripts and summarized the factors that influenced the implementation of CHC-related policies. FINDINGS: Since the inception of the community health strategy, the roles of CHCs in community participation have been consistently vague. Primary health workers found the policy content related to CHCs challenging to translate into practice. They also had an inadequate understanding of the roles of CHCs, partly because policy content was not adequately disseminated at the primary healthcare level. It emerged that actors involved in organizing and providing community health services did not perceive CHCs as valuable mechanisms for community participation. County governments did not allocate funds to support CHC activities, and policies focused more on incentivizing community health volunteers (CHVs) who, unlike CHCs, provide health services at the household level. CHVs are incorporated in CHCs. CONCLUSION: Kenya's community health policy inadvertently created role conflict and competition for resources and recognition between community health workers involved in service delivery and those involved in overseeing community health services. Community health policies and related bills need to clearly define the roles of CHCs. County governments can promote the implementation of CHC policies by including CHCs in the agenda during the annual review of performance in the health sector.

Art for public engagement on emerging and controversial technologies: A literature review.

Art is increasingly used to engage publics on emerging and controversial technologies, but we still know little about what works in art-based engagement and why. To investigate what art can do for public engagement, we systematically reviewed academic work published from 2000 to 2018 about the effect of art on organized public engagement. We used the dimensions of Responsible Research and Innovation as an analytical framework to identify what outcomes are achieved and what processes contribute to those outcomes. The 30 included studies showed that art mainly supported engagement by (1) reaching wider audiences, (2) fueling individual reflection, and (3) making visible how technologies come into being and interact with the world. With due consideration of the risks of instrumentalization, future research should empirically and reflexively investigate the outcomes and methodologies of art-based engagement, especially concerning collective reflection and change.

Understanding Discrepancies in Nutritional Outcomes Among Under-Fives in Laos: A Mixed-Methods Study Using the Positive Deviance Approach.

BACKGROUND: Stunting is one of the main contributing factors in the under-five mortality rate worldwide. In Laos, the prevalence of stunting remains high, particularly in mountainous rural areas. To prevent stunting, insight into positive deviant behaviors can help understand how people can cope or adapt in resource-poor settings. OBJECTIVE: This study aims to analyze the practices and underlying factors that explain discrepancies in nutritional outcomes in children under the age of 5 in remote mountainous areas in Laos. METHODS: This mixed-methods study included all children under the age of 5 living in 6 selected villages. Anthropometric measurements were taken, and a Z-score for stunting was calculated to select the positive and negative deviant children. To identify the causes of discrepancies in childhood stunting, household questionnaires, focus group discussions, observations, and individual interviews with family members and health workers were conducted. RESULTS: Fifty-five percent of children were stunted. Inappropriate care and feeding practices were observed such as providing unbalanced diets and not attending health facilities. Positive deviant mothers were less likely to follow inappropriate practices, experienced less food insecurity, and had higher motivation and autonomy, which resulted in prioritizing their children's health. An active role of fathers seemed to benefit positive practices within households. CONCLUSIONS: The combination of many different practices in which positive deviant families are doing slightly better was associated with in less stunting of children. Those practices are related to the household resources, such as access to food and social support; and the mother's motivation, autonomy, and perspectives on child health.

Adoption of harmonisation policy for the midwives' training programme in Mali: A policy analysis.

West Africa is engaged in a process of harmonising health workers' training programmes as a means to regulate regional training standards and thus improve their quality. There is currently a lack of documented information regarding the adoption of these revised training programmes. In 2012 a harmonised programme, the WAHO competency-based curriculum, was introduced in Mali for training midwives. The present study explores the barriers and facilitators of the adoption of this programme and how the content, context, process, and actor-related factors influenced this. We used a qualitative research design consisting of document analysis (n = 25) and semi-structured interviews (n = 21) with policymakers, students, and those in charge of implementing the training programme. Information was collected on education and training policies, the context and process of the harmonised curriculum development, its adoption, and the actors involved in the adoption strategy, along with their role. The study shows that the adoption of the harmonised curriculum in Mali offered midwives an opportunity to attain a higher standard of training and level of qualification than before. It also displayed both the government's and the public school's willingness and commitment to improve maternal and child health through enhancing midwives' training standards. The most salient factors that influenced adoption were the lack of available resources, and the lack of involvement of, and coordination with, relevant actors for successful policy adoption. Mali's experience of adopting the harmonisation policy of training curricula demonstrates the need for the authorities to collaborate with relevant actors for information dissemination and in the adoption process. It also demonstrates the need for finding innovative ways to secure and diversify funding opportunities, as well as establish a supervisory body for health worker training.

Perceived barriers in accessing sexual and reproductive health services for youth in Lao People's Democratic Republic.

BACKGROUND: Sexual activity during youth is common in Lao PDR. However, young people seldom utilize sexual and reproductive health services and subsequently suffer from poor sexual and reproductive health. The aim of this qualitative study was to explore the barriers perceived by youth that prevent their access to sexual and reproductive health services. METHODS: Twenty-nine semi-structured interviews were conducted with 22 participants aged 15-25 years, from urban and rural areas. A vignette was used during interviews with those who had no experience with sexual and reproductive health services. Additionally, seven semi-structured interviews were conducted with health providers from youth-friendly health clinics and from public sexual and reproductive health services. Data were analyzed using a thematic approach. RESULTS: The main barriers preventing young people from accessing sexual and reproductive health services were related to cognitive accessibility and psychosocial accessibility. The cognitive accessibility barriers were a lack of sexual knowledge and a lack of awareness of services. Perceived barriers in psychosocial accessibility were the feelings of shyness and shame caused by negative cultural attitudes to premarital sex, and the fear of parents finding out about visits to public sexual and reproductive health services, due to lack of confidentiality in the services and among health providers. In addition, the barriers of geographical accessibility, mainly insufficient availability of youth-friendly health clinics. CONCLUSION: To improve access to services, a multi-component strategy is needed: promotion of youth-friendly health clinics; sexual education in schools; a formal referral system between schools and youth-friendly health clinics; and community support interventions. Prior to implementation, more research should be done on the applicability of these methods in the Laos context. Future research should try to determine the cost-effectiveness of youth-friendly health clinics integrated in a district hospital and stand-alone clinics, to provide insight into which form should be further developed.

Informal social accountability in maternal health service delivery: A study in Northern Malawi.

Despite the expansion of literature on social accountability in low-and middle-income countries, little is known about how health providers experience daily social pressure and citizen feedback. This study used a narrative inquiry approach to explore the function of daily social accountability relations among maternal health care workers in rural Malawi. Through semi-structured interviews with 32 nurses and 19 clinicians, we collected 155 feedback cases allowing the identification of four main strategies social actors use to express their opinion and concerns about maternal health services. We found that women who used delivery care express their appreciation for successful deliveries directly to the health worker but complaints, such as on absenteeism and poor interpersonal behaviour, follow an indirect route via intermediaries such as the health workers' spouse, co-workers or the health committee who forward some cases of misbehaviour to district authorities. The findings suggest that citizen feedback is important for the socialization, motivation and retention of maternal healthcare workers in under resourced rural settings. Practitioners and external development programmes should understand and recognize the value of already existing accountability mechanisms and foster social accountability approaches that allow communities as well as health workers to challenge the systemic obstacles to quality and respectful service delivery.

"I should have started earlier, but I was not feeling ill!" Perceptions of Kalenjin women on antenatal care and its implications on initial access and differentials in patterns of antenatal care utilization in rural Uasin Gishu County Kenya.

AIM: The aim of this study was to explore how Kalenjin women in rural Uasing Gishu County in Kenya perceive antenatal care and how their perceptions impede or motivate earlier access and continuous use of antenatal care services. METHODS: A study was conducted among 188 pregnant and post-natal mothers seeking care in 23 rural public health facilities. Gestational age at the initial antenatal care booking was established from their medical cards. Further researcher-administered questionnaire with closed and open-ended questions was used. Key informant interviews with traditional birth attendants (n = 6) and maternal and child health nursing officers (n = 6) were also conducted for triangulation. Descriptive statistics were applied using SPSS programme. The interviews of women who gave consent to be audio recorded (n = 52) were transcribed and thematically analysed using MAXQDA program, based on Andersen and Newman's (1973) behavioural model of health services utilization. RESULTS: The mean gestational age at booking initial biomedical care was 23.36 weeks. Only 18 patients (10%) booked before 13 weeks and 45% made four or more visits. The main reasons given for early booking were: illness in index pregnancy (42%) checking the foetus position and monitoring foetus progress (7%). The main reasons given for late booking were: no reason (31%), was not feeling sick (16%), fear or shame due to unexpected pregnancy (13%). Almost half of the respondents (44%) used both biomedical and traditional antenatal care services. Main reasons for visiting traditional care were to: check foetus position and reposition it (63%), collect medicinal herbs (31%), relief discomforts through massage (18%). CONCLUSION: Early antenatal care booking is meant for women with unpleasant physical signs and symptoms. Later ANC is meant to check foetus position and reposition it to cephalic presentation and monitor its progress and this is only possible if the foetus is large.

The Effect of a Community Health Worker Utilized Mobile Health Application on Maternal Health Knowledge and Behavior: A Quasi-Experimental Study.

BACKGROUND: Mobile technology (mHealth) is increasingly being used to achieve improved access and quality of maternal care, particularly in rural areas of low- and middle-income countries. In 2011, a mobile application-Mobile for Mothers (MfM)-was implemented in Jharkhand, India to support home visits by community health workers. The objective of this study is to assess the impact of the mHealth intervention on maternal health. METHODS: Households from three subdistricts in the Deoghar district of Jharkhand were selected using a multistage cluster sampling approach. Households from the Sarwan subdistrict received the MfM intervention, those from Devipur subdistrict received other interventions asides MfM from the implementing non-governmental organization (NGO), while households from Mohanpur subdistrict received the current standard of care. Women (n = 2,200) between the ages of 18 and 45 who had delivered a baby in the past 1 year were enrolled into the study. The primary outcomes of interest were maternal health knowledge, antenatal care (ANC) attendance, and delivery in a health facility. RESULTS: Post-intervention, women in the MfM group had higher maternal health knowledge, were more likely to attend four or more ANC visits, and deliver at the health facility when compared with the NGO and standard care group. After controlling for predictors, women in the intervention group significantly performed better than both the NGO and standard care groups on all three-outcome variables (all P > 0.05). CONCLUSION: The results indicate that although the MfM mHealth intervention could influence adherence and practice of recommended maternal health behaviors, it could not overcome key sociocultural determinants of maternal health such as caste and educational status, which are specific to the Indian context. mHealth holds continued promise for maternal health but implementers and policy makers must additionally address health system and sociocultural factors that play a significant role in the uptake of recommended maternal health practices.

Health provider responsiveness to social accountability initiatives in low- and middle-income countries: a realist review.

Social accountability in the health sector has been promoted as a strategy to improve the quality and performance of health providers in low- and middle-income countries. Whether improvements occur, however, depends on the willingness and ability of health providers to respond to societal pressure for better care. This article uses a realist approach to review cases of collective citizen action and advocacy with the aim to identify key mechanisms of provider responsiveness. Purposeful searches for cases were combined with a systematic search in four databases. To be included in the review, the initiatives needed to describe at least one outcome at the level of frontline service provision. Some 37 social accountability initiatives in 15 countries met these criteria. Using a realist approach, retroductive analysis and triangulation of methods and sources were performed to construct Context-Mechanism-Outcome configurations that explain potential pathways to provider responsiveness. The findings suggest that health provider receptivity to citizens' demands for better health care is mediated by health providers' perceptions of the legitimacy of citizen groups and by the extent to which citizen groups provide personal and professional support to health providers. Some citizen groups activated political or formal bureaucratic accountability channels but the effect on provider responsiveness of such strategies was more mixed. Favourable contexts for health provider responsiveness comprise socio-political contexts in which providers self-identify as activists, health system contexts in which health providers depend on citizens' expertise and capacities, and health system contexts where providers have the self-perceived ability to change the system in which they operate. Rather than providing recipes for successful social accountability initiatives, the synthesis proposes a programme theory that can support reflections on the theories of change underpinning social accountability initiatives and interventions to improve the quality of primary health care in different settings.

"When a woman is pregnant, her grave is open": health beliefs concerning dietary practices among pregnant Kalenjin women in rural Uasin Gishu County, Kenya.

BACKGROUND: Reducing malnutrition remains a major global challenge especially in low- and middle-income countries. Lack of knowledge on the motive of nutritional behaviour could ultimately cripple nutrition intervention outcomes. The purpose of this study was to investigate how health beliefs influence nutritional behaviour intention of the pregnant Kalenjin women of rural Uasin Gishu County in Kenya. The study findings provide useful information for culturally congruent nutrition counselling and intervention. METHODS: In this qualitative study semi-structured interviews were conducted with 42 pregnant and post-natal (with children less than one year) Kalenjin women in selected rural public health facilities of Uasin Gishu County Kenya. Furthermore, key informant interviews took place with 6 traditional birth attendants who were also pregnancy herbalists, two community health workers and one nursing officer in charge of Maternal and Child Health (MCH) for triangulation and provision of in-depth information. Content analysis of interview transcripts followed a grounded theory (Protection Motivation Theory) approach, using software MAXQDA version 12.1.3. RESULTS: Abstracted labour (big babies and lack of maternal strength), haemorrhage (low blood), or having other diseases and complications (evil or bad food) were the major perceived health threats that influence nutritional behaviour intention of the pregnant Kalenjin women in rural Uasin Gishu County in Kenya. CONCLUSION: The pregnancy nutritional behaviour and practices of the Kalenjin women in rural Uasin Gishu County act as an adaptive response to the perceived health threats, which seem to be within the agency of pregnant women. As a result, just giving antenatal nutritional counselling without addressing these key health assumptions that underlie a successful pregnancy outcome is unlikely to lead to changes in nutritional behaviour.

Optimising the benefits of community health workers' unique position between communities and the health sector: A comparative analysis of factors shaping relationships in four countries.

Community health workers (CHWs) have a unique position between communities and the health sector. The strength of CHWs' relationships with both sides influences their motivation and performance. This qualitative comparative study aimed at understanding similarities and differences in how relationships between CHWs, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and CHWs' 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 CHWs and the health sector resulted in weaker relationships between CHWs and communities. The broader context (such as the socio-economic situation) and programme context (related to, for example, task-shifting, volunteering and supervision) in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust CHW 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 CHWs to perform well and responding to the opportunities offered by their unique intermediary position.