Technology-Assisted Mental Health Intervention Delivered by Frontline Workers at Community Doorsteps for Reducing Anxiety and Depression in Rural Pakistan: Protocol for the mPareshan Mixed Methods Implementation Trial.

BACKGROUND: There is a dearth of specialized mental health workforce in low- and middle-income countries. Use of mobile technology by frontline community health workers (CHWs) is gaining momentum in Pakistan and needs to be explored as an alternate strategy to improve mental well-being. OBJECTIVE: The aim of this study is to assess the feasibility, acceptability, and usefulness of an app-based counseling intervention delivered by government lady health workers (LHWs) to reduce anxiety and depression in rural Pakistan. METHODS: Project mPareshan is a single-arm, pre- and posttest implementation research trial in Badin District, Sindh, using mixed methods of data collection executed in 3 phases (preintervention, intervention, and postintervention). In the preintervention phase, formative qualitative assessments through focus group discussions and in-depth interviews assess the acceptability and appropriateness of intervention through perceptions of all concerned stakeholders using a specific interview guide. A REDCap (Research Electronic Data Capture)-based baseline survey using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 Scale (GAD-7) determines the point prevalence of depression and anxiety among consenting men and women older than 18 years. Individuals with mild and moderate anxiety and depression are identified as screen positives (SPs) and are eligible for mPareshan app-based intervention. Mental health literacy of health workers is improved through customized training adapting the World Health Organization's Mental Health Gap Action Programme guide 2.0. The intervention (mPareshan app) consists of tracking, counseling, and referral segments. The tracking segment facilitates participant consent and enrollment while the referral segment is used by LHWs to transfer severe cases to the next level of specialist care. Through the counseling segment, identified SPs are engaged during LHWs' routine home visits in 6 face-to-face 20-minute counseling sessions over 6 months. Each session imparts psychoeducation through audiovisual aids, breathing exercises, and coping skills to reduce stress. Clinical and implementation outcomes include change in mean anxiety and depression scores and identification of facilitators and barriers in intervention uptake and rollout. RESULTS: At the time of this submission (April 2024), we are analyzing the results of 366 individuals who participated in the baseline prevalence survey, the change in knowledge and skills of 72 health workers who took the mPareshan training, change in anxiety and depression scores of 98 SPs recruited for app-based counseling intervention, and perceptions of stakeholders pre- and postintervention gathered through 8 focus group discussions and 18 in-depth interviews. CONCLUSIONS: This trial will assess the feasibility of early home-based mental health screening, counseling, and prompt referrals by frontline health workers to reduce anxiety and depression in the community. The study findings will set the stage for integrating mental health into primary health care. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12622000989741; https://tinyurl.com/5n844c8z. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54272.

A systematic review of mental health of women in fragile and humanitarian settings of the Eastern Mediterranean Region.

Background: The increasing emergencies and humanitarian challenges have worsened the mental health condition of women in the Eastern Mediterranean Region. Aim: To assess the prevalence, determinants and interventions to address mental health among women in fragile and humanitarian settings in the Eastern Mediterranean Region. Methods: Using the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines, we reviewed 59 peer-reviewed published studies (PubMed, IMEMR) and grey literature (WHO/IRIS) from January 2001 to February 2023, focusing on women's mental health in the Eastern Mediterranean Region. We then conducted a descriptive analysis of the sociodemographic characteristics. Results: Among the 59 studies reviewed, only 13 of the 48 peer-reviewed studies focused primarily on women's mental health, 11 grey literature records mostly presented grouped regional data, 11 of the 25 studies on mental health among migrants were about those taking refuge in high-income countries. The average prevalence of mental disorders from 32 cross-sectional studies on women aged 12-75 years was 49%, average prevalence of anxiety was 68%, post-traumatic stress disorder was 52%, and depression was 43%. Women exhibited higher level depression than men. Age, educational disparities, and limited access to services were important risk factors for mental health disorder. Several promising interventions emerged. Conclusion: More efforts should be made to provide customized, context-specific solutions to the mental health challenges of women in humanitarian and fragile settings in the Eastern Mediterranean Region, including allocation of more resources to mental health programmes, addressing barriers, enhancing mental health surveillance, and reduction of stigma.

Listening to Caregivers: Narratives of Health Seeking for Children Under Five with Pneumonia and Diarrhea: Insights from the NIGRAAN Trial in Pakistan.

Background: Understanding health-seeking behaviors of caregivers is important to reduce child mortality. Several factors influence decision-making related to childhood illnesses. Objective: The objective of this study was to gather caretaker narratives to develop a comprehensive understanding of the context and process of caregiving at household level during all stages of an episode of diarrhea and pneumonia in children <5. Methods: Using a narrative interview approach, stories from caregivers of children <5 were collected from a rural district in Sindh Pakistan. Eleven households with children <5 were randomly selected and purposive sampling was done to interview 20 caregivers. All data collection was conducted privately in participants' homes and informed consent taken. Manual content analysis was carried out by three independent researchers and emerging themes drawn. Results: The role of joint family system is integral in making decisions and the child's paternal grandmother, is an important and trusted source of information regarding child sickness in the household. They often promote home remedies with considerable authority prior to formal consultation with the health care system. Caregivers were generally dissatisfied with doctors in the public sector who were perceived to be providing free consultation with a poor quality of care and long waiting time as compared to private doctors. Financial considerations and child support were favorably addressed in households with a joint family system. Conclusion: The joint family system provides a strong support system, but also tends to reduce parental autonomy in decision-making and delay first contact with formal health providers. Prevalent home remedies, and authority of elders in the family influence management practices. Interventions for reducing improving child mortality should be cognizant of the context of decision-making and social influences at the household level.

Protecting and promoting the rights of the 'reserve army of labour': a policy analysis of structural determinants of migrant worker health in Pakistan and Qatar.

Labour migrants who travel overseas for employment can face deep health inequities driven in large part by upstream social and structural determinants of health. We sought to study the 'labour migrant health ecosystem' between one sending country (Pakistan) and one host country (Qatar), with a focus on how the ecosystem realizes the rights of labour migrants when addressing the social and structural determinants (e.g. housing, employment law, etc.) of health. Study objectives were to (1) undertake an in-depth review of policies addressing the structural and social determinants of the health of labour migrants in both Pakistan and Qatar, analysing the extent to which these policies align with global guidance, are equity-focused and have clear accountability mechanisms in place, and (2) explore national stakeholder perspectives on priority setting for labour migrant health. We used a mixed methods approach, combining policy content analysis and interviews with stakeholders in both countries. We found a wide range of guidance from the multilateral system on addressing structural determinants of the health of labour migrants. However, policy responses in Pakistan and Qatar contained a limited number of these recommended interventions and had low implementation potential and minimal reference to gender, equity and rights. Key national stakeholders had few political incentives to act and lacked inter-country coordination mechanisms required for an effective and cohesive response to labour migrant health issues. Effectively addressing such determinants to achieve health equity for labour migrants will depend on a shift in governments' attitudes towards migrants-from a reserve army of transient, replaceable economic resources to rights-holding members of society deserving of equality, dignity and respect.

Addition of mental health to the lady health worker curriculum in Pakistan: now or never.

The technical advisory group of the World Health Organization (Geneva, Switzerland) has suggested person-centered and community-based mental health services in response to the long-term and far-reaching mental health impacts of the COVID-19 pandemic. Task shifting is a pragmatic approach to tackle the mental health treatment gap in low- and middle-income countries. Pakistan is dismally resourced to address the mental health challenges. Pakistan's government has established a lady health worker's program (LHW-P) which can be effectively utilized to provide some basic mental health services at community doorsteps. However, lady health workers' current curriculum does not include mental health as a subject. WHO's Mental Health Gap Intervention Guide (mhGAP-IG) Version 2.0 for mental, neurological, and substance use disorders in non-specialist health settings can be adapted and utilized to be included as part of the LHW-P curriculum in Pakistan. Thus, the historical lack of access to mental health support workers, counsellors, and specialists can be addressed. Additionally, this will also help to reduce the stigma associated with seeking mental health care outside the boundaries of home, mostly at a huge cost.

Promoting labour migrant health equity through action on the structural determinants: A systematic review.

BACKGROUND: Labour migrants, who represent over sixty per cent of international migrants globally, frequently have poorer health status than the population of host countries. These health inequities are determined in a large part by structural drivers including political, commercial, economic, normative and social factors, including living and working conditions. Achieving health equity for migrant workers requires structural-level interventions to address these determinants. METHODS: We undertook a systematic review of peer-reviewed literature designed to answer the question "what is the evidence for the effectiveness of interventions to address the structural determinants of health for labour migrants?" using the Ovid Medline electronic database. FINDINGS: We found only two papers that evaluated structural interventions to improve the health of labour migrants. Both papers evaluated the impact of insurance - health or social. In contrast, we found 19 evaluations of more proximal, small-scale interventions focused on changing the knowledge, attitudes and behaviours of labour migrants. INTERPRETATION: Despite the rise in international migration, including for work, and evidence that labour migrants have some higher health risks, there is a paucity of research addressing the structural determinants of health inequities in labour migrants. The research community (including funders and academic institutions) needs to pay greater attention to the structural determinants of health - which generally requires working across disciplines and sectors and thinking more politically about health and health inequities. FUNDING: Wellcome Trust (208712/Z/17/Z).

Perceived risk and distress related to COVID-19 in healthcare versus non-healthcare workers of Pakistan: a cross-sectional study.

BACKGROUND: Healthcare workers (HCWs) have found themselves and their families more susceptible to contracting COVID-19. This puts them at a higher risk of psychological distress, which may compromise patient care. In this study, we aim to explore the risk perceptions and psychological distress between HCWs and non-healthcare workers (NHCWs) in Pakistan. METHODS: A cross-sectional study was conducted using an online self-administered questionnaire. Psychological distress was assessed through The Hospital Anxiety and Depression Scale (HADS). Comparisons were made between HCWs (front/backend, students/graduates) and NHCWs related to risk perceptions and stress levels related to COVID-19. Following tests for normality (Shapiro-Wilk test), variables that fulfilled the normality assumption were compared using the independent samples t-test, while for other variables Mann-Whitney U-test was employed. Pearson Chi-square test was used to compare categorical data. Multiple logistic regression techniques examined the association of participant age, gender, household income, and the presence of COVID-19 symptoms with depression and anxiety levels. RESULTS: Data from 1406 respondents (507 HCWs and 899 NHCWs) were analyzed. No significant difference was observed between HCWs and NHCWs' perception of susceptibility and severity towards COVID-19. While healthcare graduates perceived themselves (80% graduates vs 66% students, p-value 0.011) and their family (82% graduates vs 67% students, p-value 0.008) to be more susceptible to COVID-19, they were less likely to experience depression than students. Frontline HCWs involved in direct patient care perceived themselves (83% frontline vs. 70% backend, p-value 0.003) and their family (84% frontline vs. 72% backend, p-value 0.006) as more susceptible to COVID-19 than backend healthcare professionals. Over half of the respondents were anxious (54% HCWs and 55% NHCWs). Female gender, younger age, lower income, and having COVID-19 related symptoms had a significant effect on the anxiety levels of both HCWs and NHCWs. CONCLUSION: Frontline HCWs, young people, women, and individuals with lower income were at a higher risk of psychological distress due to the pandemic. Government policies should thus be directed at ensuring the mental well-being of frontline HCWs and improving their satisfaction to strengthen the health care delivery system. The findings suggest the need to provide mental health support for health workers.

Changing Perceptions of Rural Frontline Workers and Caregivers About Management of Childhood Diarrhea and Pneumonia Despite Several Inequities: The Nigraan Plus Trial in Pakistan.

PURPOSE: Diarrhea and pneumonia greatly contribute to high childhood mortality in Pakistan. Frontline community health workers or the Lady Health Workers (LHWs) provide care at the doorstep of over 60% of Pakistan's rural residents. Difficult terrain, lack of supplies, and inadequate supervision put these LHWs at an added disadvantage in the timely diagnosis and delivery of known treatment options to community caregivers (CCGs). This study aims to assess whether a supportive supervision intervention through Lady Health Supervisors (LHSs) using enhanced mentorship and written feedback cards have the potential to improve case management of childhood diarrhea and pneumonia. STUDY SETTING AND DESIGN: This perception-based qualitative inquiry nested within the Nigraan Plus trial included LHSs, LHWs, and CCGs as the participants. Twenty-two in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were conducted before a supportive supervision intervention in 2017, and 10 FGDs were conducted in 2019 once the intervention concluded. Data were analyzed using manual content analysis. RESULTS: The perceived ability of LHWs and LHSs to describe the danger signs of diarrhea and pneumonia, classify dehydration and relate respiratory rate to the severity of pneumonia improved over time. Appropriate prescription of zinc in diarrhea and antibiotics in pneumonia was noted. Furthermore, CCGs' trust in LHWs increased following the intervention, and they reported a growing inclination to contact LHWs as their first point of care. LHWs in the intervention arm were more satisfied with their job due to frequent supervisory visits and continuous feedback by LHSs. CONCLUSION: Despite geographic, social, and economic inequities, supportive supervision has the potential to improve knowledge, practice, and skills of frontline health workers related to CCM of childhood diarrhea and pneumonia in disadvantaged rural communities. Additionally, the trust of CCGs in the health workers' ability to manage such cases is also enhanced.

Gender-specific psychological and social impact of COVID-19 in Pakistan.

BACKGROUND: COVID-19 has rapidly spread across the world. Women may be especially vulnerable to depression and anxiety as a result of the pandemic. AIMS: This study attempted to assess how gender affects risk perceptions, anxiety levels and behavioural responses to the COVID-19 pandemic in Pakistan, to recommend gender-responsive health policies. METHODS: A cross-sectional online survey was conducted. Participants were asked to complete a sociodemographic data form, the Hospital Anxiety and Depression Scale, and questions on their risk perceptions, preventive behaviour and information exposure. Multiple logistic regression analysis was used to assess the effects of factors such as age, gender and household income on anxiety levels. RESULTS: Of the 1391 respondents, 478 were women and 913 were men. Women considered their chances of survival to be relatively lower than men (59% v. 73%). They were also more anxious (62% v. 50%) and more likely to adopt precautionary behaviour, such as avoiding going to the hospital (78% v. 71%), not going to work (72% v. 57%) and using disinfectants (93% v. 86%). Men were more likely to trust friends, family and social media as reliable sources of COVID-19 information, whereas women were more likely to trust doctors. CONCLUSIONS: Women experience a disproportionate burden of the psychological and social impact of the pandemic compared with men. Involving doctors in healthcare communication targeting women might prove effective. Social media and radio programmes may be effective in disseminating COVID-19-related information to men.

Does supportive supervision intervention improve community health worker knowledge and practices for community management of childhood diarrhea and pneumonia? Lessons for scale-up from Nigraan and Nigraan Plus trials in Pakistan.

BACKGROUND: Lack of programmatic support and supervision is one of the underlying reasons of the poor performance of Pakistan's Lady Health Worker Program (LHWP). This study describes the findings and potential for scale-up of a supportive supervision intervention in two districts of Pakistan for improving LHWs skills for integrated community case management (iCCM) of childhood diarrhea and pneumonia. METHODS: The intervention comprised an enhanced supervision training to lady health supervisors (LHSs) and written feedback to LHWs by LHSs, implemented in Districts Badin and Mirpur Khas (MPK). Clinical skills of LHWs and LHSs and supervision skills of LHSs were assessed before, during, and after the intervention using structured tools. RESULTS: LHSs' practice of providing written feedback improved between pre- and mid-intervention assessments in both trials (0% to 88% in Badin and 25% to 75% in MPK) in the study arm. Similarly, supervisory performance of study arm LHSs was better than that in the comparison arm in reviewing the treatment suggested by workers' (94% vs 13% in MPK and 94% vs 69% in Badin) during endline skills assessment in both trials. There were improvements in LHWs' skills for iCCM of childhood diarrhea and pneumonia in both districts. In intervention arm, LHWs' performance for correctly assessing for dehydration (28% to 92% in Badin and 74% to 96% in MPK), and measuring the respiratory rate correctly (12% to 44% in Badin and 46% to 79% in MPK) improved between baseline and endline assessments in both trials. Furthermore, study arm LHWs performed better than those in comparison arm in classifying diarrhea correctly during post-intervention skills assessment (68% vs 40% in Badin and 96% vs 83% in MPK). CONCLUSION: Supportive supervision including written feedback and frequent supervisor contact could improve the performance of community-based workers in managing diarrhea and pneumonia among children. Positive lessons for provincial scale-up can be drawn. Trial registration Both trials are registered with the 'Australian New Zealand Clinical Trials Registry'. Registration numbers: Nigraan Trial: ACTRN1261300126170; Nigraan Plus: ACTRN12617000309381.

The social and structural determinants of sexual and reproductive health and rights in migrants and refugees: a systematic review of reviews.

BACKGROUND: The sexual and reproductive health and rights (SRHR) of migrants and refugees present important public health challenges. Social and structural determinants affect both the general health and SRHR of migrants, but the drivers of SRHR among migrant and refugee populations remain understudied. AIMS: To identify upstream social and structural determinants of SRHR health of migrants and refugees reported in systematic reviews. METHODS: We conducted a systematic review of reviews. We studied 3 aspects of SRHR: sexually transmitted infections, sexual violence and unintended pregnancy in migrants and refugees. We used an inductive approach to synthesize emerging themes, summarized them in a narrative format and made an adapted version of Dahlgren and Whitehead's social determinants of health (SDH) model. RESULTS: We included 12 systematic reviews, of which 10 were related to sexually transmitted infections, 4 to sexual violence and 2 to unintended pregnancy. We identified 6 themes that operate at 4 different levels in an adapted version of the Dahlgren and Whitehead SDH model: economic crisis and hostile discourse on migration; limited legal entitlements, rights and administrative barriers; inadequate resources and financial constraints; poor living and working conditions; cultural and linguistic barriers; and stigma and discrimination based on migration status, gender, sex and ethnicity. CONCLUSION: This review provides evidence of how upstream social and structural determinants undermine the SRHR of refugees and migrants. Unless these are addressed in policy-making and planning, the health of migrants and refugees is at risk.

The state of diet-related NCD policies in Afghanistan, Bangladesh, Nepal, Pakistan, Tunisia and Vietnam: a comparative assessment that introduces a 'policy cube' approach.

We assessed the technical content of sugar, salt and trans-fats policies in six countries in relation to the World Health Organization 'Best Buys' guidelines for the prevention and control of non-communicable diseases (NCDs). National research teams identified policies and strategies related to promoting healthy diets and restricting unhealthy consumption, including national legislation, development plans and strategies and health sector-related policies and plans. We identified relevant text in relation to the issuing agency, overarching aims, goals, targets and timeframes, specific policy measures and actions, accountability systems, budgets, responsiveness to inequitable vulnerabilities across population groups (including gender) and human rights. We captured findings in a 'policy cube' incorporating three dimensions: policy comprehensiveness, political salience and effectiveness of means of implementation, and equity/rights. We compared diet-related NCD policies to human immunodeficiency virus policies in relation to rights, gender and health equity. All six countries have made high-level commitments to address NCDs, but dietary NCDs policies vary and tend to be underdeveloped in terms of the specificity of targets and means of achieving them. There is patchwork reference to internationally recognized, evidence-informed technical interventions and a tendency to focus on interventions that will encounter least resistance, e.g. behaviour change communication in contrast to addressing food reformulation, taxation, subsidies and promotion/marketing. Policies are frequently at the lower end of the authoritativeness spectrum and have few identified budgetary commitments or clear accountability mechanisms. Of concern is the limited recognition of equity and rights-based approaches. Healthy diet policies in these countries do not match the severity of the NCDs burden nor are they designed in such a way that government action will focus on the most critical dietary drivers and population groups at risk. We propose a series of recommendations to expand policy cubes in each of the countries by re-orienting diet-related policies so as to ensure healthy diets for all.

Improving community health worker performance through supportive supervision: a randomised controlled implementation trial in Pakistan.

AIM: To assess the effect of enhanced supportive supervision of lady health workers (LHWs) by lady health supervisors on integrated community case management of childhood pneumonia and diarrhoea. METHODS: A total of thirty-four supervisors were randomly assigned to intervention and comparison arms. The intervention included enhanced training of supervisors on supervisory skills and written feedback to LHWs by supervisors. The performance of both cadres was assessed three times. Household surveys judged caregiver practices. RESULTS: Intervention arm LHWs performed better than those in the comparison arm in assessing dehydration (92% [n = 25] vs 64% [n = 25]) and in classifying diarrhoea correctly (68% [n = 25] vs 40% [n = 25]). The two arms differed little in correct disease classification for pneumonia (44% [n = 25] vs 40% [n = 25]). Supervisory performance of intervention arm supervisors was better than that in the comparison arm in correcting the workers' clinical examination skills (64% [n = 25] vs 40% [n = 25]) and more frequent feedback. In the household survey, only 18% (n = 2182) intervention and 23% (n = 2197) comparison arm caregivers considered LHWs capable of providing diarrhoea and pneumonia care. Commodities for integrated community case management were not regularly available to workers. CONCLUSION: Supportive supervision can improve community case management performance. Support through refresher training, logistics and commodities is essential.

Exploring health care seeking knowledge, perceptions and practices for childhood diarrhea and pneumonia and their context in a rural Pakistani community.

BACKGROUND: Where access to facilities for childhood diarrhea and pneumonia is inadequate, community case management (CCM) is an effective way of improving access to care. In Pakistan, utilization of CCM for these diseases through the Lady Health Worker Program remains low. Challenges of access to facilities persist leading to delayed care and poor outcomes. Estimating caregiver knowledge, understanding their perceptions and practices, and recognizing how these are related to care seeking decisions about childhood diarrhea and pneumonia is crucial to bring about coherence between supply and demand-side practices. METHODS: Data was collected from family caregivers to explore their knowledge, perceptions and practices regarding childhood diarrhea and pneumonia. Data from a household survey with 7025 caregivers, seven focus group discussion (FGDs), seven in-depth interviews (IDIs), and 20 detailed narrative interviews are used to explore caregiver knowledge, perceptions and practices. RESULTS: Household survey shows that most family caregivers recognize main signs and symptoms of diarrhea such as loose stools (76%). Fewer recognize signs and symptoms of pneumonia such as breathing problems (21%). Few caregivers (18%) have confidence in lady health workers' (LHWs) ability to treat childhood diarrhea and pneumonia. Care seeking from LHWs remains negligible (< 1%). Caregivers overwhelmingly prefer to seek care from doctors (97%). Seventy-five percent caregivers sought care from private providers and 45% from public providers. FGDs, IDIs, and narrative interviews show that care mostly begins with home remedies and sometimes self-prescribed medicines. Treatment delays occur because of caregiver inability to recognize disease, use of home remedies, financial constraints, and low utilization of community based LHW services. Caregivers do not seek care from LHWs because of lack of trust and LHWs' inability to provide medicines. If finances allow, private doctors, who caregivers perceive as more responsive, are preferred over public sector doctors. Financial resources, availability of time, support for household chores by family and community determine whether, when, and from whom caregivers seek care. CONCLUSIONS: Many children do not receive recommended diarrhea and pneumonia treatment on time. Taking into consideration caregiver concerns, adequate supply of medicines to LHWs, improved facility level care could improve care seeking practices and child health outcomes. TRIAL REGISTRATION: The trial is registered with 'Australian New Zealand Clinical Trials Registry'. Registration Number: ACTRN12613001261707 . Registered 18 November 2013.

Motivating and Demotivating Factors for Community Health Workers Engaged in Maternal, Newborn and Child Health Programs in Low and Middle-Income Countries: A Systematic Review.

This systematic review aimed to synthesize primary research on motivating factors of community health workers (CHWs) for maternal, neonatal, and child health (MNCH) in low and middle-income countries (LMICs). Peer-reviewed literatures were systematically searched in five databases. Identified studies were then screened and selected for inclusion. The eligibility criteria were reported primary qualitative, quantitative, or mixed methods research, with participants being CHWs in LMICs who address MNCH, which investigated motivation or related concepts of retention, attrition, and performance. A thematic synthesis process was used to analyze findings of motivating factors, reported by included studies. Seventeen qualitative, quantitative, or mixed methods studies met inclusion criteria. Two overarching themes were developed: Levels of motivation (i.e. individual, community, and health system) and stages of motivation (i.e. recruitment, retention, and attrition). Nine sub-themes were further developed at the intersection of each level and stage of motivation. Each subtheme comprises the motivating factors that are influential to community health workers at each stage and level. These themes and sub-themes are presented in a Community Health Worker Motivation Model. The motivation model can be used to identify what motivating factors are relevant to community health workers motivation and the stakeholders necessary to address each motivating factor. Recruitment of community health workers for maternal, neonatal, and child health relies largely on individual level of motivation. At retention, individual level motivating factors remain influential; and community and health system begin to influence motivation positively. But, overall health systems in low and middleincome countries are demotivating the health workers rather than motivating them.

Population Health Science: A Core Element of Health Science Education in Sub-Saharan Africa.

Sub-Saharan Africa suffers an inordinate burden of disease and does not have the numbers of suitably trained health care workers to address this challenge. New concepts in health sciences education are needed to offer alternatives to current training approaches.A perspective of integrated training in population health for undergraduate medical and nursing education is advanced, rather than continuing to take separate approaches for clinical and public health education. Population health science educates students in the social and environmental origins of disease, thus complementing disease-specific training and providing opportunities for learners to take the perspective of the community as a critical part of their education.Many of the recent initiatives in health science education in sub-Saharan Africa are reviewed, and two case studies of innovative change in undergraduate medical education are presented that begin to incorporate such population health thinking. The focus is on East Africa, one of the most rapidly growing economies in sub-Saharan Africa where opportunities for change in health science education are opening. The authors conclude that a focus on population health is a timely and effective way for enhancing training of health care professionals to reduce the burden of disease in sub-Saharan Africa.

Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?

BACKGROUND: Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005-2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges. MAIN TEXT: The challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs). CONCLUSION: SPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.

Health workers' perspectives, knowledge and skills regarding community case management of childhood diarrhoea and pneumonia: a qualitative inquiry for an implementation research project "Nigraan" in District Badin, Sindh, Pakistan.

BACKGROUND: Pakistan's Lady Health Worker Programme aims to provide care to children sick with pneumonia and diarrhoea, which continues to cause 27 % under-five mortality in Pakistan. The quality of supervision received by Lady Health Workers (LHWs) in the programme influence their knowledge and skills, in turn impacting their ability to provide care. METHODS: This study is part of an implementation research project titled "Nigraan" (an Urdu word meaning supervisor), and explores LHW and Lady Health Supervisor (LHS) perspectives regarding the role of supervision in improving LHWs performance and motivation in district Badin, Sindh, Pakistan. Their knowledge and skills regarding integrated community case management (iCCM) of diarrhoea and pneumonia were also assessed. Fourteen focus group discussions and 20 in-depth interviews were conducted as part of this qualitative inquiry. Analysis was done using QSR NVivo version 10. RESULTS: Most LHWs and LHSs identified pneumonia and diarrhoea as two major causes of death among children under-five. Poverty, illiteracy, poor hygiene and lack of clean drinking water were mentioned as underlying causes of high mortality due to diarrhoea and pneumonia. LHWs and LHSs gaps in knowledge included classification of dehydration, correctly preparing ORS and prescribing correct antibiotics in pneumonia. Lack of training, delayed salaries and insufficient medicines and other supplies were identified as major factors impeding appropriate knowledge and skill development for iCCM of childhood diarrhoea and pneumonia. LHWs considered adequate supervision and the presence of LHSs during household visits as a factor facilitating their performance. LHWs did not have a preference for written or verbal feedback, but LHSs considered written individual feedback to LHWs to be more useful than group and verbal feedback. CONCLUSION: LHWs have knowledge and skill gaps that prevent them from providing effective care for diarrhoea and pneumonia. Enhanced supportive feedback from LHSs could improve LHWs skills and performance.

Inspiring health worker motivation with supportive supervision: a survey of lady health supervisor motivating factors in rural Pakistan.

BACKGROUND: Community health worker motivation is an important consideration for improving performance and addressing maternal, newborn, and child health in low and middle-income countries. Therefore, identifying health system interventions that address motivating factors in resource-strained settings is essential. This study is part of a larger implementation research project called Nigraan, which is intervening on supportive supervision in the Lady Health Worker Programme to improve community case management of pneumonia and diarrhea in rural Pakistan. This study explored the motivation of Lady Health Supervisors, a cadre of community health workers, with particular attention to their views on supportive supervision. METHODS: Twenty-nine lady health supervisors enrolled in Nigraan completed open-ended structured surveys with questions exploring factors that affect their motivation. Thematic analysis was conducted using a conceptual framework categorizing motivating factors at individual, community, and health system levels. RESULTS: Supportive supervision, recognition, training, logistics, and salaries are community and health system motivating factors for lady health supervisors. Lady health supervisors are motivated by both their role in providing supportive supervision to lady health workers and by the supervisory support received from their coordinators and managers. Family support, autonomy, and altruism are individual level motivating factors. CONCLUSIONS: Health system factors, including supportive supervision, are crucial to improving lady health supervisor motivation. As health worker motivation influences their performance, evaluating the impact of health system interventions on community health worker motivation is important to improving the effectiveness of community health worker programs.

Hospital management training for the Eastern Mediterranean Region: time for a change?

PURPOSE: The WHO Eastern Mediterranean Regional Office has emphasized health system strengthening among the top five strategic priorities. One of the integral elements of health systems are the hospitals. The purpose of this paper is to review the need for formalized training in hospital management to improve the quality of care. DESIGN/METHODOLOGY/APPROACH: Literature review and hands on experience of conducting a regional training in hospital management for Eastern Mediterranean Region (EMR) countries. FINDINGS: Majority of patients in EMR bypass Primary Health Care facilities due to inadequate quality of services and prefer seeking specialized care at a tertiary level. There is mounting evidence of mediocre to poor patient satisfaction due to inefficient health care practices in hospitals of EMR. Strengthening the management capacity of the hospitals through a formal training programme is therefore necessary for improving the performance of health care delivery and the overall health system. Hospital management encompasses hospital planning and operational activities including development and implementation of organizational strategies to ensure adequate numbers and quality of trained human resources and effective financial management, disaster management, health management information system utilization, support services, biomedical engineering, transport and waste management. Such training will prepare health care professionals with leadership skills to deliver quality hospital services. ORIGINALITY/VALUE: This is one of the first papers emphasizing the need for a formal structured regional training in hospital management for the countries of EMR. A modular incremental training approach developing an EMR Credit Transfer and Accumulation system is proposed.