Can a community health worker and a trained traditional birth attendant work as a team to deliver child health interventions in rural Zambia?

BACKGROUND: Teaming is an accepted approach in health care settings but rarely practiced at the community level in developing countries. Save the Children trained and deployed teams of volunteer community health workers (CHWs) and trained traditional birth attendants (TBAs) to provide essential newborn and curative care for children aged 0-59 months in rural Zambia. This paper assessed whether CHWs and trained TBAs can work as teams to deliver interventions and ensure a continuum of care for all children under-five, including newborns. METHODS: We trained CHW-TBA teams in teaming concepts and assessed their level of teaming prospectively every six months for two years. The overall score was a function of both teamwork and taskwork. We also assessed personal, community and service factors likely to influence the level of teaming. RESULTS: We created forty-seven teams of predominantly younger, male CHWs and older, female trained TBAs. After two years of deployment, twenty-one teams scored "high", twelve scored "low," and fourteen were inactive. Teamwork was high for mutual trust, team cohesion, comprehension of team goals and objectives, and communication, but not for decision making/planning. Taskwork was high for joint behavior change communication and outreach services with local health workers, but not for intra-team referral. Teams with members residing within one hour's walking distance were more likely to score high. CONCLUSION: It is feasible for a CHW and a trained TBA to work as a team. This may be an approach to provide a continuum of care for children under-five including newborns.

Prevention and management of neonatal hypothermia in rural Zambia.

BACKGROUND: Neonatal hypothermia is increasingly recognized as a risk factor for newborn survival. The World Health Organization recommends maintaining a warm chain and skin-to-skin care for thermoprotection of newborn children. Since little is known about practices related to newborn hypothermia in rural Africa, this study's goal was to characterize relevant practices, attitudes, and beliefs in rural Zambia. METHODS AND FINDINGS: We conducted 14 focus group discussions with mothers and grandmothers and 31 in-depth interviews with community leaders and health officers in Lufwanyama District, a rural area in the Copperbelt Province, Zambia, enrolling a total of 171 participants. We analyzed data using domain analysis. In rural Lufwanyama, community members were aware of the danger of neonatal hypothermia. Caregivers' and health workers' knowledge of thermoprotective practices included birthplace warming, drying and wrapping of the newborn, delayed bathing, and immediate and exclusive breastfeeding. However, this warm chain was not consistently maintained in the first hours postpartum, when newborns are at greatest risk. Skin-to-skin care was not practiced in the study area. Having to assume household and agricultural labor responsibilities in the immediate postnatal period was a challenge for mothers to provide continuous thermal care to their newborns. CONCLUSIONS: Understanding and addressing community-based practices on hypothermia prevention and management might help improve newborn survival in resource-limited settings. Possible interventions include the implementation of skin-to-skin care in rural areas and the use of appropriate, low-cost newborn warmers to prevent hypothermia and support families in their provision of newborn thermal protection. Training family members to support mothers in the provision of thermoprotection for their newborns could facilitate these practices.

Factors influencing the low utilization of curative child health services in Shebedino District, Sidama Zone, Ethiopia.

BACKGROUND: Use and coverage of curative interventions for childhood pneumonia, diarrhea, and malaria were low in Ethiopia before integrated community-based case management (iCCM). OBJECTIVES: To examine factors accounting for low use of iCCMin Shebedino District applying a "Pathway to Sur- vival" approach to assess illness recognition; home care; labeling and decision-making; patterns of care-seeking; access, availability and quality of care; and referral. METHODS: Shortly after introduction of iCCM, we conducted five studies in Shebedino District in May 2011: a population-based household survey; focus group discussions of mothers of recently ill children; key informant in- terviews, including knowledge assessment, with Health Extension Workers at health posts and with health workers at health centers; and an inventory of drugs, supplies, and job aids at health posts and health centers. RESULTS: The many barriers to use of evidence-based treatment included: (1) home remedies of uncertain effect and safety that delay care-seeking; (2) absent decision-maker; (3) fear of stigma; (4) expectation of non-availability of service or medicine; (5) geographic and financial barriers; (6) perception of (or actual) poor quality of care; and (7) accessible, available, affordable, reliable, non-standard, alternative sources of care. CONCLUSION: Only a system-strengthening approach can overcome such manifold barriers to use of curative care that has not increased much after ICCM introduction.

Illness recognition, home care, and care-seeking for sick infants less than two months of age in Shebedino District, Sidama Zone, Ethiopia.

BACKGROUND: The incidence of newborn and young infant health danger signs is unknown in Ethiopia. Neverthe- less, experience shows that care-seeking is far lower than conservative morbidity estimates would project. OBJECTIVES: To examine illness recognition, home care, decision-making, and care-seeking for sick infants less than two months of age in Shebedino District, Southern Nations, Nationalities and Peoples Region in 2011. METHODS: Focus group interviews of mothers (n = 60) of recently ill children. RESULTS: Mothers reported recognizing many, but not all, evidence-based newborn danger signs. Home care ranged from probably harmless to harmful and delayed definitive care-seeking. Decision-making was widespread, but patterns of care-seeking rarely led to prompt, evidence-based care. Mothers reported 10 barriers to care- seeking at health posts: lack of knowledge about availability of curative services, fear of evil eye, social stigma, perceived financial barrier, perceived young infant fragility, an elder's contrary advice, distance, husband's re- fusal, fear of injection, and belief in recovery without medicine. CONCLUSION: Young infants are more vulnerable to illness than their older counterparts, yet they are less likely to receive the care they need without a targeted, contextualized communication strategy to generate demand for case management services that are accessible, available, and of good quality.

Measuring teamwork and taskwork of community-based "teams" delivering life-saving health interventions in rural Zambia: a qualitative study.

BACKGROUND: The use of teams is a well-known approach in a variety of settings, including health care, in both developed and developing countries. Team performance is comprised of teamwork and task work, and ascertaining whether a team is performing as expected to achieve the desired outcome has rarely been done in health care settings in resource-limited countries. Measuring teamwork requires identifying dimensions of teamwork or processes that comprise the teamwork construct, while taskwork requires identifying specific team functions. Since 2008 a community-based project in rural Zambia has teamed community health workers (CHWs) and traditional birth attendants (TBAs), supported by Neighborhood Health Committees (NHCs), to provide essential newborn and continuous curative care for children 0-59 months. This paper describes the process of developing a measure of teamwork and taskwork for community-based health teams in rural Zambia. METHODS: Six group discussions and pile-sorting sessions were conducted with three NHCs and three groups of CHW-TBA teams. Each session comprised six individuals. RESULTS: We selected 17 factors identified by participants as relevant for measuring teamwork in this rural setting. Participants endorsed seven functions as important to measure taskwork. To explain team performance, we assigned 20 factors into three sub-groups: personal, community-related and service-related. CONCLUSION: Community and culturally relevant processes, functions and factors were used to develop a tool for measuring teamwork and taskwork in this rural community and the tool was quite unique from tools used in developed countries.

Newborn survival in Malawi: a decade of change and future implications.

Malawi is one of two low-income sub-Saharan African countries on track to meet the Millennium Development Goal (MDG 4) for child survival despite high fertility and HIV and low health worker density. With neonatal deaths becoming an increasing proportion of under-five deaths, addressing newborn survival is critical for achieving MDG 4. We examine change for newborn survival in the decade 2000-10, analysing mortality and coverage indicators whilst considering other contextual factors. We assess national and donor funding, as well as policy and programme change for newborn survival using standard analyses and tools being applied as part of a multi-country analysis. Compared with the 1990s, progress towards MDG 4 and 5 accelerated considerably from 2000 to 2010. Malawi's neonatal mortality rate (NMR) reduced slower than annual reductions in mortality for children 1-59 months and maternal mortality (NMR reduced 3.5% annually). Yet, the NMR reduced at greater pace than the regional and global averages. A significant increase in facility births and other health system changes, including increased human resources, likely contributed to this decline. High level attention for maternal health and associated comprehensive policy change has provided a platform for a small group of technical and programme experts to link in high impact interventions for newborn survival. The initial entry point for newborn care in Malawi was mainly through facility initiatives, such as Kangaroo Mother Care. This transitioned to an integrated and comprehensive approach at community and facility level through the Community-Based Maternal and Newborn Care package, now being implemented in 17 of 28 districts. Addressing quality gaps, especially for care at birth in facilities, and including newborn interventions in child health programmes, will be critical to the future agenda of newborn survival in Malawi.

A results framework serves both program design and delivery science.

Health programmers and researchers must collaborate despite different mandates and technical languages. A results framework is a simple model that both disciplines can use to understand complexity, clarify assumptions and hypotheses, design programs, and ask questions to inform action research. Typically, a health program's results framework has 3 tiers and 6 boxes: a base of 4 health service intermediate results (access, quality, demand, and environment), which lead to a midlevel strategic objective (use of life-saving intervention), which leads to the goal (improved health). A situation analysis directly informs intervention selection; more difficult is selecting strategies to deliver the interventions, especially in settings of health system weakness. We propose menus and submenus of strategies to achieve each intermediate result, illustrate the use of the results framework in a program design and in clarifying research questions, and begin to propose a research agenda for "delivery scientists" responsible for recommending optimal investments to maximize use of interventions by those who need them most.