How female community health workers navigate work challenges and why there are still gaps in their performance: a look at female community health workers in maternal and child health in two Indian districts through a reciprocal determinism framework.

BACKGROUND: Accredited Social Health Activists (ASHAs) are community health workers tasked to deliver health prevention in communities and link them with the health care sector. This paper examines the social, cultural, and institutional influences that either facilitate or impede ASHAs' abilities to deliver services effectively through the lens of the reciprocal determinism framework of social cognitive theory. METHODS: We conducted 98 semi-structured, in-depth interviews with ASHAs (n = 49) and their family members (n = 49) in Gurdaspur and Mewat districts. Data were analyzed by comparing and contrasting codes leading to the identification of patterns which were explained with the help of a theoretical framework. RESULTS: We found that while the work of ASHAs led to some positive health changes in the community, thus providing them with a sense of self-worth and motivation, community norms and beliefs as well as health system attitudes and practices limited their capacity as community health workers. CONCLUSION: We outline potential mechanisms for improving ASHA capacity such as improved sensitization about religious, cultural, and gender norms; enhanced communication skills; and sensitization and advocating their work with health and state officials.

Improving voluntary medical male circumcision standards adherence and post-procedure follow-up in Uganda: A mixed methods study.

Voluntary medical male circumcision (VMMC) has been demonstrated to reduce the transmission of HIV by 60%. Scaling up VMMC services requires that they be of high quality, socially accepted, and effective. We evaluated an intervention aimed at improving VMMC standards adherence and patient follow-up rates in nine facilities in Uganda. We also qualitatively explored why some men return for follow-up care and others do not. The completeness and quality of clinical documentation was poor at baseline, but significantly improved at endline. We observed significant improvements in management systems; supplies, equipment, and environment; and monitoring and evaluation. Due to the volume of missing data, results were less clear for registration, group education, and information, education and communication; individual counselling and HIV testing; and infection prevention. Significant improvements were also observed in follow-up rates at 48 hours and 7 days, and 6 weeks. Interviews revealed the importance of peers, including female partners, in deciding to get circumcised and in seeking follow-up care. Among the men who did not return for follow-up services, most reported they had no problems and did not see it as necessary. For those who did have mild or moderate adverse events, follow-up care was often sought at a facility closer to the patients' home rather than the circumcising facility. However, information systems were unable to capture this. Applying improvement approaches to VMMC services can promote improved standards adherence and follow-up rates and should be integrated into scale-up plans.

Supporting close-to-community providers through a community health system approach: case examples from Ethiopia and Tanzania.

INTRODUCTION: Close-to-community (CTC) providers, including community health workers or volunteers or health extension workers, can be effective in promoting access to and utilization of health services. Tasks are often shifted to these providers with limited resources and support from CTC programmes or communities. The Community Health System Strengthening (CHSS) model is part of an improvement approach which draws on existing formal and informal networks within a community, such as agricultural or women's groups, to support CTC providers and address gaps in community-based health services. The model offers a framework for bringing representatives from existing community networks, CTC providers, and health facility staff together to form a community team charged with identifying challenges in service delivery, testing solutions, and monitoring changes. CTC providers draw upon fellow community team members to disseminate health messages and refer community members in need of services. CASES: Two cases are presented. In Ethiopia, the CHSS model was applied in 18 communities to increase HIV testing among pregnant women and antenatal care service utilization and improve sanitation. Prior to implementation, representatives from community groups were unaware of health extension workers or were uncomfortable making referrals. By participating on the community team, representatives became familiar with and comfortable referring people to health extension workers and spreading health messages. During implementation, more pregnant women registered for antenatal care and tested for HIV; health extension workers conducted more postnatal visits; and more households had functioning latrines and proper latrine use increased. In Tanzania, the CHSS model was applied in five communities to improve HIV testing and retention into care. Community team members talked to their families and social networks about HIV testing and, when they identified someone who had dropped out of treatment, they referred those individuals to the home-based care volunteer. Increases in HIV testing and a reduction in patients lost to follow-up were observed. DISCUSSION AND CONCLUSION: The CHSS model brings together existing networks within communities to support and lend legitimacy to CTC providers. This approach may result in sustainable community-based programmes, especially in HIV where the continuum of care extends beyond the facility and into the community.

Patient and provider perspectives on improving the linkage of HIV-positive pregnant women to long-term HIV care and treatment in eastern Uganda.

Despite strong evidence that antiretroviral therapy (ART) reduces the risk of mother-to-child transmission of HIV and improves the health of HIV-positive mothers, many HIV-positive pregnant women do not enrol into long-term HIV care and treatment. This study examined barriers and facilitators to the linkage of HIV-positive pregnant women from antenatal care (ANC) to long-term HIV care from patient and provider perspectives, following the implementation of a collaborative quality improvement project in Eastern Uganda. It also solicited recommendations for improving linkages to HIV care. Structured interviews were conducted with 11 health providers and 48 HIV-positive mothers enrolled in HIV care. Facilitators to linking HIV-positive pregnant women to long-term HIV care identified included support from expert clients, escorted referrals, same-day HIV care registration, and coordination between ANC and HIV services. Barriers reported included shortages in HIV testing kits and fear of social, physical and medical consequences. Participants recommended integration of ANC and HIV services, reduction in waiting times, HIV counselling by expert clients, and community-based approaches for improving linkages to HIV care. Linking HIV-positive pregnant women to HIV care can be improved through deliberate implementation of quality improvement interventions in facilities to address barriers to access and provide stronger support and community mobilisation.

The cost-effectiveness of three methods of disseminating information to improve medical male circumcision in Uganda.

BACKGROUND: Uganda is working to increase voluntary medical male circumcision (VMMC) to prevent HIV infection. To support VMMC quality improvement, this study compared three methods of disseminating information to facilities on how to improve VMMC quality: M-providing a written manual; MH-providing the manual plus a handover meeting in which clinicians shared advice on implementing key changes and participated in group discussion; and MHC-manual, handover meeting, and three site visits to the facility in which a coach provided individualized guidance and mentoring on improvement. We determined the different effects these had on compliance with indicators of quality of care. METHODS: This controlled pre-post intervention study randomized health facility groups to receive M, MH, or MHC. Observations of VMMCs performance determined compliance with quality indicators. Intervention costs per patient receiving VMMC were used in a decision-tree cost-effectiveness model to calculate the incremental cost per additional patient treated to compliance with indicators of informed consent, history taking, anesthesia administration, and post-operative instructions. RESULTS: The most intensive method (MHC) cost $28.83 per patient and produced the biggest gains in history taking (35% improvement), anesthesia administration (20% improvement), and post-operative instructions (37% improvement). The least intensive method (M; $1.13 per patient) was most efficient because it produced small gains for a very low cost. The handover meeting (MH) was the most expensive among the three interventions but did not have a corresponding positive effect on quality. CONCLUSION: Health workers in facilities that received the VMMC improvement manual and participated in the handover meeting and coaching visits showed more improvement in VMMC quality indicators than those in the other two intervention groups. Providing the manual alone cost the least but was also the least effective in achieving improvements. The MHC intervention is recommended for broader implementation to improve VMMC quality in Uganda.

The Mixed Nature of Incentives for Community Health Workers: Lessons from a Qualitative Study in Two Districts in India.

Incentives play an important role in motivating community health workers (CHWs). In India, accredited social health activists (ASHAs) are female CHWs who provide a range of services, including those specific to reproductive, maternal, neonatal, child, and adolescent health. Qualitative interviews were conducted with 49 ASHAs and one of their family members (husband, mother-in-law, sister-in-law, or son) from Gurdaspur and Mewat districts to explore the role of family, community, and health system in supporting ASHAs in their work. Thematic analysis revealed that incentives were both empowering and a source of distress for ASHAs and their families. Earning income and contributing to the household's financial wellbeing inspired a sense of financial independence and self-confidence for ASHAs, especially with respect to relations with their husbands and parents-in-law. In spite of the empowering effects of the incentives, they were a cause of distress. Low incentive rates relative to the level of effort required to complete ASHA responsibilities, compounded by irregular and incomplete payment, put pressure on families. ASHAs dedicated much of their time and own resources to perform their duties, drawing them away from their household responsibilities. Communication around incentives from supervisors may have led ASHAs to prioritize and promote those services that yielded higher incentives, as opposed to focusing on the most appropriate services for the client. ASHAs and their families maintained hope that their positions would eventually bring in a regular salary, which contributed to retention of ASHAs. Incentives, therefore, are both motivating and inspiring as well as a cause dissatisfaction among ASHAs and their families. Recommendations include revising the incentive scheme to be responsive to the time and effort required to complete tasks and the out-of-pocket costs incurred while working as an ASHA; improve communication to ASHAs on incentives and responsibilities; and ensure timely and complete payment of incentives to ASHAs. The findings from this study contribute to the existing literature on incentivized CHW programs and help throw added light on the role incentives play in family dynamics which affects performance of CHW.

Improving voluntary medical male circumcision standards adherence and post-procedure follow-up in Uganda: A mixed methods study

Voluntary medical male circumcision (VMMC) has been demonstrated to reduce the transmission of HIV by 60%. Scaling up VMMC services requires that they be of high quality, socially accepted, and effective. We evaluated an intervention aimed at improving VMMC standards adherence and patient follow-up rates in nine facilities in Uganda. We also qualitatively explored why some men return for follow-up care and others do not. The completeness and quality of clinical documentation was poor at baseline, but significantly improved at endline. We observed significant improvements in management systems; supplies, equipment, and environment; and monitoring and evaluation. Due to the volume of missing data, results were less clear for registration, group education, and information, education and communication; individual counselling and HIV testing; and infection prevention. Significant improvements were also observed in follow-up rates at 48 hours and 7 days, and 6 weeks. Interviews revealed the importance of peers, including female partners, in deciding to get circumcised and in seeking follow-up care. Among the men who did not return for follow-up services, most reported they had no problems and did not see it as necessary. For those who did have mild or moderate adverse events, follow-up care was often sought at a facility closer to the patients' home rather than the circumcising facility. However, information systems were unable to capture this. Applying improvement approaches to VMMC services can promote improved standards adherence and follow-up rates and should be integrated into scale-up plans