Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice.

BACKGROUND: The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve? METHODS: We searched six academic databases for recent (2014-2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis. RESULTS: One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps. CONCLUSION: In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity. TRIAL REGISTRATION: PROSPERO registration number CRD42020177333 .

"No One Does This for the Money or Lifestyle": Abortion Providers' Perspectives on Factors Affecting Workforce Recruitment and Retention in the Southern United States.

OBJECTIVES: Movements to stem abortion accessibility and provision are underway across the southern United States. Preserving access to safe abortion requires a steady maternal health workforce. Targeted laws and limiting environments have contributed to a regional dearth of abortion providers. This study evaluates the consequences of restrictive environments for the abortion workforce to inform strategies to reduce the provider shortage in the South. METHODS: We recruited twelve physicians using purposive sampling and interviewed them on their motivations and experiences practicing in the South. We employed grounded theory analysis to translate their perspectives into recommendations for provider recruitment and retention. RESULTS: Abortion providers identified challenges relating to restrictive legislation, institutional separation of abortion from other medical services, training unavailability, safety concerns, identity struggles, and marginalization within their profession. This contributed to providers widely experiencing stigma and isolation within their work and life environments. Their motivations for practicing in the South despite these challenges included wanting to be impactful in areas of high need, combating health access disparites, and having personal ties to the region. Providers' suggested increasing regional networking and training opportunities, creating an information clearinghouse, and offering additional compensation to better support their work. We conceptualized these findings into a framework detailing the challenges, impacts and opportunities for abortion provision in the southern United States. CONCLUSIONS FOR PRACTICE: Our recommendations for provider recruitment and retention include cooperation between professional organizations, training programs, and healthcare institutions to create opportunities for training and networking and encourage abortion-supportive organizational and policy environments.

Building sustainable and scalable peer-based programming: promising approaches from TESFA in Ethiopia.

BACKGROUND: Girls in Ethiopia's Amhara region experience high rates of child marriage and are less able to negotiate sex or use family planning. Seeking to improve their lives, CARE's TESFA programme delivered reproductive health and financial savings curricula to married girls via reflective dialogues in peer-based solidarity groups. From 2010 to 2013, 5,000 adolescent girls participated via three intervention arms: sexual and reproductive health, economic empowerment, and a combination of both. At end-line, participants reported improvements across health and empowerment outcomes. Four years post-TESFA, 88% of groups reported meeting without continued assistance from CARE. Some original participants had created new groups based on the TESFA model, and some girls not recruited for TESFA spontaneously replicated it to create their own groups. However, questions remained about what had contributed to this organic sustainment and scale-up of groups. METHODS: This 2018 study investigated factors affecting sustainability and scale-up of peer solidarity groups through a systematic mapping of TESFA groups across five woredas (districts) and interviews with key stakeholders. Data were collected from 39 focus groups with active and dissolved Girl Groups, Social Analysis and Action groups, and girls' husbands and from 29 in-depth interviews with group facilitators and community health workers across three districts. Data were coded and analyzed per grounded theory principles. RESULTS: Changes in reproductive health knowledge and specific behaviours, such as contraceptive use and institutional delivery, were maintained 5 years after the intervention ended. Group connectedness, spousal support, integration of holistic community platforms, and opportunities for financial independence were found to be important for group sustainability. Observed changes in TESFA girls' confidence to negotiate and assert their rights, hopes of improved mobility, and the promise of economic opportunity commonly inspired spontaneous replication of groups. Recommendations for future peer-based programmes include creating environments of solidarity and holistically engaging intervention communities. CONCLUSION: By increasing knowledge of and access to reproductive health services, TESFA mitigates some of the harmful effects of child marriage. The maintenance and organic replication of groups suggest that TESFA provides a successful, scalable and sustainable tested model for reproductive health program delivery through peer-based solidarity groups.

In Ethiopia, married girls are a particularly vulnerable adolescent population because of the many health risks associated with early marriage. Peer-based approaches are a common strategy to improve sexual and reproductive health knowledge and behaviours for marginalized groups. Critiques of these approaches are that they lack sustainability without ongoing investment and have no lasting impact on health behaviours. CARE's TESFA programme, a peer-based approach with married adolescent girls in South Gondar, was found to be effective in creating long-term behavior change related to uptake of family planning and rates of institutional delivery. Some 88% of groups who received the TESFA curriculum were still meeting 4 years after the programme had concluded. Some participants even created groups of their own, scaling TESFA beyond the original audience, suggesting a potential approach to wider scale-up. To explore lessons learned around scale and sustainability, this study interviewed TESFA participants and stakeholders.Improvements in behaviours related to contraceptive use, institutional delivery, and girls' agency in reproductive decision-making were sustained over time regardless of group status. Factors that affected the sustainability and scale-up of groups included solidarity among group members, support from husbands and community members, ongoing savings and loan structures, flexibility of group processes, and availability of relevant curriculum topics. Through an analysis of these findings, this paper discusses recommendations for sustainable and scalable peer-based programme design via existing Ethiopian community structures. Using TESFA principles as a model, practitioners could design and implement scalable and sustainable peer-based programming for adolescents sexual and reproductive health.

Bringing women's voices to PMTCT CARE: adapting CARE's Community Score Card© to engage women living with HIV to build quality health systems in Malawi.

BACKGROUND: Coverage of prevention of mother-to-child transmission of HIV (PMTCT) services has expanded rapidly but approaches to ensure service delivery is patient-centered have not always kept pace. To better understand how the inclusion of women living with HIV in a collective, quality improvement process could address persistent gaps, we adapted a social accountability approach, CARE's Community Score Card© (CSC), to the PMTCT context. The CSC process generates perception-based score cards and facilitates regular quality improvement dialogues between service users and service providers. METHODS: Fifteen indicators were generated by PMTCT service users and providers as part of the CSC process. These indicators were scored by each population during three sequential cycles of the CSC process which culminates in a sharing of scores in a collective meeting followed by action planning. We aggregated these scores across facilities and analyzed the differences in first and last scorings to understand perceived improvements over the course of the project (z-test comparing the significance of two proportions; one-tailed p-value ≤ .05). Data were collected over 12 months from September 2017 to August 2018. RESULTS: Fourteen of the fifteen indicators improved over the course of this project, with eight showing statistically significant improvement. Out of the indicators that showed statistically significant improvement, the majority fell within the control of local communities, local health facilities, or service providers (7 out of 8) and were related to patient or user experience and support from families and community members (6 out of 8). From first to last cycle, scores from service users' and service providers' perspectives converged. At the first scoring cycle, four indicators exhibited statistically significant differences (p-value ≤ .05) between service users and service providers. At the final cycle there were no statistically significant differences between the scores of these two groups. CONCLUSIONS: By creating an opportunity for mothers living with HIV, health service providers, communities, and local government officials to jointly identify issues and implement solutions, the CSC contributed to improvements in the perceived quality of PMTCT services. The success of this model highlights the feasibility and importance of involving people living with HIV in quality improvement and assurance efforts. TRIAL REGISTRATION: Trial registration: ClincalTrials.gov NCT04372667 retrospectively registered on May 1st 2020.

Elevating Married Adolescents' Voices for Responsive Reproductive Healthcare in Syria.

Increases in early marriage and pregnancy resulting from Syria's humanitarian crisis highlight a critical gap in adolescents' access to life-saving sexual and reproductive health information and services, and a larger need for adolescent-specific interventions grounded in gender transformative approaches. Seeking to address this, CARE, UNFPA and Syria Relief and Development adapted global evidence-based approaches to humanitarian contexts to create the Adolescent Mothers Against all Odds (AMAL) Initiative for pregnant girls and first-time mothers aged 10 to 18 years. Designed to improve the lives of young girls through responsive health systems and enabling environments, AMAL includes three components: a Young Mothers Club for first-time mothers and pregnant girls, participatory dialogues with health providers, and reflective dialogues with girls' marital family and community members. The AMAL Initiative intends to ensure responsiveness to the unique vulnerabilities of adolescent sub-groups by co-implementing with them. Select girls undergo additional leadership training and serve as adolescent representatives on community advisory groups sharing feedback for program improvement. One hundred-four first-time mothers and pregnant girls, 219 community members, and 120 health providers participated in AMAL in northwest Syria. In a mixed methods evaluation, facilitators administered monitoring tools to identify program improvements, pre-post surveys to assess outcomes, and end-line discussions to gather perceptions of impact. Girls reported a 47% overall increase in self-esteem, confidence, health-seeking capacity, and communication ability. Community support for girls' use of family planning increased by 27% and girls' equal access to services by 35%. Findings across all participant groups demonstrate decreased expectations of early marriage and increased acceptance of family planning post-marriage. Areas that participants cited for potential improvement included programming for girls/women above the age of 18 years, and additional training for health providers on long-acting contraceptive methods. These results show that participatory adolescent-centered sexual and reproductive health programming is not only feasible in crisis settings but can improve the self-efficacy of vulnerable adolescents to overcome barriers to accessing healthcare and improving well-being. The AMAL Initiative is now being scaled up through local partners in Syria and piloted in northern Nigeria.