Ward nurses' experiences and perceptions of the critical care outreach service: A qualitative study undertaken in a large teaching hospital in the West of Ireland.

BACKGROUND: The critical care outreach service (CCOS) was established in a large teaching hospital in the West of Ireland in 2014 to provide an extension of CCOS between the intensive care unit (ICU) and the wards outside ICU. With the ever-increasing pressure on ICU resources, CCOS seems to offer an additional service to patients who are critically ill and deteriorating in hospital wards. AIM: The aim of this study is to explore ward nurses' experiences and perceptions of the CCOS. STUDY DESIGN: A qualitative descriptive methodology aimed to obtain a descriptive account of ward nurses' experiences of the CCOS. Data were collected using semi-structured interviews. Twelve nurses from the West of Ireland participated in the study. Braun and Clarke's six-step thematic analysis was used to analyse the data. RESULTS: Three core themes identified in this study included clinical support and decision-making; sharing knowledge and skills, and communication. All 12 nurses identified the positive impacts that they felt the current outreach service provided to them on a daily basis. CONCLUSIONS: Study findings indicate that nurses value the role of the CCOS in supporting the care of the critically ill and deteriorating patients at ward level. The CCOS has become invaluable to the ward nurses in their daily practice especially at a time when resources are lacking and patient acuity is on the rise.

Community health worker motivation to perform systematic household contact tuberculosis investigation in a high burden metropolitan district in South Africa.

BACKGROUND: South Africa faces a chronic shortage of professional health workers. Accordingly, community health workers (CHWs) are being employed to mitigate the ongoing health workforce deficiencies. As increased access to quality service delivery hinges upon their motivation, this study explored CHWs' motivation to deliver systematic household contact tuberculosis (TB) investigation (SHCI). METHODS: In 2017, a cross-sectional survey was conducted among CHWs in the Mangaung Metropolitan District, Free State Province. Exploratory factor analysis was performed on a 30-item scale to determine the dimensions underlying CHW motivation. Items with factor loadings of 0.4 and above were retained. Descriptive and inferential analyses were used to determine CHW motivation levels. Multiple linear regression analysis was used to investigate the determinants of CHW motivation. RESULTS: Out of 235 participants, 89.2% were female. Participants' median age was 39 (inter-quartile range: 33-45) years. CHW motivation was defined by 16 items across three dimensions - intrinsic job satisfaction, burnout and team commitment, together explaining 56.04% of the total variance. The derived scale showed satisfactory internal consistency (Cronbach's alpha: 0.81), with a mean motivation score of 52.26 (standard deviation [sd]: 5.86) out of 64. Statistically significant differences were observed between formal CHWs - those with at least phase 1 standardised accredited training, and informal CHWs - those without such accredited training regarding team commitment scores (17.82 [sd: 2.48] vs. 17.07 [sd: 2.82]; t(233) = 2.157; p = 0.013). CHW age (ß = 0.118, p = 0.029), location (ß = 1.737, p = 0.041), length of service (ß = - 0.495, p < 0.001), attendance of TB SHCI training (ß = 1.809, p = 0.036), and TB SHCI competence (ß = 0.706, p < 0.001), contributed statistically significantly to CHW motivation. CONCLUSION: CHW motivation to perform TB SHCI was both intrinsic and extrinsic. The high overall mean score implies that the CHWs were well-motivated to perform TB SHCI. To ensure sustained improved access to quality TB SHCI service provision, programme managers in the Free State and similar settings could potentially use the tool derived from this study to monitor and inform CHW motivation interventions. Interventions should pay close attention to the CHWs' formalisation, competence and training.

Exploration of Community Health Workers' views about in their role and support in Primary Health Care in Northern Cape, South Africa.

Community health workers (CHWs) play a significant role in Primary health Care due to their proximity to households, communities and the health care system. Many studies focus on CHWs and the work they do. However, few have examined their experiences and identity and how that might influence how they view and perform their roles. The objectives of the study were to: Describe the role of CHWs in community-based health care in Northern Cape, Identify the perceived barriers and enablers to CHWs role performance, Explore CHWs views regarding the support from the communities and the formal healthcare system in Northern Cape. An exploratory qualitative design using focus groups was adopted. Forty-six (46) CHWs were purposively selected using the critical case sampling approach. Data were collected through three focus group interviews in three regions. Analysis followed the Graneheim & Lundman thematic analysis. Three themes emerged from data: perceived contribution to Primary Health Care, recognition of CHWs role, measures to improve working conditions. Findings showed that CHWs were engaged in various health and social care roles, they believed that they made a significant contribution to PHC, and that the health system persistently relied on their services. The enabler for finding meaning in their work was the positive community response and the good relations they had with the team leaders. The major barrier was the structure of the CHWs programme and the perceived lack of support by the government. The complex issues CHWs address in the community call for a review of their roles and workload as well as the support they receive from the formal healthcare system.

[Intensive outpatient treatment - a therapy option for all patients in child and adolescent psychiatry or just for a few?] / Kinder- und jugendpsychiatrische stationsäquivalente Behandlung (StäB): Therapieoption ­ für alle oder für wenige?

Intensive outpatient treatment - a therapy option for all patients in child and adolescent psychiatry or just for a few? Abstract. Objective: "Child and adolescent psychiatric ward-equivalent treatment" (= stationsäquivalente Behandlung, StäB) is an intensive daily home treatment that has now become available in Germany. Conditions for StäB services were negotiated were negotiated, authorized and came into force by German healthcare commissioners and hospitals on 1 January 2018. However, to date few hospitals in Germany offer StäB, and its feasibility has been questioned. This study evaluates the first 58 cases of StäB in the Department of Child and Adolescent Psychiatry, ZfP Südwürttemberg (2018-2019). Method: All patients admitted consecutively to StäB from 1 January 2018 to 15 August 2019 were included and evaluated solely using descriptive analyses in SPSS.25. Results: The average length of stay in StäB was 37.95 days (SD 15.35). 86.2 % of the families completed treatment, with 3 patients discontinuing treatment and 5 patients needing inpatient admission. Unlike in the literature, internalising disorders predominated (70.7 %), whereas externalizing disorders were diagnosed in only 27.8 % of the patients. The cost of treatment in StäB was on average 8779.25 €. Conclusions: StäB is a viable and well-accepted new treatment alternative for patients requiring inpatient admission. The multiprofessionality of treatment as well as daily contacts are required. Feasibility under the conditions set is given. The average length of stay is slightly longer, but the costs are lower than those of inpatient treatment.

[From home treatment to psychiatric ward-equivalent treatment (StäB) - A systematic review of outpatient treatment in Germany]. / Vom Hometreatment zur stationsäquivalenten Behandlung (StäB).

From home treatment to psychiatric ward-equivalent treatment (StäB) - A systematic review of outpatient treatment in Germany Abstract. Objective: In the past, home treatment was not available in Germany for children and adolescents with mental health problems. However, enactment of the PsychVVG law on 1 January 2017 has changed this, so that intensive home treatment (stationsäquivalente Behandlung, StäB) can now be offered as an alternative to inpatient treatment. This literature review a) analyzes existing German home treatment studies for effectiveness, b) determines from international reviews criteria for effective home treatment, and c) aligns these with the standardized StäB criteria. Method: We performed a systematic literature search in PubMed, Scopus, PsycINFO, and Cochrane Library referencing "hometreatment AND children" as well as "hometreatment AND adolesc*. Results: Flexibility, mobility, multiprofessionality, a wide spectrum of possible interventions, the option of inpatient admission, 24/7 availability as well as daily treatment sessions have been found to be factors for effective home treatment. In German studies, home treatment was shown to enhance psychosocial functioning, parental competences, long-term effectiveness, and acceptance by the families. The highest effect for home treatment was demonstrated in children and adolescents with externalizing disorders. Conclusion: Intensive home treatment (StäB) meets the criteria identified in the literature and is a good addition to existing treatment options for children and adolescents with mental health problems in Germany.

High non-compliance rate with anti-tuberculosis treatment: a need to shift facility-based directly observed therapy short course (DOTS) to community mobile outreach team supervision in Saudi Arabia.

BACKGROUND: Tuberculosis (TB) remains a major global public health problem in many developing countries including Kingdom of Saudi Arabia (KSA). Patient compliance with anti-tuberculosis treatment is a determining factor in controlling the spread of TB. This study compares the default rate and the perception of their treatment among TB patients being treated by means of a community mobile outreach approach, with those of patients being treated by means of a facility-based Directly Observed Treatment Short course (DOTS) in the Jeddah region of Saudi Arabia. METHODS: A comparative cross-sectional study of 200 TB patients who presented at the Madain Alfahd Primary Health Care Center (PHCC) Jeddah, between January 2018 and November 2018 was undertaken. In one group, randomly assigned patients were served by mobile outreach teams who administered oral anti-TB treatment under the DOTS regime. In the other group, the patients were treated by means of the traditional facility-based DOTS treatment. A questionnaire measuring patient attitudes and understanding of the disease and their treatment modes was completed by patients at the beginning of their treatment, and again after 3 months. The results were analysed by means of independent and Paired T Tests, along with chi square analysis. RESULTS: We found that the overall default rate among those patients served by our mobile outreach team was only 3%, compared with a 22% default rate among non-mobile team treated patients (p = < 0.001). A major change in the attitude and understanding scores of patients was noted in both groups after 3 months. A significant difference was also noted in the mean compliance scores (mobile team served =58.43 and facility-based =55.55, p < 0.001) after 3 months of treatment. CONCLUSION: Our study indicated that treatment by means of our mobile outreach DOTS can offer an effective strategy for the treatment of TB patients. A reduced patient default rate and a better understanding of the disease and its treatment confirmed a positive impact of mobile outreach teams on these patients. Treating TB patients by means of mobile outreach teams can thus be recommended as a means for the cure and prevention of the further spread of the disease.

Insights of health district managers on the implementation of primary health care outreach teams in Johannesburg, South Africa: a descriptive study with focus group discussions.

BACKGROUND: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering in South Africa. It attempts to move the deployment of community health workers (CHWs) from vertical programmes into an integrated generalised team-based approach to care for defined populations in municipal wards. There has little evaluation of PHC outreach teams. Managers' insights are anecdotal. METHODS: This is descriptive qualitative study with focus group discussions with health district managers of Johannesburg, the largest city in South Africa. This was conducted in a sequence of three meetings with questions around implementation, human resources, and integrated PHC teamwork. There was a thematic content analysis of validated transcripts using the framework method. RESULTS: There were two major themes: leadership-management challenges and human resource challenges. Whilst there was some positive sentiment, leadership-management challenges loomed large: poor leadership and planning with an under-resourced centralised approach, poor communications both within the service and with community, concerns with its impact on current services and resistance to change, and poor integration, both with other streams of PHC re-engineering and current district programmes. Discussion by managers on human resources was mostly on the plight of CHWs and calls for formalisation of CHWs functioning and training and nurse challenges with inappropriate planning and deployment of the team structure, with brief mention of the extended team. CONCLUSIONS: Whilst there is positive sentiment towards intent of the PHC outreach team, programme managers in Johannesburg were critical of management of the programme in their health district. Whilst the objective of PHC reform is people-centred health care, its implementation struggles with a centralising tendency amongst managers in the health service in South Africa. Managers in Johannesburg advocated for decentralisation. The implementation of PHC outreach teams is also limited by difficulties with formalisation and training of CHWs and appropriate task shifting to nurses. Change management is required to create true integrate PHC teamwork. Policy review requires addressing these issues.

The limitations in implementing and operating a rapid response system.

Despite the widespread introduction of rapid response systems (RRS)/medical emergency teams (MET), there is still controversy regarding how effective they are. While there are some observational studies showing improved outcomes with RRS, there are no data from randomised controlled trials to support the effectiveness. Nevertheless, the MET system has become a standard of care in many healthcare organisations. In this review, we present an overview of the limitations in implementing and operating a RRS in modern healthcare.

A longitudinal cohort study evaluating the impact of a geriatrician-led residential care outreach service on acute healthcare utilisation.

BACKGROUND: over the last decade, high demand for acute healthcare services by long-term residents of residential care facilities (RCFs) has stimulated interest in exploring alternative models of care. The Residential Care Intervention Program in the Elderly (RECIPE) service provides expert outreach services to RCFs residents, interventions include comprehensive care planning, management of inter-current illness and rapid access to acute care substitution services. OBJECTIVE: to evaluate whether the RECIPE service decreased acute healthcare utilisation. DESIGN: a retrospective cohort study using interrupted time series analysis to analyse change in acute healthcare utilisation before and after enrolment. SETTING: a 300-bed metropolitan teaching hospital in Australia and 73 RCFs within its catchment. SUBJECTS: there were 1,327 patients enrolled in the service with a median age of 84 years; 61% were female. METHODS: data were collected prospectively on all enrolled patients from 2004 to 2011 and linked to the acute health service administrative data set. Primary outcomes change in admission rates, length of stay and bed days per quarter. RESULTS: in the 2 years prior to enrolment, the mean number of acute care admissions per patient per year was 3.03 (SD 2.9) versus post 2.4 (SD 3.3), the service reducing admissions by 0.13 admissions per patient per quarter (P = 0.046). Prior to enrolment, the mean length of stay was 8.6 (SD 11.0) versus post 3.5 (SD 5.0), a reduction of 1.5 days per patient per quarter (P = 0.003). CONCLUSIONS: this study suggests that an outreach service comprising a geriatrician-led multidisciplinary team can reduce acute hospital utilisation rates.

Privacy and confidentiality in Massachusetts' post-overdose outreach programs: Mixed methods analysis of outreach staff surveys and interviews.

BACKGROUND: Public health-public safety partnerships for post-overdose outreach have emerged in many communities to prevent future overdose events. These efforts often identify overdose survivors through emergency call data and seek to link them with relevant services. The aim of this study was to describe how post-overdose outreach programs in Massachusetts manage the confidentiality of identifiable information and privacy of survivors. METHODS: In 2019, 138 Massachusetts programs completed surveys eliciting responses to questions about program operations. Descriptive statistics were calculated from the closed-ended survey responses. Thirty-eight interviews were conducted among outreach staff members during 2019-2020. Interview transcripts and open-ended survey responses were thematically analyzed using deductive and inductive approaches. RESULTS: Of programs that completed the survey, 90 % (n = 124/138) reported acting to protect the privacy of survivors following overdose events, and 84 % (n = 114/135) reported implementing a protocol to maintain the confidentiality of personal information. Interviews with outreach team members indicated substantial variation in practice. Outreach programs regularly employed discretion in determining actions in the field, sometimes undermining survivor privacy and confidentiality (e.g., by disclosing the overdose event to family members). Programs aiming to prioritize privacy and confidentiality attempted to make initial contact with survivors by phone, limited or concealed materials left behind when no one was home, and/or limited the number of contact attempts. CONCLUSIONS: Despite the establishment of privacy and confidentiality protocols within most post-overdose outreach programs, application of these procedures was varied, discretionary, and at times viewed by staff as competing with engagement efforts. Individual outreach overdose teams should prioritize privacy and confidentiality during outreach to protect overdose survivors from undesired exposure. In addition to individual program changes, access to overdose survivor information could be changed across all programs to bolster privacy and confidentiality protocols. For example, transitioning the management of overdose-related information to non-law enforcement agencies would limit officers' ability to disseminate such information at their discretion.

[Effect on the time of admission to the Intensive Care Unit of the start-up of an Critical Care Outreach Team]. / Efecto sobre el momento del ingreso en la unidad de cuidados intensivos de la puesta en marcha de un servicio extendido de medicina intensiva.

INTRODUCTION: The implementation of the Critical Care Outreach Teams can influence the time of admission of patients to the Intensive Care Unit (ICU). MATERIAL AND METHODS: Retrospective, descriptive, quasi-experimental "before-after" cohort study. All patients admitted to the unit urgently from Monday to Friday for two periods (between February 1, 2022 and June 30 and between February 1, 2023 and June 30, 2023) are included. The patients were divided into regular shift admissions (08-15h) and on-call (15-08h). The secondary objective was to assess whether there were differences in mortality between the two periods. RESULTS: During the first period of the study, 239 patients were admitted. 29.29% entered the ordinary shift and 70.71% on duty shift. During the second period, 211 patients were included with 43.13% of admissions in the ordinary shift. The comparison between the two periods observed a significant increase in the percentage of admissions in the morning hours in the second period (P=.0031). Mortality in the first period was 13.80% and in the second period 9.95%. The comparison between the two periods did not reveal significant differences. CONCLUSIONS: The start-up of the Critical Care Outreach Teams is associated with an increase in the proportion of ICU admissions in the morning period without any observed changes in mortality.

Views of community health workers on the integration of a physiotherapist into a ward-based outreach team.

Background: Due to changes in the disease profile and lifestyle of individuals in South Africa, the limited health care facilities available have experienced congestion and overcrowding, affecting health care service delivery. Ward-based outreach team (WBOT) programmes were implemented to strengthen primary health care, improve access and alleviate the congestion occurring at these facilities. However, WBOTs have limitations in terms of medical knowledge and rehabilitative skills. Objective: To explore the views of community health workers (CHWs) on the integration of physiotherapists into WBOTs. Method: A qualitative research design making use of focus group discussions (FGDs) was used. Through purposive sampling, 58 CHWs who were members of WBOTs were recruited. The WBOTs were from 10 selected primary health care centres in the Tshwane district, Region 2. Six FGDs were conducted. The audio-recorded data were transcribed verbatim. The transcripts were transported into NVivo 12 for thematic analysis. Results: The views of the CHWs were that the WBOTs can benefit from having a physiotherapist as a member of the team. The WBOTs do not have adequate skills to attend to the physiotherapy needs of communities. People in the community have challenges in accessing physiotherapy services, and physiotherapy services can enhance the performance of the WBOTs by providing training to the WBOTs and providing clinical services to community members. Conclusion: Community-based rehabilitative services with a physiotherapist as part of the WBOTs can enhance and strengthen the services of the WBOTs, which can improve the treatment outcomes for communities. Clinical implications: The WBOTS will be empowered to provide clinical services to the vulnerable people in the community that they serve.

Facility Managers' Perceptions of Support and Supervision of Ward Based Primary Health Care Outreach Teams in National Health Insurance Pilot Districts in KwaZulu-Natal, South Africa. A Qualitative Study.

INTRODUCTION: Evidence from many countries suggests that provision of home and community-based health services, linked to care at fixed primary health care facilities, is critical to good health outcomes. In South Africa, the Ward-Based Primary Health Care Outreach Teams are well placed to provide these services. The teams report to a primary health care facility through their outreach team leader. The facility manager/operational manager provides guidance and support to the outreach team leader. AIM: The aim of the study was to explore and describe the perceptions of facility managers regarding support and supervision of ward-based outreach teams in the National Health Insurance pilot sites in Kwa Zulu-Natal. SETTING: The study was carried out in three National Health Insurance pilot districts in KwaZulu- Natal. METHODS: An exploratory qualitative design was used to interview 12 primary health care facility managers at a sub-district (municipal) level. The researchers conducted thematic analysis of data. FINDINGS: Some gaps in the supervisory and managerial relationships between ward based primary health care outreach teams and primary health care facility managers were identified. High workload at clinics may undermine the capacity of PHC facility managers to support and supervise the teams. Field supervision seems to take place only rarely and for those teams living far away from the clinic, communication with the clinic manager may be difficult. The study further highlights issues around the training and preparation of the teams. CONCLUSIONS: Ward based primary health care outreach teams have a positive impact in preventive and promotive health in rural communities. Furthermore, these teams have also made impact in improving facility indicators. However, their work does not happen without challenges.

Treatment outcomes among tuberculosis patients in Jeddah, Saudi Arabia: Results of a community mobile outreach directly observed Treatment, Short-course (DOTS) project, compared to a standard facility-based DOTS: A randomized controlled trial.

INTRODUCTION: Tuberculosis (TB) remains a global public health threat affecting people in many developing countries, including the Kingdom of Saudi Arabia. Maintaining a long-term treatment regimen has always been the cornerstone of successful treatment outcomes among tuberculosis patients. In the Jeddah region, the National Tuberculosis Control and Prevention Program is now treating TB patients by means of a community mobile outreach team approach.The objective of this study was to compare the effectiveness of the community mobile outreach approach in improving treatment outcomes (success rate) among local tuberculosis patients with those being treated with a facility-based directly observed treatment, short-course (DOTS). STUDY DESIGN: Our study consisted of a two-sample, parallel design [1:1], statistician -blind randomized control trial with 200 newly diagnosed, TB patients as subjects. SETTING/PARTICIPANTS: The patients had all presented at the Madain Alfahd Primary Health Care Center, Jeddah. Between Nov 2017 and Nov 2018, a total of 221 TB patients were screened of whom 200 were randomly selected using randomly generated sequences. INTERVENTION: Patients in the intervention sample group were treated by means of mobile outreach teams with oral anti-TB treatment under the DOTS, and control group patients were given the traditional facility-based DOTS treatment according to the WHO recommendations and national guidelines. MAIN OUTCOME: The primary outcome was the level of overall treatment success rate. It was finally determined and compared in the two sample groups using chi-square analysis and relative risk assessment. RESULTS: In the analysis stage, 97 patients were in the intervention group, while the control group consisted of 76. The overall response rate was 86.5% (173/200). We found that the percentage of overall treatment success rate among the patients served by the mobile outreach team was 97%, compared to 76% in the non-mobile team treated patients. The relative risk of treatment success rate among the intervention group was 1.27 (95% CI = 1.13-1.43) times greater than that amongst the control group. Log-rank test (log-rank statistics = 18.91; p < 0.001) identified a significant difference in the default rate after six months of treatment. CONCLUSION: This study has shown that a mobile outreach DOTS approach is an effective and acceptable strategy for treating TB patients. It also provides important data on the efficacy of using mobile outreach teams to improve TB treatment outcomes in Jeddah. Our results provide evidence and highlight the positive and significant impact of mobile outreach teams in mitigating TB recurrence rates and in improving TB treatment outcomes.Clinical Trial Registration: Clinicaltrials.gov: NCT03787914.

The use and value of maps in Community-Oriented Primary Care: Does process matter?

BACKGROUND: Maps are important tools in healthcare delivery. In Community-Oriented Primary Care (COPC), they are expected to be used to plan services and resources for defined geographical areas, delineate team practice areas, allocate healthcare workers to households and support service delivery and performance management. AIM: This is a study of the use and value of maps and mapmaking in the delivery of healthcare services through Ward-Based Outreach Teams (WBOTs). SETTING: This study was conducted between 2014 and 2016 in Mamelodi (South Africa), an urban settlement selected to begin the City of Tshwane's WBOT implementation programme in 2013. METHODS: This study is based on three qualitative participatory mapmaking projects with WBOT healthcare professionals and workers. Data generated through mapmaking, focused group discussions, individual semi-structured interviews, reflective writing and feedback workshops were analysed thematically. RESULTS: Through mapmaking and discussions about the maps, healthcare providers took ownership of the maps they were creating or viewing, added their own information onto the maps, voiced issues about their practice, generated new knowledge and shared ideas and solutions for challenges. These processes expanded the use and value of maps beyond assisting participants to gain insights into the context, people and organisations of their places of work. CONCLUSION: Maps become creative learning tools that can be used in emergent ways to solve healthcare service and other problems when they are actively generated and engaged through facilitated discussion and reflection. This allows WBOTs to see maps as dynamic canvasses that they can use to improve service delivery.

The experiences of home-based care workers when rendering services in the communities in Northern Tshwane and Madibeng districts.

BACKGROUND: Despite the provision of the policy for Ward-based Primary Healthcare Outreach Teams, which requires home-based care workers to be supported by different categories of health professionals, home-based care workers continue to experience challenges during service provision in the communities. Home-based care workers form an integral part of the Ward-based Primary Healthcare Outreach Teams that form part of the streams of primary healthcare re-engineering. The aim of the study was to explore and describe the experiences of home-based care workers (HBCWs) when rendering services in the communities of Northern Tshwane district in Gauteng province and Madibeng district in the North West province. METHODS: The study design was qualitative, exploratory and descriptive. Purposive sampling was used from the population of HBCWs in Gauteng and North West. Focus group interviews were conducted. Tesch's data analysis method was used. Themes and subthemes were identified by the researcher and co-coder, and these were summarised into subjects that were interrelated. RESULTS: Diverse experiences of participants emerged. These experiences included lack of human and material resources, poor funding, lack of knowledge, lack of support and respect and the need for psychological support. CONCLUSION: There is a need for a collaborative approach amongst the National Department of Health, non-governmental organisations (NGOs) and HBCWs in patient care. Policies and support structures should be strengthened or reformed to promote comprehensive and integrated care to sustain HBCWs.

Barriers to the Implementation of the Ward-Based Outreach Team Program in Mpumalanga Province: Results From Process Evaluation.

BACKGROUND: South Africa adopted the ward-based outreach team (WBOT) program as one aspect of the three-stream approach to primary health care (PHC) re-engineering. PHC re-engineering seeks to modify the hospicentric and curative approach into a more preventive and promotive approach to improve health outcomes. There has not been an evaluation of the implementation of the WBOTs in Nkangala District since its inception in 2012. METHODS: A process evaluation approach using qualitative methods was used to examine and describe the contextual, organizational, health provider, and program-related barriers considered to affect the implementation of the WBOTs 3 sub-districts in one of the health districts in Mpumalanga Province, South Africa. The framework for this evaluation was informed by the logic model framework developed by the Center for Disease Control as well as the 3 domains of evaluation recommended by the Medical Research Council Guidance on process evaluation. Data were collected through in-depth interviews with multiple data sources directly involved in the implementation of the WBOTs. A thematic analysis was done using NVivo 11. RESULTS: The key critical barriers identified by the evaluation include the inadequate provision of resources, the lack of supervision, the heavy workload for outreach teams, the inadequate and irregular payment of stipends, threats to the safety of the CHWs, and the cultural beliefs and practices of the communities who are to receive the services. The lack of adequate financial resources was the main challenge, and will continue to pose a risk to the successful implementation of the WBOTs. CONCLUSIONS: Although the barriers are being reported as separate contextual factors, the internal and external contexts are interdependent, interact with one each other, and should not be considered in isolation. The need to improve stakeholder engagement on the WBOT program underscores the importance of the external context in the successful implementation of WBOTs.

The Perspectives of Programme Staff and Recipients on the Acceptability and Benefits of the Ward-Based Outreach Teams in a South African Province.

The re-engineering of primary health care (PHC) called for the establishment of ward-based outreach teams as a reform strategy to bridge the gap between health facilities and communities. The Nkangala district established ward-based outreach teams in 2012. We used process evaluation to assess the acceptability of the outreach teams from the perspectives of those involved in the implementation as well as the clients who are the recipients of the outreach services in order to describe how the programme benefits the recipients, the staff, and the health system. Data were collected through interviews with multiple data sources. A thematic analysis was done using NVivo 11. The outreach programme is acceptable to the recipients and staff. The acceptability translated into measurable benefits for the recipients and the health system. Health benefits included increased access to services, support for treatment adherence, and linkages to various sector departments for social support. Since the inception of outreach teams, the district has recorded low utilisation of PHC services and improved priority indicators such as immunisation coverage, early antenatal bookings, treatment adherence, TB cure rates, and decreased default rates. The positive effects of the outreach teams on indicators underscore the need to roll the programme out to all sub-districts.

Evaluating community health worker education policy through a National Certificate (Vocational) Primary Health qualification lens.

BACKGROUND: In 2018, the South African National Department of Health (NDoH) published a 5-year policy framework and strategy for Ward-Based Primary Healthcare Outreach teams to improve team management and leadership and support service delivery. In the same year, the World Health Organization (WHO) published guidelines on health policy and system support to optimise Community Health Worker (CHW) programmes. AIM: This article aims to assess the National Certificate (Vocational), or NC(V), Primary Health qualification in terms of the education and training guidelines and recommendations of the 2018 NDoH and WHO policy documents. SETTING: The qualification was initiated in 2013 at 12 Technical and Vocational Education and Training (TVET) colleges across South Africa. The evaluation covered the period 2013-2017. METHODS: Pragmatic qualitative enquiry was used to examine the context, design, implementation and outcomes of the qualification. Data collection involved document reviews, key informant in-depth interviews and focused group discussions, and individual reflections with respondents from one part-time and two full-time offerings at two colleges. Analyses of emergent themes were interpreted using appropriate models and theoretical frameworks. RESULTS: The Department of Higher Education and Training (DHET) created and implemented a standardised, curriculated national programme for CHW education that structured theoretical and practical learning over time to ensure assimilation of content and its application in practice. CONCLUSION: NC(V) Primary Health, as a single, national, quality-assured qualification for CHWs, meets WHO 2018 guidelines and recommendations, NDoH training needs and CHWs learning expectations, especially when offered part-time. Despite the termination of the programme, it remains a relevant option for CHWs in South Africa and elsewhere.

The roles, responsibilities and perceptions of community health workers and ward-based primary health care outreach teams: a scoping review.

BACKGROUND: Community health workers play important roles in rural primary health care settings. They work within ward-based primary health care outreach teams yet their roles are not always clearly defined and operationalized. There is thus a need to explore perceptions about the roles and responsibilities of community health workers. OBJECTIVE: To investigate the roles, responsibilities and effectiveness of community health workers working within ward-based primary health care outreach teams. METHOD: A scoping review of the published peer reviewed literature on community health workers working in ward-based primary health care outreach teams within low and middle-income countries was conducted. The following five electronic databases were searched: EBSCOhost, Google Scholar, Science Direct, EMBASE, PubMed, and Clinical key. Out of 69,969 identified articles, 31 met the inclusion criteria. The majority of the studies were from South Africa. RESULTS: Both positive and negative perceptions were reported. Suggestions for improvements were also put forward. Positive factors included: ongoing training and up skilling; collaboration and trust building with other health care workers; mentoring and supervision; motivation and recognition, and incentives and remuneration. Negative factors covered: inadequate mentorship and poor supervision; role conflict; lack of support; poor remuneration; inadequate manpower; poor knowledge, and insufficient training. The review identified the following as the roles and responsibilities of community health workers: conducting home visits; identifying vulnerable community groups; promoting health and wellness; increasing access to health care; contact tracing; delivering health education; giving counselling and psychosocial support, and providing preventive health services. CONCLUSION: The information available for community health workers in terms of their roles, responsibilities and effectiveness is inadequate, considering their roles and responsibilities in ward-based primary health care outreach teams. This lack of information constitutes barriers to effective service delivery, a common situation among this group of community health workers.