A qualitative assessment of barriers and facilitators of telemedicine volunteerism during the COVID-19 pandemic in India.

BACKGROUND: The COVID-19 pandemic further propelled the recent growth of telemedicine in low-resource countries, with new models of telemedicine emerging, including volunteer-based telemedicine networks. By leveraging existing infrastructure and resources to allocate health personnel more efficiently, these volunteer networks eased some of the pandemic burden placed on health systems. However, there is insufficient understanding of volunteer-based telemedicine models, especially on the human resources engagement on such networks. This study aims to understand the motivations and barriers to health practitioner engagement on a volunteer telemedicine network during COVID-19, and the mechanisms that can potentially sustain volunteer engagement to address healthcare demands beyond the pandemic. METHODS: In-depth qualitative interviews were conducted with health practitioners volunteering on an Indian, multi-state telemedicine network during the COVID-19 pandemic. Data were analyzed using thematic content analysis methods. RESULTS: Most practitioners reported being motivated to volunteer by a sense of duty to serve during the pandemic. Practitioners suggested organizational-level measures to make the process more efficient and facilitate a more rewarding provider-patient interaction. These included screening calls, gathering patient information prior to consultations, and allowing for follow-up calls with patients to close the loop on consultations. Many practitioners stated that non-financial incentives are enough to maintain volunteer engagement. However, practitioners expressed mixed feelings about financial incentives. Some stated that financial incentives are needed to maintain long-term provider engagement, while others stated that financial incentives would devalue the volunteer experience. Most practitioners highlighted that telemedicine could increase access to healthcare, especially to the rural and underserved, even after the pandemic. Practitioners also expressed an interest in continuing to volunteer with the network if the need arose again. CONCLUSION: Our study findings suggest that practitioners are highly intrinsically motivated to volunteer during large healthcare emergencies and beyond to address the healthcare needs of the underserved. Following the recommendations presented in the study, telemedicine networks can more successfully engage and maintain volunteer practitioners. Volunteer-based telemedicine networks have the potential to bridge shortages of health personnel in resource-constrained settings both in times of crises and beyond.

Health service utilization, perspectives, and health-seeking behavior for maternal and child health services in the Amazon of Peru, a mixed-methods study.

BACKGROUND: Various factors influence health service utilization at the community level. Research on the barriers to uptake of local health services is essential to reduce maternal and child mortality and morbidity. The Amazon region of Peru has some of the poorest health indicators in the country. The current study set out to better understand the health-seeking behavior and perspectives of mothers in Amazonian communities, exploring individual- and contextual-level barriers for seeking care at local health facilities for common maternal and child health issues. METHODS: The study employed a mixed-methods design by conducting 50 structured interviews with mothers of children under the age of 4. The study took place in 5 communities in Loreto, Peru. The quantitative data was analyzed with descriptive statistics to identify participants' socio-demographic characteristics and reported utilization of health services. The qualitative data was analyzed in three rounds: inductive codebook development, application of the codebook, and thematic synthesis to contextualize the quantitative results and better understand the perspectives of the mothers regarding maternal and child health issues and the local health services. RESULTS: Overall, reported health service utilization among study participants was relatively high. However, the mothers identified several individual- and contextual-level factors that may affect their experiences and the health-seeking behaviors of other mothers in their communities: (i) embarrassment, fear, and trust, (ii) insufficient number and poor attitudes of health personnel, (iii) limited supply of basic medicines and materials in the health facility, and (iv) low demand for family planning services and limited awareness of adolescent-specific services. CONCLUSION: Several findings in the current study reflect the reduced conditions of health services, while others display that many mothers maintain a positive outlook on the health services available to them and are proactive in the care of their child. The study provides valuable insight into the use of local health services and the common perspectives that are hindering further uptake at the community level in the Amazon of Peru, with important implications for health policy.

Knowledge, attitudes, and practices regarding cystic echinococcosis and sheep herding in Peru: a mixed-methods approach.

BACKGROUND: The parasitic disease, cystic echinococcosis (CE), is prevalent in low-income, livestock-raising communities and 2000 new people will be diagnosed this year in South America alone. The disease usually passes from livestock to dogs to humans, making it a zoonotic disease and part of the One Health Initiative. Control of CE has been infamously difficult; no endemic areas of South America have succeeded in maintaining sustainable eradication of the parasite. For the current study, we aimed to gain a better understanding of the knowledge, attitudes, and practices of rural sheep farmers and other community leaders regarding their sheep herding practices and perspectives about a control program for CE. We also hope to identify potential barriers and opportunities that could occur in a control program. The authors conducted Knowledge, Attitude and Practices (KAP) surveys and semi-structured interviews in rural communities in the highlands of Peru. The KAP surveys were administered to 51 local shepherds, and the semi-structured interviews were administered to 40 individuals, including shepherds, community leaders, and health care providers. RESULTS: We found that the shepherds already deworm their sheep at a median of 2 times per year (N = 49, range 2-4) and have a mean willingness-to-pay of U.S. $ 0.60 for dog dewormer medication (N = 20, range = 0.00- $2.00 USD). We were not able to learn the deworming agent or agents that were being used, for neither sheep nor dogs. Additionally, 90% of shepherds slaughter their own sheep (N = 49). We also learned that the main barriers to an effective control program include: lack of education about the cause and control options for CE, accessibility to the distant communities and sparse grazing pastures, and a lack of economic incentive. CONCLUSIONS: Findings suggest it may be feasible to develop an effective CE control program which can be used to create an improved protocol to control CE in the region.

An mHealth tool for community health workers to improve caregiver knowledge of child health in the Amazon: An effectiveness-implementation hybrid evaluation.

When community health workers (CHWs) are effective, they can teach healthy child rearing practices in their communities and improve child health and development outcomes. An effective mHealth tool can improve the capacity of CHWs to transmit knowledge to caregivers. This article evaluates the implementation of an mHealth tool in a CHW program in the Amazon of Peru. The intervention was designed, implemented, and evaluated with the guidance of multiple implementation science tools. A Hybrid Type 3 evaluation design was used to test the effectiveness of the implementation strategies and appropriateness of the intervention. The implementation outcomes: acceptability, adoption, dosage, and fidelity were analyzed with mixed methods approach to determine if the intervention was successfully installed in the CHW program. The service outcome, knowledge scores, was analyzed with an independent samples t-test and one way ANOVA to determine the effect of the program. The implementation strategies resulted in high degrees of acceptability, adoption, and fidelity of the mHealth tool. The surveillance component of the mHealth tools was not adequately adopted. The group of caregivers that received home visits with the mHealth tool (N = 48) had significantly higher knowledge scores (+1.26 standard deviations) than those in the control group (N = 138) (t(184) = -4.39, p<0.001). The COVID-19 pandemic significantly decreased the dosage of the intervention received by the participants. The CHEST App intervention is a promising tool to improve the capacity of CHWs during their home visits. Trial registered with ISRCTN on 11/29/2018 at https://doi.org/10.1186/ISRCTN43591826.

Dietary intake, intestinal infection, and safe drinking water among children with anemia in Peru: a cross-sectional analysis.

BACKGROUND: Anemia is a major public health concern that is present in 41.7% of children under 5 worldwide. The prevalence of anemia in Peru was 43.6% in 2017, a decrease by only 6.8% in 8 years. Despite great efforts made by the government to reduce anemia by distributing free multi-micronutrient supplements and promote the consumption of iron rich foods, progress has been slow. The current study sought to better understand why the prevalence remains high by analyzing the dietary intake, incidence of intestinal infectious disease, and access to safe drinking water by children with anemia in Peru. METHODS: A cross-sectional analysis was conducted using data from two national surveys that were combined by child ID. Descriptive statistics was analyzed to understand the experience of children with anemia in comparison to child without anemia. Logistic multivariate regression analyses were conducted to test the associations between anemia and dietary intake, intestinal infection, and access to safe drinking water. RESULTS: The sample included 586 children between 6 and 35 months. The prevalence of anemia in this population was 53%. The portion of children that consumed sufficient iron to meet the recommendation for their age was 62%. Of the children with anemia, 52% consumed sufficient iron to meet their recommendation, vs. 72% of children without anemia (p < 0.001). The children with anemia were more likely to have an intestinal infection during the previous year (35% vs. 26%, p = 0.057) and less likely to have access to safe drinking water (77% vs. 86%, p = 0.002) than those without anemia. The logistic analysis revealed that having an intestinal infection increased the odds of having anemia (OR = 1.64, CI 95% [1.041-2.584]), and having access to safe drinking waters decreased the odds of having anemia (OR = 0.578, [0.334-0.998]). CONCLUSIONS: More than half of the children with anemia in Peru already consume sufficient iron to meet their daily requirement. However, they continue to have anemia, likely due to intestinal infection, such as diarrhea and parasites, from a lack of access to safe drinking water and hygienic practices.