"As minhas famílias": gênero, trabalho de cuidados e produção de subjetividades na atuação de mulheres agentes comunitárias de saúde / "My families": gender, care work and production of subjectivities by female community health agents

O presente estudo teve como objetivo compreender como se configuram relações entre gênero e trabalho de cuidado na produção de subjetividade de mulheres agentes comunitárias de saúde. Trata-se de uma pesquisa de abordagem qualitativa, construída com base em aportes teóricos dos estudos de gênero e da psicologia social do trabalho. Realizaram-se entrevistas com cinco mulheres que atuavam em um município do sul de Santa Catarina e as declarações obtidas foram analisadas pelo método de análise temática por meio de um processo que possibilitou a construção de três categorias temáticas: "as participantes em seus territórios de trabalho: relações e responsabilidades", indicando que o território de atuação se constitui como possibilidade de reconhecimento profissional, responsabilização e criação de vínculos; "gênero e trabalho de cuidado: entre o público e o privado", evidencia que o trabalho da agente comunitária de saúde é marcado pelo gênero; e, por fim, "é cansativo, mas eu gosto: o paradoxo do trabalho", categoria que aponta que os sentidos atribuídos ao trabalho são paradoxais, pois relataram realização profissional e, ao mesmo tempo, adoecimento físico e psíquico

This study examines how gender and care work are interrelated by female community health agents in the production of subjectivity. Qualitative in nature, based on theoretical contributions from gender studies and the social psychology of work, the research conducted interviews with five women working in a municipality in Southern Santa Catarina. All statements underwent thematic analysis, resulting in three thematic categories: "the participants in their work territories: relationships and responsibilities", indicating that the performance territory constitutes a possibility of professional recognition, accountability and creation of bonds; "gender and care work: between the public and the private", shows that the work of the community health worker is marked by gender; and, finally, "it's tiring, but I like it: the paradox of work", a category that points out that the meanings attributed to work are paradoxical, as they reported professional achievement and, at the same time, physical and psychological illness

Elaboration and psychometric analysis of a questionnaire to evaluate the knowledge of community health workers about breastfeeding / Elaboração e análise psicométrica de um questionário para avaliar o conhecimento de agentes comunitários de saúde sobre amamentação

Abstract Objectives: to develop and analyze the psychometric properties of a questionnaire to assess community health workers' knowledge on breastfeeding. Methods: this is a methodological study for the development of an instrument and analysis of validity and reliability. For the elaboration of items and identification of dimensions, a literature review was conducted. The items were submitted to the evaluation of a committee of judges, for apparent and content analysis. Construct validation was conducted through hypothesis test, with the participation of 282 community health workers and 19 pediatricians and obstetric nurses. For analysis and comparison of scores, the Mann-Whitney U test was used, assuming a significance level of 5%. Reliability was assessed using Cronbach's alpha coefficient and temporal consistency of the instrument was assessed using test-retest and Kappa analysis. Results: the final instrument presented a favorable opinion from the committee of judges. The hypothesis test showed that the questionnaire has discriminatory power to assess professionals with a higher level of knowledge (p<0.001). The Kappa test revealed that 63% of the items showed substantive to almost perfect agreement. The 32-item questionnaire showed a Cronbach's alpha of 0.794. Conclusion: the instrument developed was valid and reliable, allowing effective measurement of community health workers' knowledge on breastfeeding.

Resumo Objetivos: elaborar e analisar propriedades psicométricas de um questionário para avaliação do conhecimento de agentes comunitários de saúde sobre amamentação. Métodos: trata-se de estudo metodológico de elaboração de instrumento e análise de validade e confiabilidade. Para a elaboração dos itens e identificação das dimensões, realizou-se revisão da literatura. Os itens foram submetidos à apreciação de comitê de juízes, para análise aparente e de conteúdo. A validação de construto foi conduzida pelo teste de hipóteses, com participação de 282 agentes comunitários de saúde e 19 pediatras e enfermeiras obstetras. Para comparação dos escores, utilizou-se o teste U de Mann-Whitney, assumindo-se um nível de significância de 5%. A confiabilidade foi aferida por meio do coeficiente alfa de Cronbach e a consistência temporal do instrumento por meio do teste-reteste e análise de Kappa. Resultados: o instrumento final apresentou parecer favorável do comitê de juízes. O teste de hipóteses evidenciou que o instrumento tem poder discriminatório para aferir profissionais com maior nível de conhecimento (p<0,001). O teste Kappa revelou que 63% dos itens apresentaram concordância de substantiva a quase perfeita. O questionário, com 32 itens, apresentou um alfa de Cronbach de 0,794. Conclusão: o instrumento apresentou-se válido e confiável que permitirá mensurar de forma eficaz o conhecimento de agentes comunitários de saúde sobre amamentação.

HPV-associated oropharyngeal cancer: Knowledge and attitude/beliefs among non-clinical staff at community-based HIV/AIDS Service Organizations (ASO) in the south United States (U.S.) census region.

This study describes knowledge and attitude/beliefs about HPV-associated oropharyngeal cancer among non-clinical staff, at community-based HIV/AIDS Service Organizations (ASOs) located in the Southern U.S. states of South Carolina and Texas. It also explores the difference in knowledge and attitude/beliefs between Texas-based (n = 21) and South Carolina-based (n = 30) ASO staff. The ASOs in our study provide comprehensive HIV prevention, supportive and care services to individuals living with HIV/AIDS or at risk for HIV/AIDS, through partnerships and collaborations. We collected data from the two Texas-based ASOs in 2018 and the three South Carolina-based ASOs in 2016 via a 118-item, self-administered needs assessment survey. Data were analysed using Stata/SE 15.1. Over half the study participants were females (59%), black (78%), heterosexual (61%) and mean age (years) 44.2 ± 12.8 SD. Most participants (73%) believed that quitting smoking positively impacts health. Alarmingly though, only 32% were aware about HPV as a risk factor for oropharyngeal cancer, and over half (53%) were unsure about the success of the HPV vaccine in preventing oropharyngeal cancer. In addition, there were no statistically significant differences observed in the oropharyngeal cancer-related knowledge and attitudes/beliefs, between ASOs in Texas and South Carolina. ASO staff work closely with people living with HIV (PLWH), who are disproportionately affected by HPV-associated cancers. The low/poor knowledge and attitudes/beliefs regarding the role of HPV in causing oropharyngeal cancer ascertain the need for equipping community health workers with adequate education/training that improves their knowledge and attitudes/beliefs about the role of HPV in causing various forms of cancer.

A violência contra a criança e o adolescente na perspectiva de agentes comunitários da saúde / Violence against children and adolescents in the perspective of community health agents / La violencia contra el niño y el adolescente en la perspectiva de agents comunitarios de la salud

A violência intrafamiliar é aquela praticada por familiares, constituindo-se em grave violação dos direitos da criança e do adolescente. O objetivo desse estudo foi investigar se Agentes Comunitários de Saúde (ACS) reconhecem sinais de violência intrafamiliar, se fazem notificação, se conhecem fatores de risco e proteção e se na sua formação receberam informações sobre essas temáticas. Participaram do estudo 119 ACS que responderam três questionários. Constatou-se que os conhecimentos sobre sinais de violência, em especial, de violência sexual e psicológica, sobre notificação, sobre fatores de risco e proteção e sobre práticas parentais e habilidades sociais infantis deveriam fazer parte de cursos de capacitação dos ACS, bem como de toda a Equipe de Saúde, pelo fato de atuarem cotidianamente com as famílias no território. Conclui-se que os ACS não tiveram acesso aos conhecimentos produzidos pela psicologia do desenvolvimento infantil que poderiam orientar sua ação protetiva e preventiva junto às famílias (AU).

Domestic violence is normally practiced by relatives, constituted in serious violation of the rights of the child and the adolescent. The objective of this study was to investigate whether Community Health Agents (CHA) recognize signs of intra-family violence, if they make the notification, if they know risk and protection factors and if in their training they received information about these issues. A total of 119 ACS respond to three questionnaires. We found that knowledge about signs of violence, especially sexual and psychological violence, about notification, about risk and protection factors, and about parental practices and children's social skills should be part of CHA training courses, as well as the Health Team, because they work with families on a daily basis. It is concluded that the ACS did not have access to the knowledge produced by the child development psychology that could guide their protective and preventive action with the families (AU).

La violencia intrafamiliar es aquella practicada por familiares, constituido en grave violación de los derechos del niño y del adolescente. El objetivo de este estudio fue investigar si los Agentes Comunitarios de Salud (ACS) reconocen señales de violencia intrafamiliar, se hacen notificación, si conocen factores de riesgo y protección y si en su formación recibieron informaciones sobre esas temáticas. En este estudio 119 ACS respondieran a tres cuestionarios. Se constató que los conocimientos sobre señales de violencia, en especial, de violencia sexual y psicológica, notificación, factores de riesgo y protección, prácticas parentales y habilidades sociales infantiles deberían formar parte de cursos de capacitación de los ACS, así como de todo el equipo de salud, por el hecho de actuaren cotidianamente con las familias. Se concluye que los ACS no tuvieron acceso a los conocimientos da psicología del desarrollo que podrían orientar su acción proyectiva y preventiva junto a las familias (AU).

Getting more than "claps": incentive preferences of voluntary community-based mobilizers in Tanzania.

BACKGROUND: Marie Stopes Tanzania works with a voluntary cadre of 66 community-based mobilizers (CBMs), who are tasked with raising awareness, generating demand and providing referral to potential clients for family planning, comprehensive post-abortion care and cervical cancer screening. CBMs extend the reach of urban clinics to peri-urban communities, enhancing access to sexual and reproductive health services. In an effort to optimize performance of CBMs, a study was conducted to explore the drivers of CBM motivation and inform the design of an incentive scheme. METHODS: Three focus group discussions with 17 CBMs and 11 interviews with CBM supervisors and managers were conducted in three clinics and the head office. After thematic analysis of transcripts, findings on motivational factors were discussed in a reflection workshop and informed the development of a discrete choice experiment (DCE) involving 61 CBMs as respondents. The DCE included eight choice questions on two incentive schemes, each consisting of five attributes related to remuneration, training, supervision, benefits and identification. For each attribute, different incentive options were presented, based on the outcomes of the qualitative assessment. The DCE results were analysed using conditional logistic regression. RESULTS: A variety of factors motivated CBMs. Most CBMs were motivated to conduct their work because of an intrinsic desire to serve their community. The most mentioned extrinsic motivational factors were recognition from the community and supervisors, monthly allowance, availability of supporting materials and identification, trainings, supervision and feedback on performance. Recommendations for improvement were translated into the DCE. Incentive attributes that were found to be significant in DCE analysis (p < 0.05), in preference order, were carrying an ID card, bi-monthly training, supervision conducted via both monthly meetings at clinics and visits from the head office, and a monthly flat rate remuneration (over pay for performance). CONCLUSION: Despite the recognition that being a CBM is voluntary, incentives, especially those of non-financial nature, are important motivators. Incentive schemes should include basic compensation with a mix of other incentives to facilitate CBMs' work and enhance their motivation. Programme designs need to take into account the voices of community-based workers, to optimize their performance and service delivery to communities they serve.

Supporting hearing health in vulnerable populations through community care workers using mHealth technologies.

Objective: Access to hearing care is challenging in low- and middle-income countries, where the burden of hearing loss is greatest. This study investigated a community-based hearing screening programme using smartphone testing by community care workers (CCWs) in vulnerable populations infected or affected by HIV. Experiences of CCWs were also surveyed. Design: The study comprised two phases. Phase one employed a cross-sectional research design to describe the community-based programme. Phase two was a survey design to describe CCW's knowledge and experiences. Study Sample: Fifteen trained CCWs administered hearing screenings on 511 participants during home-based visits using a validated smartphone application (hearScreen™) during phase one. Diagnostic follow-up assessments included evaluation using the smartphone test (hearTest™), otoscopy and tympanometry. Phase two surveyed the 15 CCW screening experiences. Results: Referral rates for adults and children were 5.0% and 4.2%, respectively. 75.0% of referred participants returned for follow-up diagnostic assessments, 33.3% were diagnosed with hearing loss and referred for further intervention. All 15 CCWs agreed that communities needed hearing services and only 6.6% did not want to continue providing hearing screening. Conclusion: Trained CCWs can decentralise hearing services to vulnerable communities using smartphone screening incorporating automated testing and measures of quality control.

Effectiveness of a health belief model intervention using a lay health advisor strategy on mouth self-examination and cancer screening in remote aboriginal communities: A randomized controlled trial.

OBJECTIVE: Oral cancers caused by chewing betel nuts have a poor prognosis. Using a lay health advisor (LHA) can increase access to health care among underprivileged populations. This study evaluated a health belief model (HBM) intervention using LHAs for oral cancer screening (OCS) and mouth self-examination (MSE) in remote aboriginal communities. METHODS: The participants were randomly assigned to intervention (IG; n = 171) and control groups (CG; n = 176). In the IG, participants received a three-chapter one-on-one teaching course from LHAs, whereas those in the CG received only a leaflet. RESULTS: The IG participants were 2.04 times more likely to conduct a monthly MSE than those in the CG (95% confidence interval: 1.31-3.17) and showed significantly higher self-efficacy levels toward OSC and MSE (ß = 0.53 and 0.44, effect size = 0.33 and 0.25, respectively) and a lower barrier level for OSC (ß = -1.81, effect size = -0.24). CONCLUSION: The LHA intervention had a significantly positive effect on MSE, strengthening self-efficacy and reducing barriers to OCS among aboriginal populations. PRACTICE IMPLICATIONS: The effectiveness of the clinical treatment of underprivileged group can be improved through early diagnosis, which can be achieved using LHAs to reduce barriers to OSC.

Understanding behaviour change in context: examining the role of midstream social marketing programmes.

This research examines how midstream social marketing programmes that adopt a relational and community-based approach create opportunities for individuals to make incremental changes to health behaviour. Specifically, it applies Bourdieusian theory to explore how interactions between community healthcare workers (CHWs) and members of the public generate impetus for change and foster individual agency for improved health. Qualitative interviews were carried out with members of the public and CHWs engaged in a Smokefree home and cars initiative. The findings suggest that although CHWs are challenged by resource constraints, their practices in working with individuals and families build trust and enable dialogue that bridges smoking-related health insight with home logics. These interactions can promote individual agency with a transformative effect through small changes to smoking-related dispositions, norms and practices. However, tensions with the habitus of other household members and other capital deficits can inhibit progress towards embedding new practices. The study concludes that interventions built upon community relationships show potential for addressing limitations of information-focused campaigns but there is a need to also respond to key social structures relating to the field of action for new health dispositions to become embedded in practice.

HIV testing in a large community health center serving a multi-cultural patient population: A qualitative study of providers.

In the United States, 15% of HIV-positive individuals do not know their HIV serostatus. While CDC guidelines recommend HIV testing for individuals age 13-64 years, racial and ethnic minorities continue to experience delays in HIV diagnosis. We assessed providers' perspectives on HIV testing at an urban community health center serving racial/ethnic minority populations of low socioeconomic status. We conducted five focus groups from January 2017 to November 2017 with 74 health center staff: 20 adult medicine/primary care providers, 34 community health workers (CHWs) and community health administrators, six urgent care physicians, and fourteen behavioral health providers. Study staff analyzed transcripts using a grounded theory approach and used open coding to develop themes. We identified five themes affecting HIV testing: 1) provider perception of patients' preferences for HIV testing; 2) competing medical and social issues; 3) inter-professional communication; 4) knowledge of clinical indicators for HIV testing; and 5) knowledge of frequency of HIV testing. Primary care physicians desired mechanisms to easily identify patients for HIV testing and assistance with testing for non-English speakers. Training to improve comfort with HIV testing, integrating CHWs into routine practice, and focusing on patients' cultural beliefs may increase HIV testing in diverse community health centers..

Lay Advisor Interventions in Rural Populations: A Systematic Review and Meta-analysis.

CONTEXT: Age-adjusted death rates for heart disease are higher in rural areas than in urban areas. Lay advisors could potentially facilitate improvement in cardiovascular health outcomes. The aim of this systematic review and meta-analysis is to estimate lay advisor intervention effects on cardiovascular health metrics in rural populations. EVIDENCE ACQUISITION: Searches of databases including MEDLINE, CINAHL, and Scopus from 1975 through October 2017 retrieved 323 citations, of which 272 abstracts were reviewed. Two authors independently abstracted data from eligible studies. Analysis was conducted in March 2018. EVIDENCE SYNTHESIS: Of 21 articles included in the systematic review, eight were RCTs and 13 were pre- and post-intervention studies. Of the RCTs, three took place in the U.S. Only two studies had low risk of bias. Using a random effects model, meta-analysis of six RCTs (1,641 participants) showed that lay advisor interventions in rural residents were associated with improvement in HbA1c of 0.4% (95% CI=0.13, 0.66, p=0.004, I2=60.65%). From four RCTs (873 participants), lay advisor interventions significantly improved BMI with pooled effect of 2.18 (95% CI=1.13, 3.24, p<0.001, I2=0.00%). Most studies had normal baseline blood pressure and cholesterol levels before intervention, and no significant effects were noted for these outcomes. Diverse types of measures used for diet, physical activity, and smoking precluded statistical synthesis. CONCLUSIONS: Lay advisor interventions had significant positive effects on glycemic control and BMI for rural residents; however, further rigorous studies are needed in U.S. rural populations, and elements of effective lay advisor interventions require further investigation.

Introducing post-discharge malaria chemoprevention (PMC) for management of severe anemia in Malawian children: a qualitative study of community health workers' perceptions and motivation.

BACKGROUND: Severe malarial anaemia is one of the leading causes of paediatric hospital admissions in Malawi. Post-discharge malaria chemoprevention (PMC) is the intermittent administration of full treatment courses of antimalarial to children recovering from severe anaemia and findings suggest that this intervention significantly reduces readmissions and deaths in these children. Community delivery of health interventions utilizing community health workers (CHWs) has been successful in some programmes and not very positive in others. In Malawi, there is an on-going cluster randomised trial that aims to find the optimum strategy for delivery of dihydroartemesinin-piperaquine (DHP) for PMC in children with severe anaemia. Our qualitative study aimed to explore the feasibility of utilizing CHWs also known as health surveillance assistants (HSAs) to remind caregivers to administer PMC medication in the existing Malawian health system. METHODS: Between December 2016 and March 2018, 20 individual in-depth-interviews (IDIs) and 2 focus group discussions (FGDs) were conducted with 39 HSAs who had the responsibility of conducting home visits to remind caregivers of children who were prescribed PMC medication in the trial. All interviews were conducted in the local language, transcribed verbatim, and translated into English. The transcripts were uploaded to NVIVO 11 and analysed using the thematic framework analysis method. RESULTS: Although intrinsic motivation was reportedly high, adherence to the required number of home visits was very poor with only 10 HSAs reporting full adherence. Positive factors for adherence were the knowledge and perception of the effectiveness of PMC and the recognition from the community as well as health system. Poor training, lack of supervision, high workload, as well as technical and structural difficulties; were reported barriers to adherence by the HSAs. CONCLUSIONS: Post-discharge malaria chemoprevention with DHP is perceived as a positive approach to manage children recovering from severe anaemia by HSAs in Malawi. However, adherence to home visit reminders was very poor and the involvement of HSAs in a scale up of this intervention may pose a challenge in the existing Malawian health system. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02721420 . The trial was registered on 26 March 2016.

Adopción e implementación del ofrecimiento de la autotoma VPH por agentes sanitarios en Jujuy, Argentina / Adoption and implementation of HPV self-collection sampling by CHWs in Jujuy, Argentina

Resumen: Objetivo: Evaluar la adopción e implementación en escala de la estrategia orientada a ofrecer puerta a puerta la autotoma de la prueba del virus del papiloma humano (AT-VPH), por parte de agentes sanitarios (AS), en Jujuy, Argentina. Material y métodos: Se aplicó una encuesta autoadministrada a 478 AS. Las dimensiones de adopción e implementación fueron evaluadas con el modelo RE-AIM. Resultados: Adopción: 81.8% de los AS ofreció la AT-VPH y 86.4% expresó gratificación con la estrategia. Implementación: los problemas encontrados fueron la demora en la entrega de tubos (61.3%) y resultados (70.0%); falta de recursos humanos (28.3%), y dificultades al obtener turnos para realizar el triage (26.1%). El principal obstáculo fue la sobrecarga de trabajo (50.2%), mientras que la capacitación (38.0%) y el listado de mujeres a contactar (28.7%) fueron los elementos facilitadores. Conclusiones: La adopción de la AT-VPH fue alta entre los AS. Deben reforzarse las estrategias programáticas para motivar a los AS y reducir su carga de trabajo al implementar la AT-VPH.

Abstract: Objective: To evaluate adoption and implementation of scaling up of HPV self-collection (SC) strategy offered door-to-door by Community Health Workers (CHWs) in Jujuy, Argentina. Materials and methods: A self-administered questionnaire was applied to 478 CHWs. RE-AIM model was used to evaluate adoption and implementation dimensions. Results: Adoption: 81.8% offered SC and 86.4% were satisfied with the strategy. Implementation: main problems were delays in the delivery of tubes (61.3%) and results (70.0%), lack of human resources (28.3%) and difficulties in obtaining an appointment for triage (26.1%). The main obstacle was the excessive workload of CHWs (50.2%). Training (38.0%) and the list of women to be offered the test (28.7%) were identified as facilitators. Conclusions: The adoption of SC strategy was high among CHWs. Program strategies should be strengthened to motivate and reduce the excessive workload of CHWs when implementing SC strategy.

[Adoption and implementation of HPV self-collection sampling by CHWs in Jujuy, Argentina]. / Adopción e implementación del ofrecimiento de la autotoma VPH por agentes sanitarios en Jujuy, Argentina.

OBJECTIVE: To evaluate adoption and implementation of scaling up of HPV self-collection (SC) strategy offered doorto-door by Community Health Workers CHWs) in Jujuy, Argentina. MATERIALS AND METHODS: A self-administered questionnaire was applied to 478 CHWs.RE-AIM model was used to evaluate adoption and implementation dimensions. RESULTS: Adoption:81.8% offered SC and 86.4% were satis- fied with the strategy. Implementation: main problems were delays in the delivery of tubes (61.3%) and results (70.0%), lack of human resources (28.3%) and difficulties in obtaining an appointment for triage (26.1%). The main obstacle was the excessive workload of CHWs (50.2%).Training (38.0%) and the list of women to be offered the test (28.7%) were identified as facilitators. CONCLUSIONS: The adoption of SC strategy was high among CHWs.Program strategiesshould be strengthened to motivate and reduce the excessive workload of CHWs when implementing SC strategy.

OBJETIVO: Evaluar la adopción e implementación en escala de la estrategia orientada a ofrecer puerta a puerta la autotoma de la prueba del virus del papiloma humano (AT-VPH),por parte de agentessanitarios(AS),en Jujuy,Argentina. MATERIAL Y MÉTODOS: Se aplicó una encuesta autoadministrada a 478 AS. Las dimensiones de adopción e implementación fueron evaluadas con el modelo RE-AIM. RESULTADOS: Adopción: 81.8% de los AS ofreció la AT-VPH y 86.4% expresó gratificación con la estrategia. Implementación: los problemas encontrados fueron la demora en la entrega de tubos (61.3%) y resultados (70.0%); falta de recursos humanos (28.3%), y dificultades al obtener turnos para realizar el triage (26.1%). El principal obstáculo fue la sobrecarga de trabajo (50.2%), mientras que la capacitación (38.0%) y el listado de mujeres a contactar (28.7%) fueron los elementos facilitadores. CONCLUSIONES: La adopción de la AT-VPH fue alta entre los AS. Deben reforzarse las estrategias programáticas para motivar a los AS y reducir su carga de trabajo al implementar laAT-VPH.

Effectiveness of SMS Technology on Timely Community Health Worker Follow-Up for Childhood Malnutrition: A Retrospective Cohort Study in sub-Saharan Africa.

BACKGROUND: The Millennium Villages Project facilitated technology-based health interventions in rural under-resourced areas of sub-Saharan Africa. Our study examined whether data entry using SMS compared with paper forms by community health workers (CHWs) led to higher proportion of timely follow-up visits for malnutrition screening in under-5 children in Ghana, Rwanda, Senegal, and Uganda. METHODS: Children under 5 years were screened for malnutrition every 90 days by CHWs using mid-upper arm circumference (MUAC) readings. CHWs used either SMS texts or paper forms to enter MUAC data. Reminder texts were sent at 15 days before follow-up was needed. Chi-square tests assessed proportion of timely follow-up visits within 90 days between SMS and paper groups. Logistic regression analysis was conducted in a step-wise multivariate model. Post-hoc power calculations were conducted to verify strength of associations. RESULTS: SMS data entry was associated with a higher proportion of timely malnutrition follow-up visits compared with paper forms across all sites. The association was strongest with consistent SMS use over consecutive visits. SMS use at the first of 2 consecutive visits was most effective, highlighting the importance of SMS reminder alerts. CONCLUSIONS: SMS technology with reminders increased timely CHW malnutrition screening visits for under-5 children in Ghana, Rwanda, Senegal, and Uganda, highlighting the importance of such technology for improving health worker behavior in low-resource settings.

Healthcare providers' understanding of HIV serodiscordance in South Africa and Uganda: implications for HIV prevention in sub-Saharan Africa.

HIV transmission within stable heterosexual HIV serodiscordant couples accounts for almost half the new incident infections in South Africa and Uganda. Advances in HIV prevention provide opportunities to reduce transmission risk within serodiscordant partnerships (e.g., antiretroviral treatment (ART), pre-exposure prophylaxis (PrEP), medical male circumcision, and couples-based HIV counselling and testing). These interventions require a clinical encounter with a provider who recognises prevention opportunities within these partnerships. We explored healthcare provider understanding of HIV serodiscordance in a reproductive counselling study with providers in eThekwini district, South Africa, and Mbarara district, Uganda. In eThekwini, in-depth interviews (29) and focus group discussions (2) were conducted with 42 providers (counsellors, nurses and doctors) from public sector clinics. In Mbarara, in-depth interviews were conducted with 38 providers (medical officers, clinical officers, nurses, peer counsellors and village health workers). Thematic analysis was conducted using NVivo software. In eThekwini, many providers assumed HIV seroconcordance among client partners and had difficulty articulating how serodiscordance occurs. Mbarara providers had a better understanding of HIV serodiscordance. In the two countries, providers who understood HIV serodiscordance were better able to describe useful HIV-prevention strategies. Healthcare providers require training and support to better understand the prevalence and mechanisms of HIV serodiscordance to implement HIV-prevention strategies for HIV serodiscordant couples.

Community health worker interventions to promote psychosocial outcomes among people living with HIV-A systematic review.

BACKGROUND: Community health worker (CHW) interventions are a successful strategy to promote health among HIV-negative and persons living with HIV (PLWH). Psychosocial factors are critical dimensions of HIV/AIDS care contributing to prognosis of the disease, yet it is unclear how CHW interventions improve psychosocial outcomes in PLWH. The purpose of this study was to critically appraise the types, scope, and nature of CHW interventions designed to address psychosocial outcomes in PLWH. METHODS: We performed database searches-PubMed, EMBASE, CINAHL, and Cochrane-to identify randomized controlled trials published in English before April 2017. Fourteen articles met the eligibility criteria. RESULTS: Half of the studies were conducted in the United States. Social cognitive theory was used more than once in nine theory-guided studies. CHW interventions were largely focused on reducing depression (n = 6) or stigma related to HIV (n = 4), or promoting quality of life (n = 4), social support (n = 4), and self-efficacy (n = 4). Didactic methods and role-playing were used to train CHWs. CHWs played multiple roles in delivering intervention, including a counselor and a supporter (n = 10), educator (n = 5), or a navigator (n = 3). CHW intervention fidelity was assessed in 4 studies. Five studies found positive changes in six psychosocial outcomes including quality of life (2 of 4) and self-efficacy (2 of 4). CHW interventions had no effect on social support in 2 of 4 studies, and stigma in 3 of 4 studies. None of the CHW interventions were successful in reducing depressive symptoms among PLWH. CONCLUSIONS: Evidence partially supported the use of CHWs in promoting psychosocial outcomes in PLWH. Future CHW intervention should be expanded in scope to address key psychosocial determinants of HIV/AIDS outcomes such as health literacy. Further, fidelity measures should be incorporated into intervention delivery.

The acceptability and feasibility of lay-health led interventions for the prevention and early detection of cancer.

BACKGROUND: US-based evidence suggests that lay-health worker (LHW) interventions can increase awareness around cancer risk-related lifestyles, symptom recognition, and screening programme uptake. The suitability of LHW interventions in the UK and the potential barriers and facilitators for implementation is currently unknown. This study explored the acceptability and feasibility of developing LHW interventions for cancer prevention, screening, and early diagnosis. METHODS: Purposive sampling recruited 5 separate lay groups: (1) completed cancer treatment; (2) friends/family of cancer patients; (3) cancer hospital volunteers; (4) cancer charity volunteers; and (5) members of the public. Audio-recorded focus groups and semi-structured interviews were transcribed for thematic analysis using framework matrices. RESULTS: Forty-one people (66% female, aged 23-84 years) participated. Three main themes are reported: (1) scope of LHW roles, with a clear remit embedded within communities or primary care practices; (2) defining LHW tasks, with a focus on supporting people overcome barriers including lack of cancer symptom knowledge and non-attendance at screening; and (3) clear boundaries, with LHW training and on-going support from healthcare staff seen as key for intervention success. All groups were uncomfortable about having lifestyle-related risk conversations and potentially inflicting guilt. The post-treatment group expressed less concern about the possible emotional impact of discussing cancer symptoms, compared with the other groups. CONCLUSIONS: LHW interventions to promote early diagnosis or screening were generally considered acceptable in a UK context. LHW interventions focussing on reducing cancer risk may be less feasible.

Perceived barriers to early detection of breast cancer in Wakiso District, Uganda using a socioecological approach.

BACKGROUND: Early detection of breast cancer is known to improve its prognosis. However, women in most low and middle income countries, including Uganda, do not detect it early hence present at an advanced stage. This study investigated the perceived barriers to early detection of breast cancer in Wakiso district, Uganda using a multilevel approach focused through a socioecological framework. METHODS: Using qualitative methods, participants were purposively selected to take part in the study. 5 semi-structured interviews were conducted among the community members while two focus groups were conducted amongst women's group and community health workers (CHWs) in Ssisa sub county, Wakiso district. In addition, 7 key informant interviews with health professionals, policy makers and public health researchers were carried out. RESULTS: Findings from the study revealed that barriers to early detection of breast cancer are multifaceted and complex, cutting across individual, interpersonal, organizational, community and policy barriers. The major themes that emerged from the study included: knowledge, attitudes, beliefs and practices (KABP); health system and policy constraints; and structural barriers. Prominent barriers associated with KABP were low knowledge, apathy, fear and poor health seeking behaviours. Barriers within the health systems and policy arenas were mostly centred around competing health care burdens within the country, lack of a cancer policy and weak primary health care capacity in Wakiso district. Distance, poverty and limited access to media were identified as the most prominent structural barriers. CONCLUSION: Barriers to early detection of breast cancer are complex and go beyond individual behaviours. These barriers interact across multiple levels of influence such as organizational, community and policy. The findings of this study could provide opportunities for investment in multi-level interventions.

Commune Health Workers' Methadone Maintenance Treatment (MMT) Knowledge and Perceived Difficulties Providing Decentralized MMT Services in Vietnam.

BACKGROUND: With the initial establishment of countrywide methadone maintenance therapy (MMT) system, Vietnam is in the process of expanding and decentralizing the MMT program to community-based healthcare settings. OBJECTIVE: The study aimed to measure the MMT-related knowledge and perceived difficulties in treating patient who use drugs (PWUD) among community-based healthcare providers, e.g., commune health workers (CHW), and examine its correlated factors. METHODS: A total of 300 CHW from 60 communes in two provinces of Vietnam completed a survey using Audio Computer-Assisted Self-Interview (ACASI) method. Twelve true-or-false questions were used to assess the CHW's MMT-related knowledge. The CHW's background characteristics and perceived difficulties treating PWUD were recorded. RESULTS: The mean MMT knowledge score was 8.2 (SD = 1.2; range: 5-11). Misconceptions toward the benefits, procedure, and side effects of MMT were prevalent. The participants perceived varying degrees of difficulties in recruiting, engaging, and communicating with PWUD. With all covariates holding constant, younger age (standardized ẞ = -0.166; p = 0.0078) was associated with less MMT-related knowledge. Number of PWUD seen in a month and MMT-related knowledge was associated with less perceived difficulties treating PWUD. Conclusions/importance: The finding shed lights on the CHW's knowledge gap, which need to be addressed to facilitate the decentralization of MMT services in Vietnam. In preparation for a decentralized MMT service delivery model, specially designed training is warranted to equip CHW with knowledge and confidence to provide MMT-related services to PWUD.

Desafios às práticas de redução de danos na atenção primária à saúde / Desafíos a las prácticas de reducción de daños en la atención primaria a la salud / Challenges to harm reduction practices in primary health care

RESUMO. Este estudo teve por objetivo analisar os saberes e práticas dos Agentes Comunitários de Saúde (ACS), direcionados a usuários de álcool e outras drogas à luz da estratégia de redução de danos. Como característica específica do público deste estudo, foram escolhidos ACS que participaram do curso Caminhos do Cuidado. Utilizando-se o método qualitativo, foram realizadas entrevistas semiestruturadas como fonte de coleta de dados e análise de conteúdo para a sistematização dos achados. Os dados demonstraram que mesmo aqueles profissionais que relatavam conhecer o conceito de redução de danos e a possibilidade de utilizar esta abordagem para o cuidado de usuários de álcool e outras drogas no contexto da Atenção Primária à Saúde (APS), não conseguem ofertar cuidados que se aproximem desta estratégia. Isto ocorre uma vez que os entrevistados não respeitam a liberdade de escolha, pautam-se no proibicionismo e no ideal de abstinência. Esta dificuldade prática em desenvolver o cuidado, baseado nesta abordagem, se relaciona com a percepção moralizante sobre o uso de drogas, sua associação ao crime e o foco na possibilidade de se extinguir o uso de drogas nas sociedades.

RESUMEN. Este estudio tuvo como objetivo analizar los saberes y prácticas de Agentes Comunitarios de Salud (ACS) frente a usuarios de sustancias psicoactivas y la estrategia de reducción de daños. Fueron elegidos ACS que participaron del curso "Caminhos do Cuidado". A partir de una perspectiva cualitativa se realizaron entrevistas semiestructuradas, la información obtenida fue análisis de contenido con el fin de sistematizar los resultados. Los datos demostraron que a pesar de que los profesionales relaten conocer el concepto de reducción de daños y la posibilidad de utilizar esta estrategia para el cuidado de usuarios de sustancias psicoactivas en el contexto de Atención Primaria en Salud (APS) no logran ofrecer cuidados que se acerquen de esta estrategia. Esto sucede principalmente cuando los ACS no respetan la libertad de elección de los usuarios, se centran en el prohibicionismo y en el ideal de abstinencia. Esta dificultad para efectuar el cuidado con base en la reducción de daños se relaciona con una percepción moralista acerca del uso de drogas, asociando el consumo con el delito, además de destacar la posibilidad de erradicar el uso de drogas en las sociedades.

ABSTRACT. This study aimed to analyze the knowledge and practices of Community Health Agents trained by the Care Pathway Project, aimed at users of alcohol and other drugs from the perspective of the Harm Reduction strategy. Data showed that even those professionals who reported knowing the concept of harm reduction and the possibility of using this approach to provide care for alcohol and other drug users in the context of Primary Health Care (PHC), they are unable to offer care as described in this strategy. This occurs because the interviewees do not respect freedom of choice, they advocate prohibitionism and the ideal of abstinence. This practical difficulty in developing care based on this approach is related to the moralizing perception about drug use, its association with crime and the focus on the possibility of extinguishing the use of drugs by societies.