"They are gaining experience; we are gaining extra hands": a mixed methods study to assess healthcare worker perceptions of a novel strategy to strengthen human resources for HIV in South Africa.

BACKGROUND: Lay health workers (LHWs) can support the HIV response by bridging gaps in human resources for health. Innovative strategies are needed to expand LHW programs in many low- and middle-income countries. Youth Health Africa (YHA) is a novel LHW approach implemented in South Africa that places young adults needing work experience in one-year non-clinical internships at health facilities to support HIV programs (e.g., as HIV testers, data clerks). While research suggests YHA can increase HIV service delivery, we need to understand healthcare worker perceptions to know if this is an acceptable and appropriate approach to strengthen human resources for health and healthcare delivery. METHODS: We conducted a convergent mixed methods study to assess healthcare worker acceptance and perceived appropriateness of YHA as implemented in Gauteng and North West provinces, South Africa and identify issues promoting or hindering high acceptability and perceived appropriateness. To do this, we adapted the Johns Hopkins Measure of Acceptability and Appropriateness to survey healthcare workers who supervised interns, which we analyzed descriptively. In parallel, we interviewed frontline healthcare workers who worked alongside YHA interns and conducted an inductive, thematic analysis. We merged quantitative and qualitative results using the Theoretical Framework of Acceptability to understand what promotes or hinders high acceptance and appropriateness of YHA. RESULTS: Sixty intern supervisors responded to the survey (91% response rate), reporting an average score of 3.5 for acceptability and 3.6 for appropriateness, on a four-point scale. Almost all 33 frontline healthcare workers interviewed reported the program to be highly acceptable and appropriate. Perceptions that YHA was mutually beneficial, easy to integrate into facilities, and helped facilities be more successful promoted a strong sense of acceptability/appropriateness amongst healthcare workers, but this was tempered by the burden of training interns and limited program communication. Overall, healthcare workers were drawn to the altruistic nature of YHA. CONCLUSION: Healthcare workers in South Africa believed YHA was an acceptable and appropriate LHW program to support HIV service delivery because its benefits outweighed its costs. This may be an effective, innovative approach to strengthen human resources for HIV services and the broader health sector.

'They can stigmatize you': a qualitative assessment of the influence of school factors on engagement in care and medication adherence among adolescents with HIV in Western Kenya.

School-related factors may influence retention in care and adherence to antiretroviral therapy (ART) among adolescents with human immunodeficiency virus (HIV). We analyzed data from in-depth interviews with 40 adolescents with HIV (aged 14 -19 years), 40 caregivers of adolescents with HIV, and 4 focus group discussions with healthcare workers to evaluate contextual factors affecting adherence to ART and clinic attendance among adolescents, with a focus on the school environment. Informed by Anderson's Model of Health Services Utilization, transcripts were systematically coded and synthesized to identify school-related themes. All groups identified the school environment as a critical barrier to engagement in HIV care and medication adherence for adolescents with HIV. Adolescent participants reported inflexible school schedules and disclosure to school staff as the biggest challenges adhering to clinic appointments and ART. Adolescents described experiencing stigma and discrimination by peers and school staff and would adjust when, where and how often they took ART to avoid inadvertent disclosure. Boarding school students faced challenges because they had limited private space or time. Caregivers were often instrumental in navigating school permissions, including identifying a treatment supporter among school staff. Additional research engaging school staff may guide interventions for schools to reduce stigma and improve adherence and retention.

Measuring for Success: Evaluating Leadership Training Programs for Sustainable Impact.

Background: In an era of global health security challenges such as the COVID-19 pandemic, there is greater need for strong leadership. Over the past decades, significant investments have been made in global health leadership development programs by governments and philanthropic organizations to address this need. Evaluating the societal impact of these programs remains challenging, despite consensus on the importance of public health leadership. Objective: This article identifies the gaps and highlights the critical role of monitoring and evaluation approaches in assessing the impact of global health leadership programs. Importantly, we also propose the theory of change (TOC) as a common framework and identify a set of tools and indicators that leadership programs can adapt and use. Methods: We carried out an informal review of major global health leadership programs, including a literature review on leadership program evaluation approaches. Current practices in assessing the short- to long-term outcomes of leadership training programs were explored and synthesized. We also examined use of program theory frameworks, such as theory of change to guide the evaluation strategy. We find the TOC approach can be enhanced by integrating evaluation-specific frameworks and establishing broad stakeholder buy-in. We highlight measurement challenges, proposed outcome indicators and evaluation methodologies, and outline the future direction for such efforts. Findings: Most evaluation of current leadership programs is focused on short-term individual-level outcomes, while reports on long-term societal impact were limited. Reciprocal impacts on and benefits for the "host" organizations were not included in evaluation metrics. Most programs had program logic or result chains, but with no well-articulated program theories. Conclusion: Key stakeholders involved in leadership training programs benefit from the evidence of rigorous program evaluations to inform decisions that address barriers in fostering global health leadership and improving population health outcomes. Insight into reciprocal change in host organizations is important. Evaluation of global health leadership training must go beyond the individual trainee and encompass organizational and community-level impacts. Documentation of long-lasting organizational and societal impacts is essential for donors to appreciate the return on their investment. Key Takeaways: Evaluation plays an important role in understanding how leadership development takes place and how it contributes to improving public health outcomes.Making the case for investments in leadership development programs requires robust evidence from monitoring and evaluation strategies that link investments beyond the individual-level to longer-term societal impacts.The first critical step towards a strategy for success is for leadership programs to clearly build, articulate, share, and use their program theories or theories of change.Theories of change help identify the pathways (and potential tensions) through which leadership development programs effect change at the individual, organizational and community levels.Evaluation methods that examine outcomes of leadership programs should be multi-method, multi-level, and where possible include counterfactual outcomes.Allocation of funds to evaluate on-going and long-lasting societal impact of leadership programs should be a routine practice.

"Our girls need to see a path to the future" --perspectives on sexual and reproductive health information among adolescent girls, guardians, and initiation counselors in Mulanje district, Malawi.

BACKGROUND: Malawi has one of the highest adolescent pregnancy rates worldwide; at 141 births/1000 girls it is 3-fold higher than the global average. Adolescent pregnancy contributes to poor maternal and neonatal outcomes, school dropout, and poverty. In preparation for an information, education, and communication (IEC) intervention to reduce unintended pregnancy among adolescent girls, formative research was conducted to understand how and what sexual and reproductive health (SRH) information is shared with girls in southern, rural Malawi, and perceptions of such information among key informants. METHODS: Forty semi-structured interviews were conducted with three participant groups: adolescent girls (n = 18), mothers/female guardians (M/FGs) of adolescent girls (n = 12), and leaders of initiation rites (n = 10). Interviews were conducted in 15 villages. Data were analyzed and coded using Dedoose 7.5. RESULTS: Participants widely acknowledged both the health risks and the general social unacceptability of early childbearing, yet adolescent pregnancy is common in the region. Respondents also acknowledged the importance of female school completion and the norm that pregnancy usually marks the end of a girl's education. Unprotected transactional sex was reported to be common and driven by poverty. Initiation rites were described as prevalent and often encourage girls to practice sex at puberty. Contraceptives, and even condoms, were reportedly discouraged for adolescents due to concerns about inappropriateness for nulliparous and young girls and misconceptions about side effects. Adolescent respondents also noted barriers to accessing condoms and contraceptives. M/FGs were described as gatekeepers to SRH information and services, and many parents reported delaying SRH discussions until after sexual debut due to concerns about encouraging sexual activity. Adolescent and M/FG participants expressed a desire for role models or "outside experts" to provide SRH education and to promote an alternate vision to adolescent motherhood. CONCLUSION: To improve SRH outcomes for adolescent girls, it is critical to engage key stakeholders and create an enabling environment so that girls can effectively act on the IEC they receive. Initiation counselors remain entrenched information sources; efforts to provide them with training on accurate SRH messaging could leverage an existing channel. Engaging parents, especially mothers, is crucial to encourage earlier SRH education and to gain their acceptance of adolescent access to SRH services. Also important is mobilizing the broader community of influencers in support of girls' SRH and vision for a healthier future. Sensitization messages focusing on the health, educational and economic benefits of preventing early pregnancy may overcome misconceptions about and barriers to contraceptive use. Finally, fostering girls' aspirations for school completion and jobs and other income generating opportunities via role models can encourage an alternative to adolescent motherhood. Ultimately, poverty and gender inequity reduction is critical for long-lasting impact on the SRH of adolescent girls in the region.

Training tomorrow's leaders in global health: impact of the Afya Bora Consortium Fellowship on the careers of its alumni.

BACKGROUND: Effective leadership is a cornerstone of successful healthcare delivery in resource limited settings throughout the world. However, few programs in Africa prepare healthcare professionals with the leadership skills vital to the success of the healthcare systems in which they work. One such program, the Afya Bora Consortium Fellowship in Global Health Leadership, has been training health professionals since 2011. The purpose of this study was to assess what career changes, if any, the Afya Bora Fellowship's alumni have experienced since completing the fellowship, and to describe those changes. METHODS: The Afya Bora Fellowship is a multidisciplinary, one-year training program that teaches health professionals leadership skills through didactic and experiential learning in four African countries. Between January 2011 and June 2013 the consortium trained 42 nurses and doctors. In November 2013, an electronic survey was sent to all alumni to assess their performance in the workplace post-fellowship. RESULTS: Thirty-one (74 %) of 42 alumni completed surveys. Twenty-one (68 %) reported changes to their position at work; of those, sixteen (76 %) believed the change was due to participation in the fellowship. All alumni reported improved performance at work, and cited the application of a wide range of fellowship skills, including leadership, research, communication, and mentoring. Twenty-six (84 %) alumni spearheaded improvements in their workplaces and almost all (97 %) remained in contact with colleagues from the fellowship. Among the respondents there were five publications, nine manuscripts in preparation, and three international conference presentations. CONCLUSIONS: Afya Bora alumni overwhelmingly reported that the one year fellowship positively influenced both their work and career trajectory. Training health professionals in leadership skills through didactic modules with the opportunity to apply learned skills at attachment sites in the Afya Bora Fellowship has an impact on performance in the workplace and the potential to improve long-term institutional capacity.

Interprofessional Fellowship Training for Emerging Global Health Leaders in Africa to Improve HIV Prevention and Care: The Afya Bora Consortium.

HIV continues to challenge health systems, especially in low- and middle-income countries in Sub-Saharan Africa. A qualified workforce of transformational leaders is required to strengthen health systems and introduce policy reforms to address the barriers to HIV testing, treatment, and other HIV services. The 1-year Afya Bora Consortium Fellowship in Global Health capitalizes on academic partnerships between African and U.S. universities to provide interprofessional leadership training through classroom, online, and service-oriented learning in 5 countries in Africa. This fellowship program prepares health professionals to design, implement, scale-up, evaluate, and lead health programs that are population-based and focused on prevention and control of HIV and other public health issues of greatest importance to African communities and health service settings. Afya Bora nurse fellows acquire leadership attributes and competencies that are continuously and systematically tested during the entire program. This multinational training platform promotes interprofessional networks and career opportunities for nurses.

Three methods of delivering clinic-based training on syndromic management of sexually transmitted diseases in South Africa: a pilot study.

INTRODUCTION: The South African National Department of Health sought to improve syndromic management of sexually transmitted infections (STIs). Continuing medical education on STIs was delivered at primary healthcare (PHC) clinics using one of three training methods: (1) lecture, (2) computer and (3) paper-based. Clinics with training were compared with control clinics. METHODS: Ten PHC clinics were randomly assigned to control and 10 to each training method arm. Clinicians participated in on-site training on six modules; two per week for three weeks. Each clinic was visited by three or four unannounced standardised patient (SP) actors pre-training and post-training. Male SPs reported symptoms of male urethritis syndrome and female SPs reported symptoms of vaginal discharge syndrome. Quality of healthcare was measured by whether or not clinicians completed five tasks: HIV test, genital exam, correct medications, condoms and partner notification. RESULTS: An average of 31% of clinicians from each PHC attended each module. Quality of STI care was low. Pre-training (n=128) clinicians completed an average of 1.63 tasks. Post-training (n=114) they completed 1.73. There was no change in the number of STI tasks completed in the control arm and an 11% increase overall in the training arms relative to the control (ratio of relative risk (RRR)=1.11, 95% CI 0.67 to 1.84). Across training arms, there was a 26% increase (RRR=1.26, 95% CI 0.77 to 2.06) associated with lecture, 17% increase (RRR=1.17, 95% CI 0.59 to 2.28) with paper-based and 13% decrease (RRR=0.87, 95% CI 0.40 to 1.90) with computer arm relative to the control. CONCLUSIONS: Future interventions should address increasing training attendance and computer-based training effectiveness. TRIAL REGISTRATION NUMBER: AEARCTR-0000668.

A framework for revising preservice curriculum for nonphysician clinicians: The mozambique experience.

Mozambique, with approximately 0.4 physicians and 4.1 nurses per 10,000 people, has one of the lowest ratios of health care providers to population in the world. To rapidly scale up health care coverage, the Mozambique Ministry of Health has pushed for greater investment in training nonphysician clinicians, Tιcnicos de Medicina (TM). Based on identified gaps in TM clinical performance, the Ministry of Health requested technical assistance from the International Training and Education Center for Health (I-TECH) to revise the two-and-a-half-year preservice curriculum. A six-step process was used to revise the curriculum: (i) Conducting a task analysis, (ii) defining a new curriculum approach and selecting an integrated model of subject and competency-based education, (iii) revising and restructuring the 30-month course schedule to emphasize clinical skills, (iv) developing a detailed syllabus for each course, (v) developing content for each lesson, and (vi) evaluating implementation and integrating feedback for ongoing improvement. In May 2010, the Mozambique Minister of Health approved the revised curriculum, which is currently being implemented in 10 training institutions around the country. Key lessons learned: (i) Detailed assessment of training institutions' strengths and weaknesses should inform curriculum revision. (ii) Establishing a Technical Working Group with respected and motivated clinicians is key to promoting local buy-in and ownership. (iii) Providing ready-to-use didactic material helps to address some challenges commonly found in resource-limited settings. (iv) Comprehensive curriculum revision is an important first step toward improving the quality of training provided to health care providers in developing countries. Other aspects of implementation at training institutions and health care facilities must also be addressed to ensure that providers are adequately trained and equipped to provide quality health care services. This approach to curriculum revision and implementation teaches several key lessons, which may be applicable to preservice training programs in other less developed countries.

Cost-effectiveness analyses of training: a manager's guide.

The evidence on the cost and cost-effectiveness of global training programs is sparse. This manager's guide to cost-effectiveness analysis (CEA) is for professionals who want to recognize and support high quality CEA. It focuses on CEA of training in the context of program implementation or rapid program expansion. Cost analysis provides cost per output and CEA provides cost per outcome. The distinction between these two analyses is essential for making good decisions about value. A hypothetical example of a cost analysis compares the cost per trainee of a computer-based anti-retroviral therapy (ART) training to a more intensive ART training. In a CEA of the same example, cost per trainee who met ART clinical performance standards is compared. The cost analysis is misleading when the effectiveness differs across trainings. Two additional hypothetical examples progress from simple to more complex costs and from a narrow to a broader scope: 1) CEA of the cost per ART patient with 95% adherence that compares the performance of doctors to counselors who attend additional training, and 2) CEA of the cost per infant HIV infection averted for a Prevention of Mother to Child Transmission program that compares the current program to one with additional training. To create an evidence base on CEA of training, more well-designed analyses and data on the cost of training are needed. Analysts should understand more about how capacity is built, how quality is improved within a health facility, and the costs associated with them. Considering the life of an investment in training, evaluations are needed on how many trainees apply the skills taught, how long trainees continue to apply them, and how long the content of the training conforms to national or international guidelines. Better data on effectiveness of training is also needed. It is feasible to measure effectiveness by clinical performance standards, or intermediate outcomes and coverage. Intermediate outcomes and coverage can also be combined with published estimates on health outcomes.

Implementation and expansion of an electronic medical record for HIV care and treatment in Haiti: an assessment of system use and the impact of large-scale disruptions.

PURPOSE: System use is a key criterion of success in an electronic medical record (EMR) implementation, and there is little research on long-term use of systems following implementation. The aim of the paper was to describe the development, implementation and use of iSanté, Haiti's national HIV care and treatment EMR. METHODS: To build a picture of the history of iSanté, we interviewed 11 staff involved with the development and implementation of the EMR, and reviewed organization records. Data entry and report use were ascertained by querying the central patient database. RESULTS: By the end of 2010 there were 67 sites with iSanté installed, and the scope of the system had been expanded to include primary care and obstetrics and gynecology. New functionality includes data forms specific to subpopulations, the ability to transfer patient records among clinics, and integration with an electronic laboratory system. We observed fluctuations in use over time, with substantial reductions in the number of active sites during times of large-scale disruptions in Haiti. A surge in report use following the January 2010 earthquake suggests that clinics found the EMR to be a valuable source of data during the recovery phase. CONCLUSION: There is real potential for EMRs in developing countries to improve clinical practice and make data available for efficient reporting, quality improvement and other population health uses. An approach of continuous system improvement, combined with regular assessments of use, is necessary for achieving an effective, national implementation of a standardized EMR. We have achieved successes in terms of rolling out new functionality and expanding to new sites, but more work remains to be done to improve perceptions of data quality and increase use of population data for accurate and timely reporting.