Facilitating access to primary care for people living in socio-economically vulnerable circumstances in Belgium through community health workers: towards a conceptual model.

INTRODUCTION: Inspired by examples in low- and middle-income countries, 50 community health workers (CHWs) were introduced in Belgium to improve access to primary care for people living in socio-economically vulnerable circumstances. This article aims to explore the ways in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care. METHODS: The qualitative research focuses on the first year of implementation of this pioneer nationwide CHW programme in Belgium. To respond to the research aim, thirteen semi-structured in-depth interviews were held with people living in socio-economically vulnerable circumstances. In addition, a photovoice study was conducted with fifteen CHWs comprising four phases: (1) photovoice training; (2) participatory observation with each CHW individually; (3) an individual semi-structured in-depth interview; and (4) three focus group discussions. The transcripts and the observation notes were analysed in accordance with the abductive analysis procedures described by Timmermans and Tavory. RESULTS: The qualitative results show that the CHWs' outreaching way of working allows them to reach people living at the crossroads of different vulnerabilities that are intertwined and reinforce each other. They experience complex care needs, while at the same time they face several barriers that interrupt the continuum of access to primary care - as conceptualised in the theoretical access-to-care framework of (Levesque et al. Int J Equity Health. 12:18, 2013). Building on the theoretical access-to-care framework described by (Levesque et al. Int J Equity Health. 12:18, 2013), the conceptual model outlines first the underlying mechanisms of CHW-facilitated access to primary care: (I) outreaching and pro-active way of working; (II) building trust; (III) providing unbiased support and guidance in a culturally sensitive manner; and (IV) tailoring the CHWs' approach to the unique interplay of barriers at the individual and health system level along the access-to-care continuum as experienced by the individual. Further disentangling how CHWs provide support to the barriers in access to care across the continuum and at each step is outlined further in the process characteristics of this conceptual model. Furthermore, the qualitative results show that the way in which CHWs support people is also impacted by the broader health system, such as long waiting times and unwelcoming healthcare professionals after referral from a CHW. DISCUSSION: The conceptual model of CHW-facilitated access to primary care developed in this article explores the way in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care in Belgium. Through their outreaching method, they play a valuable bridging role between the Belgian healthcare system and people living in socio-economically vulnerable circumstances.

Global health reciprocal innovation to address mental health and well-being: strategies used and lessons learnt.

Over the past two decades there have been major advances in the development of interventions promoting mental health and well-being in low- and middle-income countries (LMIC), including delivery of care by non-specialist providers, incorporation of mobile technologies and development of multilevel community-based interventions. Growing inequities in mental health have led to calls to adopt similar strategies in high-income countries (HIC), learning from LMIC. To overcome shared challenges, it is crucial for projects implementing these strategies in different global settings to learn from one another. Our objective was to examine cases in which mental health and well-being interventions originating in or conceived for LMIC were implemented in the USA. The cases included delivery of psychological interventions by non-specialists, HIV-related stigma reduction programmes, substance use mitigation strategies and interventions to promote parenting skills and family functioning. We summarise commonly used strategies, barriers, benefits and lessons learnt for the transfer of these innovative practices among LMIC and HIC. Common strategies included intervention delivery by non-specialists and use of digital modalities to facilitate training and increase reach. Common barriers included lack of reimbursement mechanisms for care delivered by non-specialists and resistance from professional societies. Despite US investigators' involvement in most of the original research in LMIC, only a few cases directly involved LMIC researchers in US implementation. In order to achieve greater equity in global mental health and well-being, more efforts and targeted funding are needed to develop best practices for global health reciprocal innovation and iterative learning in HIC and LMIC.

Reciprocal coproduction as a basis for the diffusion of global health innovations.

Global health reciprocal innovations originate in low-income and middle-income countries as well as high-income countries before their developers communicate about them with potential adopters in other countries as a transnational team. While communication technology has enabled a more rapid and broader sharing of information about innovations to prevent disease and improve health, innovations of various types have spread among countries, at all levels of income, for many centuries. In this article, we introduce the idea of reciprocal coproduction as a basis for the international sharing of information about innovations that exhibit potential for improving global health. Reciprocal coproduction occurs through two relational team-based processes: developer-led reinvention of an innovation so that it retains its desirable causal effects and implementer-led adaptation of that innovation so that it is compatible with new contexts into which it is introduced. Drawing on research and our own experiences across a range of health issues, we discuss common barriers to reciprocal coproduction and the diffusion of reciprocal innovations. We conclude with lessons drawn from dissemination and implementation science about the effective translation of reciprocal innovations from country to country so that researchers, policy-makers and social entrepreneurs can best ensure equity, accelerate adoptions and heighten the likelihood that global health reciprocal innovations will make a positive difference in health.

Who falls between the cracks? Identifying eligible PrEP users among people with Sub-Saharan African migration background living in Antwerp, Belgium.

INTRODUCTION: This study produces an estimate of the proportion of eligible PrEP users among people of Sub-Saharan African background based on the Belgian PrEP eligibility criteria and examines associations with socio-economic and demographic characteristics. METHODS: We performed logistic regression analysis on data of a representative community-based survey conducted among Sub-Saharan African communities (n = 685) living in Antwerp. RESULTS: Almost a third (30.3%) of the respondents were eligible to use PrEP. Those who were male, single, lower educated, undocumented, and had experienced forced sex were more likely to be eligible for PrEP use. The findings highlight the importance of taking intra-, interpersonal and structural HIV risk factors into account. CONCLUSIONS: The study shows high unmet PrEP needs in this population, especially among those with high vulnerability for HIV acquisition. A better understanding of barriers to PrEP use in this population group is needed to allow for equitable access.

Factors Associated With HIV-Related Stigma Toward Colleagues in the Health Care Workforce in South Africa.

South Africa has the highest number of people living with HIV in the world, and health care workers (HCWs) are as likely to be infected as the general population. Stigma in health care settings has severe implications for HCWs and health facilities when HCWs with HIV delay or avoid seeking care, causing increased morbidity and mortality. We explored factors associated with HIV stigma toward colleagues. A representative sample of 882 HCWs from 8 hospitals was surveyed in the Free State, South Africa. We applied multigroup structural equation modeling to compare effects between 3 professional categories. In all 3 groups, there was a significant negative relationship between stigmatizing attitudes against other co-workers and knowing a colleague living with HIV, having a colleague who worked to reduce stigma in the workplace, and having basic HIV knowledge. Our results have implications for understanding and crafting interventions to reduce HIV stigma among HCWs.