Drivers of child marriage in specific settings of Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia - findings from the Yes I Do! baseline study.

BACKGROUND: Child marriage persists in many countries and has severe impacts on health, education, economic and social status of girls. Child marriage has many interlinked causes. This study aimed to explore the drivers of child marriage in specific contexts in Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia. METHODS: The study combined a household survey among youth (15-24 years) with focus group discussions and interviews conducted with youth (15-24 years) and parents. A variety of community stakeholders were interviewed as well. Logistic regression was done to explore associations between individual and family-level characteristics of young women and the occurrence of child marriage. Transcripts were analysed using an inductive approach. Narratives on the main drivers of child marriage across study contexts were written and inspired by the theory of normative spectrum. RESULTS: A lack of education was associated with the occurrence of child marriage in Ethiopia, Kenya and Zambia. In all countries, teenage pregnancy was associated with child marriage. In Ethiopia, Kenya and Mozambique, fathers' education seemed a protective factor for child marriage. Narratives of study participants showed that in Ethiopia, Indonesia and (to a lesser extent) Kenya, child marriage was perceived as an 'appropriate practice' to avoid premarital sex or pregnancy, whether it involved sex with or without consent. In all countries, child marriage was driven by difficult economic circumstances, which were often intertwined with disapproved social circumstances, in particular teenage pregnancy, in case of Kenya, Malawi, Mozambique and Zambia. These circumstances made child marriage an 'acceptable practice'. Some youth, particularly in Indonesia, made their own choices to marry early, making child marriage a 'possible practice'. CONCLUSIONS: Multiple intersecting drivers, which were present in different degrees in each country setting, influenced the occurrence of child marriage. We found that child marriage is a manifestation of social norms, particularly related to girls' sexuality, which are intersecting with other factors at individual, social, material, and institutional level - most prominently poverty or economic constraints. Child marriage was, in some cases, a result of girls' agentic choices. Efforts to prevent child marriage need to take these realities of girls and their families into account.

Being dragged into adulthood? Young people's agency concerning sex, relationships and marriage in Malawi, Mozambique and Zambia.

This study aimed to explore how young people exercise agency in rural Malawi, Mozambique and Zambia in relation to sex, relationships and marriage, to inform local programmes aiming to prevent teenage pregnancy and child marriage. In each country, focus group discussions with young people and parents, in-depth interviews with young people and a variety of other participants, and a household survey with young people (15-24 years) were conducted. We found that (child) marriage was often a response to teenage pregnancy, which was highly prevalent in all study areas. Young people's aspirations to enter adulthood were influenced by their life circumstances. Initiation ceremonies symbolised the transition to adulthood and gave social endorsement to young people to start engaging in (often unprotected) sexual activity. Given the uncertain socio-economic context, resource constraints led families to marry off their daughters; or girls themselves to marry early to relieve the burden on their families, but also to get pregnant as a 'next step' towards adulthood. Transactional sex was common. These intersecting cultural, social and economic contextual factors constrained young women's agency, more as compared to young men. However, young women did manoeuvre within contextual constraints to exercise a degree of agency.

Exploring barriers to the use of formal maternal health services and priority areas for action in Sidama zone, southern Ethiopia.

BACKGROUND: In 2015 the maternal mortality ratio for Ethiopia was 353 per 100,000 live births. Large numbers of women do not use maternal health services. This study aimed to identify factors influencing the use of maternal health services at the primary health care unit (PHCU) level in rural communities in Sidama zone, south Ethiopia in order to design quality improvement interventions. METHODS: We conducted a qualitative study in six woredas in 2013: 14 focus group discussions (FGDs) and 44 in-depth interviews with purposefully selected community members (women, male, traditional birth attendants, local kebele administrators), health professionals and health extension workers (HEWs) at PHCUs. We digitally recorded, transcribed and thematically analysed the interviews and FGDs using Nvivo. The 'three delay model' informed the analytical process and discussion of barriers to the use of maternal health services. RESULTS: Lack of knowledge on danger signs and benefits of maternal health services; cultural and traditional beliefs; trust in TBAs; lack of decision making power of women, previous negative experiences with health facilities; fear of going to an unfamiliar setting; lack of privacy and perceived costs of maternal health services were the main factors causing the first delay in deciding to seek care. Transport problems in inaccessible areas were the main contributing factor for the second delay on reaching care facilities. Lack of logistic supplies and equipment, insufficient knowledge and skills and unprofessional behaviour of health workers were key factors for the third delay in accessing quality care. CONCLUSIONS: Use of maternal health services at the PHCU level in Sidama zone is influenced by complex factors within the community and health system. PHCUs should continue to implement awareness creation activities to improve knowledge of the community on complications of pregnancy and benefits of maternal health services. The health system has to be responsive to community's cultural norms and practices. The mangers of the woreda health office and health centres should take into account the available budgets; work on ensuring the necessary logistics and supplies to be in place at PHCU.

Performance of community health workers: situating their intermediary position within complex adaptive health systems.

Health systems are social institutions, in which health worker performance is shaped by transactional processes between different actors.This analytical assessment unravels the complex web of factors that influence the performance of community health workers (CHWs) in low- and middle-income countries. It examines their unique intermediary position between the communities they serve and actors in the health sector, and the complexity of the health systems in which they operate. The assessment combines evidence from the international literature on CHW programmes with research outcomes from the 5-year REACHOUT consortium, undertaking implementation research to improve CHW performance in six contexts (two in Asia and four in Africa). A conceptual framework on CHW performance, which explicitly conceptualizes the interface role of CHWs, is presented. Various categories of factors influencing CHW performance are distinguished in the framework: the context, the health system and intervention hardware and the health system and intervention software. Hardware elements of CHW interventions comprise the supervision systems, training, accountability and communication structures, incentives, supplies and logistics. Software elements relate to the ideas, interests, relationships, power, values and norms of the health system actors. They influence CHWs' feelings of connectedness, familiarity, self-fulfilment and serving the same goals and CHWs' perceptions of support received, respect, competence, honesty, fairness and recognition.The framework shines a spotlight on the need for programmes to pay more attention to ideas, interests, relationships, power, values and norms of CHWs, communities, health professionals and other actors in the health system, if CHW performance is to improve.

Health surveillance assistants as intermediates between the community and health sector in Malawi: exploring how relationships influence performance.

BACKGROUND: There is increasing global interest in how best to support the role of community health workers (CHWs) in building bridges between communities and the health sector. CHWs' intermediary position means that interpersonal relationships are an important factor shaping CHW performance. This study aimed to obtain in-depth insight into the facilitators of and barriers to interpersonal relationships between health surveillance assistants (HSAs) and actors in the community and health sector in hard-to-reach settings in two districts in Malawi, in order to inform policy and practice on optimizing HSA performance. METHODS: The study followed a qualitative design. Forty-four semi-structured interviews and 16 focus group discussions were conducted with HSAs, different community members and managers in Mchinji and Salima districts. Data were recorded, transcribed, translated, coded and thematically analysed. RESULTS: HSAs had relatively strong interpersonal relationships with traditional leaders and volunteers, who were generally supportive of their work. From the health sector side, HSAs linked to health professionals and managers, but found them less supportive. Accountability structures at the community level were not well-established and those within the health sector were executed irregularly. Mistrust from the community, volunteers or HSAs regarding incentives and expectations that could not be met by "higher levels" undermined support structures and led to demotivation and hampered performance. Supervision and training were sometimes a source of mistrust and demotivation for HSAs, because of the perceived disinterest of supervisors, uncoordinated supervision and favouritism in selection of training participants. Rural HSAs were seen as more disadvantaged than HSAs in urban areas. CONCLUSIONS: HSAs' intermediary position necessitates trusting relationships between them and all actors within the community and the health sector. There is a need to improve support and accountability structures that facilitate communication and dialogue, increase trust and manage expectations and thereby improve interpersonal relationships between HSAs and actors in the community and health sector. This would maximize the value of HSAs' unique intermediary position and support them to deliver equitable health services. This is particularly important in rural areas, where HSAs often constitute the only point of contact with health services, yet report limited support from the health system.

Costs and cost-effectiveness of community health workers: evidence from a literature review.

OBJECTIVE: This study sought to synthesize and critically review evidence on costs and cost-effectiveness of community health worker (CHW) programmes in low- and middle-income countries (LMICs) to inform policy dialogue around their role in health systems. METHODS: From a larger systematic review on effectiveness and factors influencing performance of close-to-community providers, complemented by a supplementary search in PubMed, we did an exploratory review of a subset of papers (32 published primary studies and 4 reviews from the period January 2003-July 2015) about the costs and cost-effectiveness of CHWs. Studies were assessed using a data extraction matrix including methodological approach and findings. RESULTS: Existing evidence suggests that, compared with standard care, using CHWs in health programmes can be a cost-effective intervention in LMICs, particularly for tuberculosis, but also - although evidence is weaker - in other areas such as reproductive, maternal, newborn and child health (RMNCH) and malaria. CONCLUSION: Notwithstanding important caveats about the heterogeneity of the studies and their methodological limitations, findings reinforce the hypothesis that CHWs may represent, in some settings, a cost-effective approach for the delivery of essential health services. The less conclusive evidence about the cost-effectiveness of CHWs in other areas may reflect that these areas have been evaluated less (and less rigorously) than others, rather than an actual difference in cost-effectiveness in the various service delivery areas or interventions. Methodologically, areas for further development include how to properly assess costs from a societal perspective rather than just through the lens of the cost to government and accounting for non-tangible costs and non-health benefits commonly associated with CHWs.

A qualitative assessment of health extension workers' relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance.

BACKGROUND: Health extension workers (HEWs) in Ethiopia have a unique position, connecting communities to the health sector. This intermediary position requires strong interpersonal relationships with actors in both the community and health sector, in order to enhance HEW performance. This study aimed to understand how relationships between HEWs, the community and health sector were shaped, in order to inform policy on optimizing HEW performance in providing maternal health services. METHODS: We conducted a qualitative study in six districts in the Sidama zone, which included focus group discussions (FGDs) with HEWs, women and men from the community and semi-structured interviews with HEWs; key informants working in programme management, health service delivery and supervision of HEWs; mothers; and traditional birth attendants. Respondents were asked about facilitators and barriers regarding HEWs' relationships with the community and health sector. Interviews and FGDs were recorded, transcribed, translated, coded and thematically analysed. RESULTS: HEWs were selected by their communities, which enhanced trust and engagement between them. Relationships were facilitated by programme design elements related to support, referral, supervision, training, monitoring and accountability. Trust, communication and dialogue and expectations influenced the strength of relationships. From the community side, the health development army supported HEWs in liaising with community members. From the health sector side, top-down supervision and inadequate training possibilities hampered relationships and demotivated HEWs. Health professionals, administrators, HEWs and communities occasionally met to monitor HEW and programme performance. Expectations from the community and health sector regarding HEWs' tasks sometimes differed, negatively affecting motivation and satisfaction of HEWs. CONCLUSION: HEWs' relationships with the community and health sector can be constrained as a result of inadequate support systems, lack of trust, communication and dialogue and differing expectations. Clearly defined roles at all levels and standardized support, monitoring and accountability, referral, supervision and training, which are executed regularly with clear communication lines, could improve dialogue and trust between HEWs and actors from the community and health sector. This is important to increase HEW performance and maximize the value of HEWs' unique position.

How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature.

BACKGROUND: Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors intersect to influence CHW performance. A systematic review with a narrative analysis was conducted to identify contextual factors influencing performance of CHWs. METHODS: We searched six databases for quantitative, qualitative, and mixed-methods studies that included CHWs working in promotional, preventive or curative primary health care services in LMICs. We differentiated CHW performance outcome measures at two levels: CHW level and end-user level. Ninety-four studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programmes. Thematic coding was conducted and evidence on five main categories of contextual factors influencing CHW performance was synthesized. RESULTS: Few studies had the influence of contextual factors on CHW performance as their primary research focus. Contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were community factors that influenced CHW performance. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes. CONCLUSIONS: Research on CHW programmes often does not capture or explicitly discuss the context in which CHW interventions take place. This synthesis situates and discusses the influence of context on CHW and programme performance. Future health policy and systems research should better address the complexity of contextual influences on programmes. This insight can help policy makers and programme managers to develop CHW interventions that adequately address and respond to context to optimise performance.

How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana.

District Health Management Teams (DHMTs) are often entry points for the implementation of health interventions. Insight into decision-making and power relationships at district level could assist DHMTs to make better use of their decision space. This study explored how district-level health system decision-making is shaped by power dynamics in different decentralised contexts in Ghana, Malawi and Uganda. In-depth interviews took place with national- and district-level stakeholders. To unravel how power dynamics influence decision-making, the Arts and Van Tatenhove (2004) framework was applied. In Ghana and Malawi, the national-level Ministry of Health substantially influenced district-level decision-making, because of dispositional power based on financial resources and hierarchy. In Uganda and Malawi, devolution led to decision-making being strongly influenced by relational power, in the form of politics, particularly by district-level political bodies. Structural power based on societal structures was less visible, however, the origin, ethnicity or gender of decision-makers could make them more or less credible, thereby influencing distribution of power. As a result of these different power dynamics, DHMTs experienced a narrow decision space and expressed feelings of disempowerment. DHMTs' decision-making power can be expanded through using their unique insights into the health realities of their districts and through joint collaborations with political bodies.

Factors influencing the scale-up of public health interventions in low- and middle-income countries: a qualitative systematic literature review.

To achieve universal health coverage, the scale-up of high impact public health interventions is essential. However, scale-up is challenging and often not successful. Therefore, a systematic review was conducted to provide insights into the factors influencing the scale-up of public health interventions in low- and middle-income countries (LMICs). Two databases were searched for studies with a qualitative research component. The GRADE-CERQual approach was applied to assess the confidence in the evidence for each key review finding. A multi-level perspective on transition was applied to ensure a focus on vertical scale-up for sustainability. According to this theory, changes in the way of organizing (structure), doing (practice) and thinking (culture) need to take place to ensure the scale-up of an intervention. Among the most prominent factors influencing scale-up through changes in structure was the availability of financial, human and material resources. Inadequate supply chains were often barriers to scale-up. Advocacy activities positively influenced scale-up, and changes in the policy environment hindered or facilitated scale-up. The most outstanding factors influencing scale-up through changes in practice were the availability of a strategic plan for scale-up and the way in which training and supervision was conducted. Furthermore, collaborations such as community participation and partnerships facilitated scale-up, as well as the availability of research and monitoring and evaluation data. Factors influencing scale-up through a change in culture were less prominent in the literature. While some studies articulated the acceptability of the intervention in a given sociocultural environment, more emphasis was placed on the importance of stakeholders feeling a need for a specific intervention to facilitate its scale-up. All identified factors should be taken into account when scaling up public health interventions in LMICs. The different factors are strongly interlinked, and most of them are related to one crucial first step: the development of a scale-up strategy before scaling up.

Does supportive supervision enhance community health worker motivation? A mixed-methods study in four African countries.

Supportive supervision is an important element of community health worker (CHW) programmes and is believed to improve CHW motivation and performance. A group supervision intervention, which included training and mentorship of supervisors, was implemented in Ethiopia, Kenya, Malawi and Mozambique. In three of the countries, this was combined with individual and/or peer supervision. A mixed-methods implementation study was conducted to assess the effect of the supervision intervention on CHWs' perceptions of supervision and CHW motivation-related outcomes. In total, 153 in-depth interviews were conducted with CHWs, their supervisors and managers. In addition, questionnaires assessing perceived supervision and motivation-related outcomes (organizational and community commitment, job satisfaction and conscientiousness) were administered to a total of 278 CHWs pre- and post-intervention, and again after 1 year. Interview transcripts were thematically analysed using a coding framework. Changes in perceived supervision and motivation-related outcomes were assessed using Friedman's ANOVA and post hoc Wilcoxon signed-rank tests. Interview participants reported that the supervision intervention improved CHW motivation. In contrast, the quantitative survey found no significant changes for measures of perceived supervision and inconsistent changes in motivation-related outcomes. With regard to the process of supervision, the problem-solving focus, the sense of joint responsibilities and team work, cross-learning and skill sharing, as well as the facilitating and coaching role of the supervisor, were valued. The empowerment and participation of supervisees in decision making also emerged in the analysis, albeit to a lesser extent. Although qualitative and quantitative findings differed, which could be related to the slightly different focus of methods used and a 'ceiling effect' limiting the detection of observable differences from the survey, the study suggests that there is potential for integrating supportive group supervision models in CHW programmes. A combination of group with individual or peer supervision, preferably accompanied with methods that assess CHW performance and corresponding feedback systems, could yield improved motivation and performance.

There Is Much to Learn When You Listen: Exploring Citizen Engagement in High- and Low-Income Countries.

The need for engaging citizens in healthcare policy making is critical, and different approaches are gaining traction internationally. However, citizen engagement seems more difficult to implement in low- and middle-income countries because of political, practical and cultural reasons. Despite this, countries such as India, Malawi, Tanzania, Ethiopia, Rwanda, Mozambique, Egypt have initiated community engagement initiatives, which are contextually unique, and can be used as examples to learn from for the future. Overall, community voices need to play a bigger role in forming policy; they hold the key to improve health and forward growth. Evidence needs to move out of communities and districts through broader communication and knowledge translation avenues to influence and shape national and global level policies and strategies.

Optimising the benefits of community health workers' unique position between communities and the health sector: A comparative analysis of factors shaping relationships in four countries.

Community health workers (CHWs) have a unique position between communities and the health sector. The strength of CHWs' relationships with both sides influences their motivation and performance. This qualitative comparative study aimed at understanding similarities and differences in how relationships between CHWs, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and CHWs' relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between CHWs and the health sector resulted in weaker relationships between CHWs and communities. The broader context (such as the socio-economic situation) and programme context (related to, for example, task-shifting, volunteering and supervision) in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust CHW programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling CHWs to perform well and responding to the opportunities offered by their unique intermediary position.

Motivation of health surveillance assistants in Malawi: A qualitative study.

BACKGROUND: Motivation of health workers is a critical component of performance and is shaped by multiple factors. This study explored factors that influence motivation of health surveillance assistants (HSAs) in Malawi, with the aim of identifying interventions that can be applied to enhance motivation and performance of HSAs. METHODS: A qualitative study capturing the perspectives of purposively selected participants was conducted in two districts: Salima and Mchinji. Participants included HSAs, health managers, and various community members. Data were collected through focus group discussions (n = 16) and in-depth interviews (n = 44). The study sample was comprised of 112 women and 65 men. Qualitative data analysis was informed by existing frameworks on factors influencing health worker motivation. RESULTS: Our analysis identified five key themes shaping HSA motivation: salary, accommodation, human resource management, supplies and logistics, and community links. Each of these played out at different levels-individual, family, community, and organisational-with either positive or negative effects. Demotivating factors related primarily to the organisational level, while motivating factors were more often related to individual, family, and community levels. A lack of financial incentives and shortages of basic supplies and materials were key factors demotivating HSAs. Supervision was generally perceived as unsupportive, uncoordinated, and top-down. Most HSAs complained of heavy workload. Many HSAs felt further recognition and support from the Ministry of Health, and the development of a clear career pathway would improve their motivation. CONCLUSIONS: Factors shaping motivation of HSAs are complex and multilayered; experiences at one level will impact other levels. Interventions are required to enhance HSA motivation, including strengthening the supervision system, developing career progression pathways, and ensuring clear and transparent incentives. HSAs have unique experiences, and there is need to hear and address these to better enable HSAs to cope with the challenging conditions they work in.

Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review.

Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review.A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance.When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.