Do cash or digital payment modalities affect community health worker performance? - a case study of a remote refugee settlement in Western Uganda.

BACKGROUND: There is inadequate evidence about the influence of digital and cash payment modalities on the performance of Community Health Workers (CHWs) in underserved communities, such as refugee settlements. OBJECTIVE: To compare the performance of CHWs when paid in cash or digitally in Kyaka II refugee settlement, Uganda. METHODS: A comparative cross-sectional mixed methods design was used. Secondary data comprising 247 CHW reports during a six-month period of cash and digital payments were analyzed using Stata v14. Eleven focus group discussions, four in-depth interviews, and ten key informant interviews were conducted among the settlement stakeholders to explore perceptions of the payment methods. Qualitative data were analyzed thematically using Atlas.ti v9. RESULTS: CHWs performed better when paid cash than digital payments (t = 5.28; df = 246; p < 0.001). During the cash payment period, at least secondary education (APR 1.71 CI: 1.14-2.58) and having a side occupation (APR 1.58; CI: 1.13-2.21) were positively associated with performance. For digital payments, being male (APR 0.58; CI: 0.34-0.98), serving longer than 9 years (APR 0.87; CI: 0.82-0.93), and being allocated more than 60 households per month (APR 0.31; CI: 0.19-0.52) were negatively associated with CHW performance. Qualitative data revealed that most stakeholders preferred cash due to inconsistent and delayed digital payments. CONCLUSION: CHWs preferred and performed better with cash payments because digital payments were associated with delays and payment shortfalls that demotivated them. Implementers should invest towards averting digital payment shortfalls in remote settings to enhance CHW motivation and performance.

Main findings: Regarding the influence of payment modalities on Community Health Workers' performance, this study found that community health workers were motivated to perform better when paid with cash compared to digital payments.Added knowledge: Cash payments offer better reliability than digital payments in refugee settlements, which underscores the need to understand further the barriers to digital payments, particularly in hard-to-reach areas.Global health impact for policy and action: Health systems adapting to digital payments should consider a gradual transition through a hybrid approach that includes cash and digital payments while addressing the challenges associated with digital payments, especially in refugee settings and similar resource-constrained contexts.

Adoptability of digital payments for community health workers in peri-urban Uganda: A case study of Wakiso district.

BACKGROUND: Whereas digital payments have been identified as a solution to health payment challenges, evidence on their adoptability among Community Health Workers (CHWs) is limited. Understanding their adoptability is crucial for sustainability. This study assessed the adoptability of digital payments for CHWs in Wakiso district, Uganda. METHODS: A convergent parallel mixed-methods study was conducted between November and December 2022, in Wakiso district, Uganda. We surveyed a random sample of 150 CHWs using a structured questionnaire and conducted key informant interviews among three purposively selected Digital payment coordinators. The study utilized the Technology Acceptance Model (TAM) framework to assess the adoptability of digital payments among CHWs. Factor analysis was performed to extract composite variables from the original constituting variables. Using the median, the outcome was converted to a binary variable and logistic regression was conducted to assess the association between the TAM constructs and adoptability of digital payments by CHWs. Quantitative data was analyzed using STATA 14, while qualitative data was transcribed verbatim and analyzed using ATLAS.ti 22. RESULTS: Nearly all participants (98.0%; n = 49) had previously received payments through mobile money, a digital payment method. (52%; n = 78) of CHWs said they intend to use digital payment modalities. Perceived risk of digital payments was associated with 83% lower odds of adoptability of digital payment modalities (OR = 0.17;95%CI:0.052, 0.54), while perceived trust had nearly three times higher odds of adoptability of digital payment modalities (OR = 2.82;95%CI:1.41, 5.67). Qualitative interviews showed that most CHWs reported positive experiences with digital health payments, including effectiveness and completeness of payments except for delays associated with mobile money payments across payment providers. Mobile money was reported to be easy to use, in addition to fostering financial responsibility compared to cash. CONCLUSION: CHWs in Wakiso district intend to use digital payment modalities, particularly mobile money/e-cash. Perceived risk of the payment method and trust are key determinants of adoptability. Synergized efforts by both payment providers to manage payment delays and mitigate risks associated with digital payments could attenuate perceived risk and build trust in digital payment modalities.

SMART2D-development and contextualization of community strategies to support self-management in prevention and control of type 2 diabetes in Uganda, South Africa, and Sweden.

Type 2 diabetes (T2D) and its complications are increasing rapidly in low- and middle-income countries, as well as among socioeconomically disadvantaged populations in high-income countries. Support for healthy lifestyle and self-management is paramount but not well implemented in health systems, and there is need for knowledge on how to design and implement interventions that are contextualized and patient centered and address special needs of disadvantaged population groups. The SMART2D project implements and evaluates a lifestyle and self-management intervention for participants recently diagnosed with or being at increased risk for T2D in rural communities in Uganda, an urban township in South Africa, and socioeconomically disadvantaged urban communities in Sweden. Our aim was to develop an intervention with shared key functions and a good fit with the local context, needs, and resources. The intervention program design was conducted in three steps facilitated by a coordinating team: (a) situational analysis based on the SMART2D Self-Management Framework and definition of intervention objectives and core strategies; (b) designing generic tools for the strategies; and (c) contextual translation of the generic tools and their delivery. This article focuses on community strategies to strengthen support from the social and physical environment and to link health care and community support. Situational analyses showed that objectives and key functions addressing mediators from the SMART2D framework could be shared. Generic tools ensured retaining of functions, while content and delivery were highly contextualized. Phased, collaborative approach and theoretical framework ensured that key functions were not lost in contextualization, also allowing for cross-comparison despite flexibility with other aspects of the intervention between the sites. The trial registration number of this study is ISRCTN11913581.

Diabetes self-management in three different income settings: Cross-learning of barriers and opportunities.

The burden of type 2 diabetes is increasing rapidly, not least in Sub-Saharan Africa, and disadvantaged populations are disproportionally affected. Self-management is a key strategy for people at risk of or with type 2 diabetes, but implementation is a challenge. The objective of this study is to assess the determinants of self-management from an implementation perspective in three settings: two rural districts in Uganda, an urban township in South Africa, and socio-economically disadvantaged suburbs in Sweden. Data collection followed an exploratory multiple-case study design, integrating data from interviews, focus group discussions, and observations. Data collection and analysis were guided by a contextualized version of a transdisciplinary framework for self-management. Findings indicate that people at risk of or with type 2 diabetes are aware of major self-management strategies, but fail to integrate these into their daily lives. Depending on the setting, opportunities to facilitate implementation of self-management include: improving patient-provider interaction, improving health service delivery, and encouraging community initiatives supporting self-management. Modification of the physical environment (e.g. accessibility to healthy food) and the socio-cultural environment (i.e. norms, values, attitudes, and social support) may have an important influence on people's lifestyle. Regarding the study methodology, we learned that this innovative approach can lead to a comprehensive analysis of self-management determinants across different settings. An important barrier was the difficult contextualization of concepts like perceived autonomy and self-efficacy. Intervention studies are needed to confirm whether the pathways suggested by this study are valid and to test the proposed opportunities for change.

Patient and Provider Dilemmas of Type 2 Diabetes Self-Management: A Qualitative Study in Socioeconomically Disadvantaged Communities in Stockholm.

Studies comparing provider and patient views and experiences of self-management within primary healthcare are particularly scarce in disadvantaged settings. In this qualitative study, patient and provider perceptions of self-management were investigated in five socio-economically disadvantaged communities in Stockholm. Twelve individual interviews and four group interviews were conducted. Semi-structured interview guides included questions on perceptions of diabetes diagnosis, diabetes care services available at primary health care centers, patient and provider interactions, and self-management support. Data was analyzed using thematic analysis. Two overarching themes were identified: adopting and maintaining new routines through practical and appropriate lifestyle choices (patients), and balancing expectations and pre-conceptions of self-management (providers). The themes were characterized by inherent dilemmas representing confusions and conflicts that patients and providers experienced in their daily life or practice. Patients found it difficult to tailor information and lifestyle advice to fit their daily life. Healthcare providers recognized that patients needed support to change behavior, but saw themselves as inadequately equipped to deal with the different cultural and social aspects of self-management. This study highlights patient and provider dilemmas that influence the interaction and collaboration between patients and providers and hinder uptake of self-management advice.