Sociocultural understanding of Tuberculosis and implications for care-seeking among adults in the province of Zambezia, Mozambique: Qualitative research.

INTRODUCTION: Mozambique has a high burden of Tuberculosis (TB) with an incidence of 368 per 100,000 population in 2020, coupled with a low all-form TB detection rate. The COVID-19 pandemic has exacerbated delays in timely diagnosis and treatment of new TB cases. Promoting active TB case finding is a national priority in Mozambique. We conducted qualitative research to explore factors influencing TB testing in Zambezia province in Mozambique. MATERIALS AND METHODS: One-to-one, semi-structured, audio-recorded telephone interviews were conducted to explore TB-related knowledge, and barriers and facilitators to TB testing. A sample of two TB Program staff, two community providers of TB services, and 19 community members (10 women and 9 men) was recruited, with support from provincial government TB staff, from four districts in Zambezia with a high TB burden. Interviews were transcribed verbatim, and thematic analysis was conducted. The Mozambican National Bioethics Committee for Health approved the study protocol. RESULTS: Our study highlights that knowledge about TB symptoms and its causes is low, which could delay timely TB testing. Sociocultural beliefs often implicate certain types of sexual activity and women as causes of TB symptoms; for example, having sex with a widow who has not been traditionally purified, or with a woman who has had an abortion. Therefore, people usually tend to first seek care from traditional healers instead of going to a health facility. Additionally, stigma associated with HIV and TB also delays care seeking. Gender-related disparities in TB care seeking were also evident. CONCLUSIONS: This study provides valuable insights into how healthcare seeking for TB is influenced by sociocultural understanding of symptoms and gender dynamics. Therefore, interventions to promote timely and appropriate care seeking for TB should be contextually tailored, culturally appropriate, and gender sensitive.

Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique's community health workforce.

BACKGROUND: Mozambique's community health programme has a disproportionate number of male community health workers (known as Agentes Polivalentes Elementares (APEs)). The Government of Mozambique is aiming to increase the proportion of females to constitute 60% to improve maternal and child health outcomes. To understand the imbalance, this study explored the current recruitment processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience and retention of APEs in Maputo Province, Mozambique. METHODS: We employed qualitative methods with APEs, APE supervisors, community leaders and a government official in two districts within Maputo Province. Interviews were recorded, transcribed and translated. A coding framework was developed in accordance with thematic analysis to synthesise the findings. FINDINGS: In-depth interviews (n = 30), key informant interviews (n = 1) and focus group discussions (n = 3) captured experiences and perceptions of employment processes. Intra-household decision-making structures mean women may experience additional barriers to join the APE programme, often requiring their husband's consent. Training programmes outside of the community were viewed positively as an opportunity to build a cohort. However, women reported difficulty leaving family responsibilities behind, and men reported challenges in providing for their families during training as other income-generating opportunities were not available to them. These dynamics were particularly acute in the case of single mothers, serving both a provider and primary carer role. Differences in attrition by gender were reported: women are likely to leave the programme when they marry, whereas men tend to leave when offered another job with a higher salary. Age and geographic location were also important intersecting factors: younger male and female APEs seek employment opportunities in neighbouring South Africa, whereas older APEs are more content to remain. CONCLUSION: Gender norms, roles and power dynamics intersect with other axes of inequity such as marital status, age and geographic location to impact recruitment and retention of APEs in Maputo Province, Mozambique. Responsive policies to support gender equity within APE recruitment processes are required to support and retain a gender-equitable APE cadre.

Strengthening referral systems in community health programs: a qualitative study in two rural districts of Maputo Province, Mozambique.

BACKGROUND: Effective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care. The effectiveness of referral systems in Mozambique depends on multiple factors that involve three main stakeholders: clients/community members; community health workers (CHWs); and facility-based health care workers. Each stakeholder is dependent on the other and could form either a barrier or a facilitator of referral within the complex health system of Mozambique. METHODS: This qualitative study, aiming to explore barriers and enablers of referral within the lens of complex adaptive health systems, employed 22 in-depth interviews with CHWs, their supervisors and community leaders and 8 focus group discussion with 63 community members. Interviews were recorded, transcribed and read for identification of themes and sub-themes related to barriers and enablers of client referrals. Data analysis was supported by the use of NVivo (v10). Results were summarized in narratives, reviewed, discussed and adjusted. RESULTS: All stakeholders acknowledged the centrality of the referral system in a continuum of quality care. CHWs and community members identified similar enablers and barriers to uptake of referral. A major common facilitator was the existence of referral slips to expedite treatment upon reaching the health facility. A common barrier was the failure for referred clients to receive preferential treatment at the facility, despite the presence of a referral slip. Long distances and opportunity and transport costs were presented as barriers to accessibility and affordability of referral services at the health facility level. Supervisors identified barriers related to use of referral data, rather than uptake of referral. Supervisors and CHWs perceived the lack of feedback as a barrier to a functional referral system. CONCLUSIONS: The barriers and enablers of referral systems shape both healthcare system functionality and community perceptions of care. Addressing common barriers to and strengthening the efficiency of referral systems have the potential to improve health at community level. Improved communication and feedback between involved stakeholders - especially strengthening the intermediate role of CHWs - and active community engagement will be key to stimulate better use of referral services and healthcare facilities.

Exploring competing experiences and expectations of the revitalized community health worker programme in Mozambique: an equity analysis.

INTRODUCTION: Mozambique launched its revitalized community health programme in 2010 in response to inequitable coverage and quality of health services. The programme is focused on health promotion and disease prevention, with 20 % of community health workers' (known in Mozambique as Agentes Polivalentes Elementares (APEs)) time spent on curative services and 80 % on activities promoting health and preventing illness. We set out to conduct a health system and equity analysis, exploring experiences and expectations of APEs, community members and healthcare workers supervising APEs. METHODS: This exploratory qualitative study captured the perspectives of a range of participants including women caring for children under 5 years (service clients), community leaders, service providers (APEs) and their supervisors. Participants in the Moamba and Manhiça districts, located in Maputo Province (Mozambique), were selected purposively. In total, 29 in-depth interviews and 9 focus group discussions were conducted in the local language and/or Portuguese. A framework approach was used for analysis, assisted by NVivo10 software. RESULTS: Our analysis revealed that health equity is viewed as linked to the quality and coverage of the APE programme. Demand and supply factors interplay to shape health equity. The availability of responsive and appropriate services led to tensions between community expectations for curative services (and APEs' willingness to perform them) and official policy focusing APE efforts mainly on preventive services and health promotion. The demand for more curative services by community members is a result of having limited access to healthcare services other than those offered by APEs. CONCLUSION: This study highlights the need to pay attention to the determinants of demand and supply of community interventions in health, to understand the opportunities and challenges of the difficult interface role played by APEs and to create communication among stakeholders in order to build a stronger, more effective and equitable community programme.

Supervision of community health workers in Mozambique: a qualitative study of factors influencing motivation and programme implementation.

BACKGROUND: Community health workers (CHWs) in Mozambique (known as Agentes Polivalentes Elementares (APEs)) are key actors in providing health services in rural communities. Supervision of CHWs has been shown to improve their work, although details of how it is implemented are scarce. In Mozambique, APE supervision structures and scope of work are clearly outlined in policy and rely on supervisors at the health facility of reference. The aim of this study was to understand how and which aspects of supervision impact on APE motivation and programme implementation. METHODS: Qualitative research methodologies were used. Twenty-nine in-depth interviews were conducted to capture experiences and perceptions of purposefully selected participants. These included APEs, health facility supervisors, district APE supervisors and community leaders. Interviews were recorded, translated and transcribed, prior to the development of a thematic framework. RESULTS: Supervision was structured as dictated by policy but in practice was irregular and infrequent, which participants identified as affecting APE's motivation. When it did occur, supervision was felt to focus more on fault-finding than being supportive in nature and did not address all areas of APE's work - factors that APEs identified as demotivating. Supervisors, in turn, felt unsupported and felt this negatively impacted performance. They had a high workload in health facilities, where they had multiple roles, including provision of health services, taking care of administrative issues and supervising APEs in communities. A lack of resources for supervision activities was identified, and supervisors felt caught up in administrative issues around APE allowances that they were unable to solve. Many supervisors were not trained in providing supportive supervision. Community governance and accountability mechanisms were only partially able to fill the gaps left by the supervision provided by the health system. CONCLUSION: The findings indicate the need for an improved supervision system to enhance support and motivation and ultimately performance of APEs. Our study found disconnections between the APE programme policy and its implementation, with gaps in skills, training and support of supervisors leading to sub-optimal supervision. Improved methods of supervision could be implemented including those that maximize the opportunities during face-to-face meetings and through community-monitoring mechanisms.