"If You Don't Have the Heart to Help, You Cannot Do This Job": The Multidimensional Wellbeing of Community Health Workers Serving Refugees During the COVID-19 Pandemic.

Community health workers are members of two groups whose short- and long-term health has been uniquely shaped by the COVID-19 pandemic: health workers and the oft-marginalized populations that they serve. Yet, their wellbeing, particularly of those serving resettled refugees, before and during the pandemic has been largely overlooked. Drawing from a holistic conceptualization of wellness, this study examined the effects of the COVID-19 pandemic on a group of cultural health navigators (CHNs), who serve resettled refugees. We conducted semi-structured individual interviews with CHNs at a southwestern U.S. hospital system between July and August 2020, a critical time in the pandemic. Our analysis produced four themes that encapsulate the effects of the pandemic on CHN wellbeing: (1) "You fear for your life": Chronic risk of COVID-19 exposure takes a toll on physical, emotional, and environmental wellbeing; (2) "It is stressful because it is completely new": Uncertainty diminishes occupational, financial, and emotional wellbeing; (3) "If you don't have the heart to help, you cannot do this job": CHNs remain committed while facing challenges to their occupational wellbeing on multiple fronts; and (4) "Now, you cannot release your stress": Loss of and shifts in outlets integral to social and spiritual wellbeing. The findings deepen empirical understanding of how the pandemic affected the holistic wellbeing of CHNs, as they continued to serve their communities in a time of crisis. We discuss the implications for addressing the multidimensionality of community health worker wellbeing in research, policy, and practice.

Individual interviews versus focus groups for evaluations of international development programs: Systematic testing of method performance to elicit sensitive information in a justice study in Haiti.

Focus group discussions (FGDs) and individual interviews (IIs) with community members are common methods used in evaluations of all kinds of projects, including those in international development. As resources are often limited, evaluators must carefully choose methods that yield the best information for their particular program. A concern with FGDs and IIs is how well they elicit information on potentially sensitive topics; very little is known about differences in disclosure by methodology in the domain of justice. Using FGDs (n = 16) and IIs (n = 46) from a USAID project in Haiti, we systematically coded responses based on a shared elicitation guide around access to and engagement with the formal and informal justice systems and performed thematic and statistical comparisons across the two methods. We introduce the continuous thought as the novel standard unit for statistical comparison. Participants in IIs were statistically more likely to provide themes relevant to genderbased violence. Importantly, sensitive themes extracted in IIs (e.g., related to sexual violence, economic dimensions, and restorative justice) did not emerge in FGDs. Given these results and other limitations to the FGD, prioritizing interviews over focus group modalities may be appropriate to guide targeted, effective programming on justice or other socially sensitive topics.

Implementation and maintenance of infant dietary diversity in Zimbabwe: contribution of food and water insecurity.

BACKGROUND: Inadequate food and water resources negatively affect child health and the efficiency of nutrition interventions. METHODS: We used data from the SHINE trial to investigate the associations of food insecurity (FI) and water insecurity (WI) on mothers' implementation and maintenance of minimum infant dietary diversity (MIDD). We conducted factor analysis to identify and score dimensions of FI (poor access, household shocks, low availability & quality), and WI (poor access, poor quality and low reliability). MIDD implementation (n = 636) was adequate if infants aged 12 months (M12) ate ≥ four food groups. MIDD maintenance (n = 624) was categorized into four mutually exclusive groups: A (unmet MIDD at both M12 and M18), B (unmet MIDD at M12 only), C (unmet MIDD at M18 only), and D (met MIDD at both M12 and M18). We used multivariable-adjusted binary logistic and multinomial regressions to determine likelihood of MIDD implementation, and of belonging to MIDD maintenance groups A-C (poor maintenance groups), compared to group D, respectively. RESULTS: Low food availability & quality were negatively associated with implementation (OR = 0.81; 0.69, 0.97), and maintenance (ORB = 1.29; 1.07, 1.56). Poor water quality was positively associated with implementation (OR = 1.25; 1.08, 1.44), but inconsistently associated with maintenance, with higher odds of infants being in group C (OR = 1.39; 1.08, 1.79), and lower odds of being in group B (OR = 0.80; 0.66, 0.96). CONCLUSION: Food security should be prioritized for adequate implementation and maintenance of infant diets during complementary feeding. The inconsistent findings with water quality indicate the need for further research on WI and infant feeding.

Women's hospital birth experiences in Harar, eastern Ethiopia: a qualitative study using Roy's Adaptation Model.

OBJECTIVE: The aim of the study was to explore women's birth in public hospitals in the Harari Region of eastern Ethiopia. DESIGN: An exploratory phenomenological qualitative study design was used. SETTING: Two public hospitals (Hiwot Fana Specialized University Hospital and Jugal General Hospital). PARTICIPANTS AND METHODS: The study enrolled women who gave birth at the selected hospitals through purposive sampling. We conducted in-depth interviews with 38 women who gave birth to singleton, full-term babies via vaginal delivery (47%; n=18) or caesarean section (53%; n=20) with no pregnancy-related complications. Interviews were audio-recorded and transcribed on the spot and the interviews were analysed using a deductive content analysis approach. Data were analysed using the four components of Roy's Adaptation Model (RAM) as a guiding framework of women's experiences: physiological, self-concept, role and function, and interdependence. RESULTS: Various behaviours were identified: under physiological mode, common behaviours identified included labour pain, fatigue, surgical site pain and anaesthesia-related complication. The women's major problems in self-concept mode were concern for future pregnancy, lack of privacy, newborn health status, relationship with healthcare providers and lack of family support. Due to the prolonged hospital stay and surgical site pain, the women who were unable to care for themselves, their newborn babies and their families adapted poorly to role and function mode. Finally, women who had no family support and who got less attention from healthcare providers reported ineffective adaption for interdependence mode. CONCLUSIONS: Application of RAM principles could be used to improve care for Ethiopian women, providing an intervention framework that can gauge and respond to interacting factors that can make women vulnerable to negative birth experiences.

A Scoping Review of Social Support Research among Refugees in Resettlement: Implications for Conceptual and Empirical Research.

This study reviewed social support research with refugees in resettlement by assessing the scope of scholarship and examining methodological approaches, definitions, theoretical frameworks, domains, and sources of support. The scoping review followed a systematic approach that retained 41 articles for analysis. The findings indicate that refugee resettlement studies seldom conceptualizes social support as a central focus, defines the concept, draws from related theory, or examines multifaceted components of the construct. The review nevertheless yielded promising findings for future conceptual and empirical research. The analysis identified a wide range of relevant domains and sources of social support, laying the foundation for a socio-ecological model of social support specific to refugee experiences in resettlement. The findings also indicate an imperative to examine and theorize social support vis-à-vis diverse groups as a main outcome of interest, in connection to a range of relevant outcomes, and longitudinally in recognition of the temporal processes in resettlement.

A cross-sectional analysis of factors associated with stress, burnout and turnover intention among healthcare workers during the COVID-19 pandemic in the United States.

In 2020, healthcare workers faced the COVID-19 pandemic amidst other salient sociopolitical stressors. This study, therefore, set out to examine associations between personal, work-related and contextual factors and three outcomes - stress, burnout and turnover intention - at a critical juncture in the pandemic. In December 2020, we recruited a broad array of healthcare workers (n = 985) in a public safety net healthcare system serving socially and economically marginalised communities in the Southwest region of the United States using a cross-sectional online survey. The results indicated that more health problems were associated with higher stress and burnout symptoms. While seeking emotional support and using drugs or alcohol to cope were associated with higher stress, a positive social outlook was associated with lower stress. Lower quality of work-life was associated with higher burnout symptoms and turnover intention. Negative effects of the pandemic on wellbeing and higher number of COVID-19-related concerns were associated with higher stress and burnout symptoms. Contrary to the original hypotheses, self-care was not associated with any of the three outcomes, and effects of the political climate and issues of racism on wellbeing were not associated with stress, burnout or turnover intention. However, identifying as a Person of Colour was associated with higher stress, as well as lower burnout. The findings on worker health, social outlook, quality of work-life and race/ethnicity, in particular, suggest a critical need for healthcare systems to address the wellbeing of workers through equitable organisational policy and practice.

Growth and growth trajectory among infants in early life: contributions of food insecurity and water insecurity in rural Zimbabwe.

Introduction: Stunting or linear growth faltering, measured by length-for-age Z-score (LAZ), remains a significant public health challenge, particularly in rural low-income and middle-income countries. It is a marker of inadequate environments in which infants are born and raised. However, the contributions of household resource insecurities, such as food and water, to growth and growth trajectory are understudied. Methods: We used the cluster-randomised Sanitation Hygiene and Infant Nutrition Efficacy trial to determine the association of household-level food insecurity (FI) and water insecurity (WI) on LAZ and LAZ trajectory among infants during early life. Dimensions of FI (poor access, household shocks, low availability and quality) and WI (poor access, poor quality, low reliability) were assessed with the multidimensional household food insecurity and the multidimensional household water insecurity measures. Infant length was converted to LAZ based on the 2006 WHO Child Growth Standards. We report the FI and WI fixed effects from multivariable growth curve models with repeated measures of LAZ at 1, 3, 6, 12 and 18 months (M1-M18). Results: A total of 714 and 710 infants were included in our analyses of LAZ from M1 to M18 and M6 to M18, respectively. Mean LAZ values at each time indicated worsening linear growth. From M1 to M18, low food availability and quality was associated with lower LAZ (ß=-0.09; 95% -0.19 to -0.13). From M6 to M18, poor food access was associated with lower LAZ (ß=-0.11; 95% -0.20 to -0.03). None of the WI dimensions were associated with LAZ, nor with LAZ trajectory over time. Conclusion: FI, but not WI, was associated with poor linear growth among rural Zimbabwean infants. Specifically, low food availability and quality and poor food access was associated with lower LAZ. There is no evidence of an effect of FI or WI on LAZ trajectory.

Household Water Insecurity Affects Child Nutrition Through Alternative Pathways to WASH: Evidence From India.

BACKGROUND: Household water security matters greatly for child nutrition outcomes in the global South. Water's role in sanitation/hygiene, via diarrheal disease, is cited as a primary mechanism here. Yet, the relationship between Water along with Sanitation and Hygiene (WASH) and child stunting remains inconclusive. Water-related mechanisms outside of the traditional scope of WASH might assist with explaining this. OBJECTIVE: We aim to test the mediating role of reduced dietary diversity as an additional potential mechanism in linking worse household water access to increased risk of early childhood stunting, separating its effects from sanitation and diarrhea among children (as a proxy for hygiene) and taking into account regional water availability. METHOD: We use nationally representative India Demographic and Health Survey (2015-16) data for 58 038 children aged 6 to 23 months, applying generalized structural equation modelling to estimate water's direct and indirect effects (as mediated through dietary diversity and access to sanitation) on a child's likelihood of being stunted. RESULTS: Suboptimal water access is significantly associated with elevated likelihood of child stunting. More than 30% of the effect is indirect. In the context of low water access and availability, children's dietary diversity alone mediates more than 20% of its total effect on child stunting. CONCLUSION: Beyond the WASH mechanisms, household water access affects child stunting indirectly, mediated through its impacts on children's dietary diversity. These mediating effects are also moderated by regional water availability. Water interventions in low-water regions should help reduce children's risk of nutrition-related stunting in households with lowest water access.

"If there is no water, we cannot feed our children": The far-reaching consequences of water insecurity on infant feeding practices and infant health across 16 low- and middle-income countries.

OBJECTIVES: Infant feeding plays a critical role in child health and development. Few studies to date have examined the link between household water insecurity and infant feeding, and none in a cross-cultural context. Therefore, we examined the perceived impact of household water insecurity in four domains: breastfeeding, non-breastmilk feeding, caregiver capabilities, and infant health. Our research was conducted as part of the Household Water Insecurity Experiences (HWISE) study. METHODS: We interviewed respondents from 19 sites in 16 low- and middle-income countries (N = 3303) about the link between water insecurity and infant feeding. We then thematically analyzed their open-ended textual responses. In each of the four domains (breastfeeding, non-breastmilk feeding, caregiver capabilities, infant health), we inductively identified cross-cultural metathemes. We analyzed the distribution of themes across sites quantitatively and qualitatively. RESULTS: Water was perceived to directly affect breastfeeding and non-breastmilk feeding via numerous pathways, including timing and frequency of feeding, unclean foods, and reduced dietary diversity. Water was perceived to indirectly affect infant feeding through caregiver capabilities by increasing time demands, exacerbating disease, undernutrition, and mortality, and requiring greater efficacy of caregivers. Respondents made connections between water challenges and infant health, for example, increased risk of infectious diseases, undernutrition, and mortality. CONCLUSIONS: These findings suggest that water presents many, and sometimes unexpected, challenges to infant feeding. By systematically investigating biocultural pathways by which water impacts infant and young child feeding, it will be possible to understand if, and how, water security can be leveraged to improve child nutrition and health.

Uncovering a health and wellbeing gap among professional nurses: situated experiences of direct care nurses in two Canadian cities.

Understanding the drivers of nurses' poor health and the implications for quality of care are important in sustaining a healthy workforce, stimulating professional nursing practice, and ensuring healthy lives while promoting the wellbeing of nurses of all ages. Previous scholarship has identified factors influencing nurses' wellbeing, but have neglected to take a comprehensive approach to assessing the multiple dimensions of nurses' wellbeing and their collective, syndemic effects. Neither have these studies explored the context within which these experiences occur, or how these experiences differ for nurses with multiple marginalized identities in spite of an increasingly diverse workforce. Using the six dimensions of wellness framework, we examined the distinct and interrelated dimensions of nurses' wellbeing that were either enhanced or aggravated by professional practice and how it changed by nurses' race and ethnicity using their situated experiences. The study was conducted using a qualitative research design, which drew on phenomenology and in-depth interviews with Registered and Practical Nurses (n = 70) in two Canadian cities. Of the six dimensions of wellbeing identified, direct care practice enhanced nurses' occupational, intellectual, and spiritual wellbeing, but worsened their physical, emotional and social health. A health gap was found along racial lines, as ethnic minority nurses reported more detrimental effects of direct care nursing on their physical, emotional, occupational, and social wellbeing than their white counterparts. Nurses resorted to institutional structures, social and emotional support from supervisors, coworkers and family members, and engaged in spiritual activities to cope with these adverse health effects. These findings highlight the utility of an adaptable framework in identifying the multiple dimensions and gaps in nurses' wellbeing. Furthermore, our findings echo the urgent need for workplace and safety policies that address issues of diversity and make the work environment safe, equitable and promote nurse productivity and quality care.

Eating Pleasure in a Sample of Obese Brazilian Women: A Qualitative Report of an Interdisciplinary Intervention Based on the Health at Every Size Approach.

INTRODUCTION: Health at Every Size (HAES) is a weight-neutral approach focused on promoting healthy behaviors in people with different body sizes and on enhancing pleasure derived from consuming food to achieve sustainable healthy eating outcomes. However, to the best of our knowledge, there are no studies in the literature assessing the effects of the HAES approach on perceptions of eating pleasure. OBJECTIVE: We qualitatively investigated the perceptions of obese women about eating pleasure before and after a new interdisciplinary, nonprescriptive intervention based on the HAES approach. DESIGN: The intervention was a randomized controlled clinical trial, designated as Health and Wellness in Obesity, conducted over 7 months at University of São Paulo (Brazil). We used a qualitative approach to data construction and analysis of perceptions about eating pleasure. Participants were randomized to either the intervention (I-HAES) group or the control (CTRL) group. The I-HAES group featured individual nutritional counseling, group practice of enjoyable physical activity, and philosophical workshops. The CTRL group was a traditional HAES intervention group (lecture-based model). Focus group discussions eliciting perceptions of pleasure around eating were conducted at baseline and post-study. Focus group transcripts were analyzed by exploratory content analysis. PARTICIPANTS: Forty-three women aged 25 to 50 years with body mass index (measured in kilograms per square meter) between 30 and 39. 9 completed the intervention and the focus groups, with 32 in the I-HAES group and 11 in the CTRL group. RESULTS: Lack of guilt about experiencing pleasure while eating and increased reflection on their own desires increased in participants of both groups after the study. The I-HAES group also displayed a greater sense of autonomy related to eating, increased pleasure in commensality, familiarity with the practice of cooking, and decreased automatic eating. CONCLUSION: HAES-based intervention featuring nutritional counseling, appreciation for physical activity, and philosophical engagement was shown to stimulate pleasure around eating without leading to indiscriminate eating.

Development and validation protocol for an instrument to measure household water insecurity across cultures and ecologies: the Household Water InSecurity Experiences (HWISE) Scale.

INTRODUCTION: A wide range of water-related problems contribute to the global burden of disease. Despite the many plausible consequences for health and well-being, there is no validated tool to measure individual- or household-level water insecurity equivalently across varying cultural and ecological settings. Accordingly, we are developing the Household Water Insecurity Experiences (HWISE) Scale to measure household-level water insecurity in multiple contexts. METHODS AND ANALYSIS: After domain specification and item development, items were assessed for both content and face validity. Retained items are being asked in surveys in 28 sites globally in which water-related problems have been reported (eg, shortages, excess water and issues with quality), with a target of at least 250 participants from each site. Scale development will draw on analytic methods from both classical test and item response theories and include item reduction and factor structure identification. Scale evaluation will entail assessments of reliability, and predictive, convergent, and discriminant validity, as well as the assessment of differentiation between known groups. ETHICS AND DISSEMINATION: Study activities received necessary ethical approvals from institutional review bodies relevant to each site. We anticipate that the final HWISE Scale will be completed by late 2018 and made available through open-access publication. Associated findings will be disseminated to public health professionals, scientists, practitioners and policymakers through peer-reviewed journals, scientific presentations and meetings with various stakeholders. Measures to quantify household food insecurity have transformed policy, research and humanitarian aid efforts globally, and we expect that an analogous measure for household water insecurity will be similarly impactful.

"I try, I do": Child feeding practices of motivated, low-income parents reflect trade-offs between psychosocial- and nutrition-oriented goals.

Although there is increased focus on behavior change programs targeting parents to promote healthy child feeding, success of these programs has been limited. To close this gap, we sought to understand parents' goals for child feeding and their motivations, abilities, and contextual environment that challenged or enabled goal achievement, with a focus on parents' own childhood food experiences. We conducted semi-structured qualitative interviews (n = 21) with low-income parents of at least one child aged 3-11 years in three semi-rural counties in upstate New York to explore their emic perspectives on child feeding goals and practices. Transcripts were coded by at least two researchers using the constant comparative approach. Emergent themes were identified and interpreted in the context of the Motivation-Ability-Opportunity framework. Low-income parents articulated and were clearly motivated to achieve both nutrition- and psychosocial-oriented goals. Salient psychosocial goals (e.g., family meals to promote family relationships, help child feel secure), often led to different child feeding practices than indicated by parents' nutrition-oriented child feeding goals (e.g., nutritious diet, healthful relationship with food). Sometimes these psychosocial goals were in conflict with the nutrition-oriented goals; for example, some parents gave into child food preferences to avoid conflict or hesitated to introduce changes in diets of overweight children to preserve child self-esteem. Prominent contextual barriers included child preferences, life disruptions, and the inflexible time and financial restrictions of poverty. Parents exhibited awareness and motivation to achieve healthy eating goals but success was often thwarted by the salience of psychosocial goals that often motivated less-healthy practices. Thus, behavior change programs should acknowledge the value and relevance of both types of goals and help parents develop strategies to address the tensions between them.

Measuring community norms around women's empowerment in the West Bank: Opportunities and challenges of a novel approach using cultural consensus.

Understanding cultural norms is essential to achieving results in development interventions and preventing interventions from causing unintended negative consequences. However, capturing norms within everyday contexts in ways that can be monitored and evaluated can be expensive and time consuming and is not always feasible. We tested a novel method, the cultural consensus analysis (CCA), in the context of monitoring and evaluating a United States Agency for International Development (USAID) justice project in the West Bank, Palestine. We conducted 392 survey interviews with men and women, using 60 true or false questions in the knowledge domains of women's empowerment and gender-based violence (GBV), and tested three gender propositions using CCA. We found no singular cultural understanding of women's empowerment and GBV across West Bank Palestinians (proposition 1). Distinctive cultural models for women and other subgroups (e.g., those living in villages, women who identified as discriminated against within Palestinian society) exist, although there were no shared cultural models among men of any subgroup (proposition 2). Program assumptions regarding structural barriers to women's empowerment conformed to the women's cultural models (proposition 3). To our knowledge, this is the first application of CCA as an approach for describing gender norms in international development programming. CCA was able to distinguish subtle cultural patterns, including between population subgroups, and to identify how those are associated with specific risks, such as GBV. We conclude that CCA is a potentially useful approach for development practice, to ground-truth program assumptions and, potentially, to track program impacts.

Household water sharing: a missing link in international health.

Water insecurity massively undermines health, especially among impoverished and marginalized communities. Emerging evidence shows that household-to-household water sharing is a widespread coping strategy in vulnerable communities. Sharing can buffer households from the deleterious health effects that typically accompany seasonal shortages, interruptions of water services and natural disasters. Conversely, sharing may also increase exposure to pathogens and become burdensome and distressing in times of heightened need. These water sharing systems have been almost invisible within global health research but need to be explored, because they can both support and undermine global public health interventions, planning and policy.

"They were just waiting to die": Somali Bantu and Karen Experiences with Cancer Screening Pre- and Post-Resettlement in Buffalo, NY.

BACKGROUND: Little is known about how pre-resettlement experiences affect refugees' uptake of cancer screenings. The objective of this study was to characterize Somali Bantu and Karen experiences with cancer and cancer screenings prior to and subsequent to resettlement in Buffalo, NY in order to inform engagement by health providers. METHODS: The study was grounded in a community-based participatory research approach, with data collection and analysis guided by the Health Belief Model and life course framework. Interviews were transcribed, independently coded by two researchers, and analyzed using an immersion-crystallization approach. We conducted 15 semi-structured interviews and six interview-focus group hybrids with Somali Bantu (n = 15) and Karen (n = 15) individuals who were predominantly female (87%). RESULTS: Cancer awareness was more prevalent among Karen compared to Somali Bantu participants. Prior to resettlement, preventative health care, including cancer screening, and treatment were unavailable or inaccessible to participants and a low priority compared with survival and acute health threats. There, Somali Bantu treated cancer-like diseases with traditional medicine (heated objects, poultices), and Karen reported traditional medicine and even late-stage biomedical treatments were ineffective due to extent of progressed, late-stage ulcerated tumors when care was sought. A fatalistic view of cancer was intertwined with faith (Somali Bantu) and associated with untreated, late-stage cancer (Karen). Karen but not Somali Bantu reported individuals living with cancer were stigmatized pre-resettlement due to the unpleasant manifestations of untreated, ulcerated tumors. Now resettled in the U.S., participants reported obtaining cancer screenings was challenged by transportation and communication barriers and facilitated by having insurance and interpretation services. While Somali Bantu women strongly preferred a female provider for screenings, Karen women felt cancer severity outweighed cultural modesty concerns in terms of provider gender. SIGNIFICANCE: Our findings suggest the need for culturally-relevant cancer education that incorporates the life course experiences and addresses logistical barriers in linking individuals with screening, to be complemented by trauma-informed care approaches by healthcare providers.

Community hygiene norm violators are consistently stigmatized: Evidence from four global sites and implications for sanitation interventions.

Community sanitation interventions increasingly leverage presumed innate human disgust emotions and desire for social acceptance to change hygiene norms. While often effective at reducing open defecation and encouraging handwashing, there are growing indications from ethnographic studies that this strategy might create collateral damage, such as reinforcing stigmatized identities in ways that can drive social or economic marginalization. To test fundamental ethnographic propositions regarding the connections between hygiene norm violations and stigmatized social identities, we conducted 267 interviews in four distinct global sites (in Guatemala, Fiji, New Zealand, USA) between May 2015 and March 2016. Based on 148 initial codes applied to 23,278 interview segments, text-based analyses show that stigmatizing labels and other indices of contempt readily and immediately attach to imagined hygiene violators in these diverse social settings. Moral concerns are much more salient at all sites than disease/contagion ones, and hygiene violators are extended little empathy. Contrary to statistical predictions, however, non-empathetic moral reactions to women hygiene violators are no harsher than those of male violators. This improved evidentiary base illuminates why disgust- and shame-based sanitation interventions can so easily create unintended social damage: hygiene norm violations and stigmatizing social devaluations are consistently cognitively connected.

Performance-Based Financing Empowers Health Workers Delivering Prevention of Vertical Transmission of HIV Services and Decreases Desire to Leave in Mozambique.

BACKGROUND: Despite increased access to treatment and reduced incidence, vertical transmission of HIV continues to pose a risk to maternal and child health in sub-Saharan Africa. Performance-based financing (PBF) directed at healthcare providers has shown potential to improve quantity and quality of maternal and child health services. However, the ways in which these PBF initiatives lead to improved service delivery are still under investigation. METHODS: Therefore, we implemented a longitudinal-controlled proof-of-concept PBF intervention at health facilities and with community-based associations focused on preventing vertical transmission of HIV (PVT) in rural Mozambique. We hypothesized that PBF would increase worker motivation and other aspects of the workplace environment in order to achieve service delivery goals. In this paper, we present two objectives from the PBF intervention with public health facilities (n=6): first, we describe the implementation of the PBF intervention and second, we assess the impact of the PBF on health worker motivation, key factors in the workplace environment, health worker satisfaction, and thoughts of leaving. Implementation (objective 1) was evaluated through quantitative service delivery data and multiple forms of qualitative data (eg, quarterly meetings, participant observation (n=120), exit interviews (n=11)). The impact of PBF on intermediary constructs (objective 2) was evaluated using these qualitative data and quantitative surveys of health workers (n=83) at intervention baseline, midline, and endline. RESULTS: We found that implementation was challenged by administrative barriers, delayed disbursement of incentives, and poor timing of evaluation relative to incentive disbursement (objective 1). Although we did not find an impact on the motivation constructs measured, PBF increased collegial support and worker empowerment, and, in a time of transitioning implementing partners, decreased against desire to leave (objective 2). CONCLUSION: Areas for future research include incentivizing meaningful quality- and process-based performance indicators and evaluating how PBF affects the pathway to service delivery, including interactions between motivation and workplace environment factors.

Increasing overweight and obesity erodes engagement in one's neighborhood by women, but not men.

Obesity is socially stigmatized in the U.S., especially for women. Significant research has focused on the role that the social and built environments of neighborhoods play in shaping obesity. However, the role of obesity in shaping neighborhood social structure has been largely overlooked. We test the hypothesis that large body size inhibits an individual's engagement in his or her neighborhood. Our study objectives are to assess if (1) body size (body mass index) interacts with gender to predict engagement in one's neighborhood (neighborhood engagement) and (2) if bonding social capital interacts with gender to predict neighborhood engagement independent of body size. We used data collected from the cross-sectional 2011 Phoenix Area Social Survey (PASS), which systematically sampled residents across four neighborhood types (core urban, urban fringe, suburban, retirement) across the Phoenix Metopolitian Area. Survey data was analyzed using logistic regression for 804 participants, including 35% for whom missing data was computed using multiple imputation. We found that as body size increases, women-but not men-have reduced engagement in their neighborhood, independent of bonding social capital and other key covariates (objective 1). We did not observe the interaction between gender and bonding social capital associated with neighborhood engagement (objective 2). Prior scholarship suggests obesity clusters in neighborhoods due to processes of social, economic, and environmental disadvantage. This finding suggests bi-directionality: obesity could, in turn, undermine neighborhood engagement through the mechanism of weight stigma and discrimination.

Strengthening Care Delivery in Primary Care Facilities: Perspectives of Facility Managers on the Immunization Program in Kenya.

BACKGROUND: Primary healthcare facility managers (PHFMs) occupy a unique position in the primary healthcare system, as the only cadre combining frontline clinical activities with managerial responsibilities. Often serving as 'street-level bureaucrats,' their perspectives can provide contextually relevant information about interventions for strengthening primary healthcare delivery, yet such perspectives are under-represented in the literature on primary healthcare strengthening. Our objective in this study was to explore perspectives of PHFMs in western Kenya regarding how to leverage human resource factors to improve immunization programs, in order to draw lessons for strengthening of primary healthcare delivery. METHODS: We employed a sequential mixed methods approach. We conducted in-depth interviews with key informants in Kakamega County. Emergent themes guided questionnaire development for a cross-sectional survey. We randomly selected 94 facility managers for the survey which included questions about workload, effects of workload on immunization program, and appropriate measures to address workload effects. Participants provided self-assessment of their general motivation at work, their specific motivation to ensure that all children in their catchment areas were fully immunized, and recommendations to improve motivation. Participants were asked about frequency of supervisory visits, supervisor activities during those visits, and how to improve supervision. RESULTS: The most frequently reported consequences of high workload were reduced accuracy of vaccination records (47%) and poor client counseling (47%). Hiring more clinical staff was identified as an effective remedy to high workload (69%). Few respondents (20%) felt highly motivated to ensure full immunization coverage and only 13% reported being very motivated to execute their role as a health worker generally. Increasing frequency of supervisory visits and acting on the feedback received during those visits were mostly perceived as important measures to improve program effectiveness. CONCLUSION: Besides increasing the number of staff providing clinical care, PHFMs endorsed introducing some financial incentives contingent on specified targets and making supervisory visits meaningful with action on feedback as strategies to increase program effectiveness in primary healthcare facilities in Kenya. Targeting health worker motivation and promoting supportive supervision may reduce missed opportunities and poor client counseling in primary healthcare facilities in Kenya.