Effects of community participation on improving uptake of skilled care for maternal and newborn health: a systematic review.

BACKGROUND: Despite a broad consensus that communities should be actively involved in improving their own health, evidence for the effect of community participation on specific health outcomes is limited. We examine the effectiveness of community participation interventions in maternal and newborn health, asking: did participation improve outcomes? We also look at how the impact of community participation has been assessed, particularly through randomised controlled trials, and make recommendations for future research. We highlight the importance of qualitative investigation, suggesting key areas for qualitative data reporting alongside quantitative work. METHODS AND FINDINGS: Systematic review of published and 'grey' literature from 1990. We searched 11 databases, and followed up secondary references. Main outcome measures were the use of skilled care before/during/after birth and maternal/newborn mortality/morbidity. We included qualitative and quantitative studies from any country, and used a community participation theoretical framework to analyse the data. We found 10 interventions. Community participation had largely positive impacts on maternal/newborn health as part of a package of interventions, although not necessarily on uptake of skilled care. Interventions improving mortality or use of skilled care raised awareness, encouraged dialogue and involved communities in designing solutions-but so did those showing no effect. DISCUSSION: There are few high-quality, quantitative studies. We also lack information about why participation interventions do/do not succeed - an area of obvious interest for programme designers. Qualitative investigation can help fill this information gap and should be at the heart of future quantitative research examining participation interventions - in maternal/newborn health, and more widely. This review illustrates the need for qualitative investigation alongside RCTs and other quantitative studies to understand complex interventions in context, describe predicted and unforeseen impacts, assess potential for generalisability, and capture the less easily measurable social/political effects of encouraging participation

Enhancing frontline health workers\u27 abilities to improve MNCH services in Bauchi State through task shifting/sharing

Frontline health workers (FLHWs), including nurses, midwives, community health extension workers, and community health officers, are healthcare providers with the greatest access to clients and patients, and provide initial care to persons in need of health services. In 2014, Nigeria’s 57th National Council on Health approved a task-shifting and sharing (TSS) policy for essential healthcare services as a promising strategy for improving access and efficiency in Nigeria’s health system. Subsequently, FLHWs in Nigeria have been trained for new roles and functions traditionally reserved for mid- or high-level cadres, to optimize available providers and their capacities. This brief reviews the strategy undertaken in Nigeria’s Bauchi state and concludes that optimizing the roles of FLHWs through TSS is a good solution for improving maternal, newborn, and child health (MNCH) services and for addressing health system challenges. Other opportunities include widespread support for improving MNCH care and addressing the unmet need for care and uneven distribution of health professionals

From the Special Issue Editors

International community-based health care is important for integrating the concept of globalization into nursing education. Through international collaboration, nurses can connect with people with the common goal of understanding global health issues, examining different health care systems, and improving health for all, regardless of color, culture, language spoken, age, or socioeconomic status. With international collaboration and clinical experiences, nurse educators can establish relationships to develop global research projects and enhance nursing students’ cultural competence. In this special issue, we address community-based care programs and research both in the United States and in international locales. The issue also explores health problems among minority populations

Community participation in health care decisions

Community participation is defined as a range of activities which involve people from various communities identifying issues and participating in decisions about planning for management and delivery ofhealth programs or policies. Participation occurs at two levels in health care. Firstly, the participation of individuals in their own health care and treatment, and secondly the involvement of people as community members, participating in decision making and debate concerning health spending priorities. There is a large body of literature that advocates community participation in health care decisions. The strongest arguments claim that involving people in the health system will assist in improving the health of populations. By setting up mechanisms that let people have a say in health care decisions, the health care system will provide more appropriate care to communities. There are a range of approaches to community participation many complex and multifaceted. The key defining characteristics of community participation are joint problem solving, joint decision making, joint responsibility and joint sharing of benefits. Models including: (A) Community Development; (B) Social Action; (C) Action Research; and (D) Participatory Research, are relevant for community participation approaches. These share similar underlying philosophies, although they are not appropriate for implementing in the same situations. Generally, community participation is viewed as positive and desirable for improving quality of health care and the health of populations, although studies show mixed success in these outcomes. Methods and philosophies of community participation models are not aligned with traditional research or health care models. Appropriateness of community participation in all situations is limited due to the nature and requirements for implementation, such as timing, provision of sufficient resources, engaging communities and determining suitable representation is a further issue. Also there are issues for community participation, in terms of implementation, evaluation, and integration with traditional health service models. In general, outcomes of community participation in health care may be discussed in terms of community empowerment and, and improved individual rights, equity, efficiency and effectiveness, accessibility, accountability and quality ofhealth services. It is recommended as a strategy to achieve the above factors as well as for debate in health spending priorities. Moves toward community participation were strengthened through a paradigm shift in ways of thinking in the last few decades, in areas in health care concerned with a population focus, including community health, health promotion and the new public health. The Ottowa Charter was a landmark document of this paradigm shift, and its principles have been internationally accepted. Community participation is a critical focus of the Ottowa Charter. The recent push for cuts in health care expenditure, has resulted in countries internationally concentrating on the need to set priorities in health care. However, techniques for prioritising are very uncertain. There are barriers and issues for community participation in health care decision making, due to the nature in which health care decisions currently take place. One element agreed upon is that priority setting inevitably involves subjective judgments, also that there is a need for development of ethical or public values to influence health decisions

Financing Community Health Centers as Patient- and Community-Centered Medical Homes: A Primer

This policy brief is part of a Commonwealth Fund-supported project that examines community health centers in the context of the patient-centered medical home (PCMH) movement. Community health centers—non-profit primary care facilities that provide care to patients regardless of their ability to pay—are widely lauded as critical components of the health care safety net, providing comprehensive primary care for lowincome, high-risk populations in both urban and rural areas. Since their inception, health centers have directed their activities at improving patient care—through comprehensive primary health care, coordination with specialty care, and the provision of enabling services—as well as improving population-level health status and access to care. Health centers are models for the organization and delivery of health care based on the principles of community-oriented primary care, which focuses on the health of both patients and communities. National discussions of health reform often consider the potential for the patient-centered medical home model to strengthen primary care, prevent or alleviate the long-term consequences of chronic health conditions and disease, and bring greater efficiency to the health care system. A 2008 report released by Senate Finance Committee Chairman Max Baucus describes an emphasis on primary care as a common element of high-performing health systems and recommends further testing and implementation of the PCMH model. The report notes that community health centers represent a critical component of the health care safety net, and have already implemented many elements of the PCMH model. An April 2009 bipartisan policy options report released by the Senate Finance Committee also cites patient-centered medical homes as a possible way to improve care for chronic health conditions. This brief provides a summary of the patient-centered medical home concept, followed by an overview of health centers and an in-depth look at health center financing. Because further evolution toward a PCMH model depends on the realignment of health center payment incentives, it is critical to understand how financing arrangements currently operate, what types of conduct and practices may be incentivized or deterred, and the types of challenges that lie ahead as health care payment policies are reformulated over time. Some of these challenges are faced by all providers as they attempt to reconcile multiple—and potentially competing or inconsistent—incentives created by insurers. Other challenges are associated with the unique mission of health centers and their ability to align quality improvement efforts with their fundamental duty to serve all community residents, regardless of their uninsured or underinsured status

Implementation of Community Health Worker Education Toolkit to Promote Compliance in Managed Care Organization

Community health workers provide case management and care coordination services to high-risk members enrolled in Louisiana Department of Health’s Medicaid program. Centers for Medicare and Medicaid Services require states entering contracts with managed care organizations to conduct external quality reviews by an independent External Quality Review Organization. Healthcare Effectiveness Data and Information Set are quality metrics managed by the National Committee for Quality Assurance. These metrics are reported annually and required by Louisiana Department of Health. Community health workers are required to demonstrate quality accreditation and meet state specific requirement compliance through documentation. The aim of this project was to increase community health worker chart audit scores to 100% by May 2021, thereby improving quality accreditation and meeting state contractual compliance. Louisiana’s managed care organizations are required to provide care coordination, medical management, and continuity of care to Medicaid enrollees through a care management program. Services are provided through telephonic and face-to-face outreach. Community health workers are non-clinical personnel and may not have prior training in health care, medical terminology, accreditation agencies or Medicaid programs. Survey Monkey online survey tool was used to conduct pre-test and post-event feedback surveys. The Plan-Do-Study-Act cycle was used to develop and implement an education toolkit. Following development of toolkit, community health workers participated in education trainings and began implementation of the toolkit. Participants’ charts were audited on 13 metrics prior to training. Pre-chart audit scores averaged 82%. One month following CHW training of education toolkit, participant chart audit average scores decreased by two percentage points to 80%. Development of CHW education toolkit did not improve overall chart audit scores. The Community Health Worker Performance Measurement Framework identifies programmatic inputs and community health worker outputs that should be examined for measuring performance. Although community health worker participants support implementation of an education toolkit and agree more training would be beneficial, other motivational factors were indicated

Community Participation and Empowerment in Community Collaboration: Using Community Collaboratives and the CHG Model for Improving Access and Quality of Care for the Low-income, Uninsured

There are an estimated 45 million uninsured individuals in the United States. In order to improve the health and well-being of these individuals, government agencies, as well as private non-governmental organizations have been financing efforts to establish and build capacity of community collaboratives. This paper defines community collaboration and its role in improving access and quality of health care for the low-income, uninsured. Four examples are provided of community collaborations that are currently working to improve access and quality of health care for low-income, uninsured populations (New Mexico‟s Health Commons, the Community Healthcare Access Program of Delaware, HealthAccess of South Carolina, and Care Share Health Alliance of North Carolina). Using these four examples as a context to describe community collaboration, the paper then introduces the community health governance (CHG) model of Lasker and Weiss. The CHG model is presented as a framework for developing new community collaboratives and/or evaluating established community collaboration to assure community participation and empowerment. With the ultimate goal of improving health and well-being of the low-income, uninsured, community collaborations can benefit the individuals they serve by increasing access to preventive services, improving care coordination for the chronically ill, improving access to medications and specialty care, attracting funding from government and non-governmental agencies for safety net and other community partner organizations involved in collaboration, and improving patient involvement as the collaborative model empowers and engages the community through participation.Master of Public Healt

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED).

BackgroundRecurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population.Methods/designIn this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care.DiscussionIf this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings.Trial registrationClinicalTrials.gov Identifier NCT01763203

Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand.

BACKGROUND: Although a number of antenatal and intrapartum interventions have shown some evidence of impact on stillbirth incidence, much confusion surrounds ideal strategies for delivering these interventions within health systems, particularly in low-/middle-income countries where 98% of the world's stillbirths occur. Improving the uptake of quality antenatal and intrapartum care is critical for evidence-based interventions to generate an impact at the population level. This concluding paper of a series of papers reviewing the evidence for stillbirth interventions examines the evidence for community and health systems approaches to improve uptake and quality of antenatal and intrapartum care, and synthesises programme and policy recommendations for how best to deliver evidence-based interventions at community and facility levels, across the continuum of care, to reduce stillbirths. METHODS: We systematically searched PubMed and the Cochrane Library for abstracts pertaining to community-based and health-systems strategies to increase uptake and quality of antenatal and intrapartum care services. We also sought abstracts which reported impact on stillbirths or perinatal mortality. Searches used multiple combinations of broad and specific search terms and prioritised rigorous randomised controlled trials and meta-analyses where available. Wherever eligible randomised controlled trials were identified after a Cochrane review had been published, we conducted new meta-analyses based on the original Cochrane criteria. RESULTS: In low-resource settings, cost, distance and the time needed to access care are major barriers for effective uptake of antenatal and particularly intrapartum services. A number of innovative strategies to surmount cost, distance, and time barriers to accessing care were identified and evaluated; of these, community financial incentives, loan/insurance schemes, and maternity waiting homes seem promising, but few studies have reported or evaluated the impact of the wide-scale implementation of these strategies on stillbirth rates. Strategies to improve quality of care by upgrading the skills of community cadres have shown demonstrable impact on perinatal mortality, particularly in conjunction with health systems strengthening and facilitation of referrals. Neonatal resuscitation training for physicians and other health workers shows potential to prevent many neonatal deaths currently misclassified as stillbirths. Perinatal audit systems, which aim to improve quality of care by identifying deficiencies in care, are a quality improvement measure that shows some evidence of benefit for changes in clinical practice that prevent stillbirths, and are strongly recommended wherever practical, whether as hospital case review or as confidential enquiry at district or national level. CONCLUSION: Delivering interventions to reduce the global burden of stillbirths requires action at all levels of the health system. Packages of interventions should be tailored to local conditions, including local levels and causes of stillbirth, accessibility of care and health system resources and provider skill. Antenatal care can potentially serve as a platform to deliver interventions to improve maternal nutrition, promote behaviour change to reduce harmful exposures and risk of infections, screen for and treat risk factors, and encourage skilled attendance at birth. Following the example of high-income countries, improving intrapartum monitoring for fetal distress and access to Caesarean section in low-/middle-income countries appears to be key to reducing intrapartum stillbirth. In remote or low-resource settings, families and communities can be galvanised to demand and seek quality care through financial incentives and health promotion efforts of local cadres of health workers, though these interventions often require simultaneous health systems strengthening. Perinatal audit can aid in the development of better standards of care, improving quality in health systems. Effective strategies to prevent stillbirth are known; gaps remain in the data, the evidence and perhaps most significantly, the political will to implement these strategies at scale