Capacity development in pursuit of social change: an examination of processes and outcomes.

HEARD, 2021.Understanding “what works” for capacity development support in an international development setting remains an important area for operational research. This mixed-methods study explored this topic within a global programme that supports civil society organisations in fifteen countries to secure the health and human rights of marginalised and underserved populations. Taking a complex adaptive systems approach, and seeking to understand the phenomena from the “receiver” perspective, the study found that the programme fostered the development of four interconnected domains of capacity through a reflexive, user-led approach. These capacity gains could be linked, although not causally, to important programmatic achievements for the programme’s focus populations

An evaluation of self-management outcomes among chronic care patients in community home-based care programmes in rural Malawi: A 12-month follow-up study.

"This paper investigates the impact of community home-based care (CHBC) on self-management outcomes for chronically ill patients in rural Malawi. A pre- and post-evaluation survey was administered among 140 chronically ill patients with HIV and non-communicable diseases, newly enrolled in four CHBC programmes. We translated, adapted and administered scales from the Stanford Chronic Disease Self-Management Programme to evaluate patient's self-management outcomes (health status and self-efficacy), at four time points over a 12-month period, between April 2016 and May 2017. The patient's drop-out rate was approximately 8%. Data analysis included descriptive statistics, tests of associations, correlations and pairwise comparison of outcome variables between time points, and multivariate regression analysis to explore factors associated with changes in self-efficacy following CHBC interventions. The results indicate a reduction in patient-reported pain, fatigue and illness intrusiveness, while improvements in general health status and quality of life were not statistically significant. At baseline, the self-efficacy mean was 5.91, which dropped to 5.1 after 12\xC2\xA0months. Factors associated with this change included marital status, education, employment and were condition-related; whereby self-efficacy for non-HIV and multimorbid patients was much lower. The odds for self-efficacy improvement were lower for patients with diagnosed conditions of longer duration. CHBC programme support, regularity of contact and proximal location to other services influenced self-efficacy. Programmes maintaining regular home visits had higher patient satisfaction levels. Our findings suggest that there were differential changes in self-management outcomes following CHBC interventions. While self-management support through CHBC programmes was evident, CHBC providers require continuous training, supervision and sustainable funding to strengthen their contribution. Furthermore, sociodemographic and condition-related factors should inform the design of future interventions to optimise outcomes. This study provides a systematic evaluation of self-management outcomes for a heterogeneous chronically ill patient population and highlights the potential and relevant contribution of CHBC programmes in improving chronic care within sub-Saharan Africa.

Patient–provider perspectives on self‐management support and patient empowerment in chronic care: A mixed‐methods study in a rural sub‐Saharan setting

Aim: To explore how provision of self‐management support to chronically‐ill patients in resource‐limited settings contributes to patient empowerment in chronic care. Design: Concurrent descriptive mixed methods research. Methods: A survey of 140 patients with chronic conditions administered at four time‐points in 12 months. We conducted 14 interviews and four focus‐group discus‐ sions with patients (N = 31); 13 healthcare provider interviews; and observations of four patient‐support group meetings. Data were collected between April 2016 ‐ May 2017 in rural Malawi. Qualitative data were analysed using a thematic approach and descriptive statistical analysis performed on survey data. Results: Healthcare professionals facilitated patient empowerment through health education, although literacy levels and environmental factors affected self‐manage‐ ment guidance. Information exchanged during patient–provider interactions varied and discussions centred around medical aspects and health promoting behaviour. Less than 40% of survey patients prepared questions prior to clinic consultations. Health education was often unstructured and delegated to non‐physician providers, mostly untrained in chronic care. Patients accessed psychosocial support from vol‐ unteer‐led community home‐based care programmes. HIV support‐groups regularly interacted with peers and practical skills exchanged in a supportive environment, reinforcing patient's self‐mangement competence and proactiveness in health care. Conclusion: For optimal self‐management, reforms at inter‐personal and organiza‐ tional level are needed including; mutual patient‐provider collaboration, diversifying access to self‐management support resources and restructuring patient support‐ groups to cater to diverse chronic conditions.Impact: Our study provides insights and framing of self‐management support and empowerment for patients in long‐term care in sub‐Saharan Africa. Lessons drawn could feed into designing and delivering responsive chronic care interventions

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district

Background: With the increasing double burden of communicable and non-communicable diseases (NCDs) in subSaharan Africa, health systems require new approaches to organise and deliver services for patients requiring longterm care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. Methods: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo. Results: Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems. Conclusion: In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives

Why doesn't the decriminalization of same sex sexuality and sex work ensure rights? : the legality and social acceptance of transgressive sexualities in urban Mozambique.

HEARD, 2021.Background: The dependence on the law to direct people’s behaviour is known for its imperfections, yet it has become a mainstream response to social problems in modern day society. It is also the pathway through which internationally-recognised rights obligations, including sexual rights, are anticipated to diffuse across distinctly different societies. We studied the introduction of new legal standards in Mozambique, with an interest in their ability to promote the rights of lesbian, gay, bisexual, transgender, intersex (LGBTI) people and sex workers. Methods: Between 2019 and 2020, we conducted sixteen key informant interviews with jurists, policymakers, and civil society advocates at national level and seventy-eight interviews with opinion leaders from local communities in three urban sites situated across Northern, Central, and Southern Mozambique. Results: The new legal standards, in which same-sex sexuality and sex work are no longer criminalised, found little resonance with intersecting religious, sexual, gender, and socio-cultural norms. Whilst there was a consensus not to discriminate, sensitisation and rehabilitation of LGBTI people and sex workers were considered imperative. This stance, coupled with a continued presence of ambiguous language in and incongruences between legislative pieces, attenuates the country’s commitment to internationally recognised rights obligations. Conclusions: In a context of weak civilian awareness and support, the legal reforms are not likely to make a profound positive impact on the lives of LGBTI people and sex workers. Policy action should extend beyond health and law enforcement institutions and draw in community leaders to mediate the social processes that undercut the universality of rights

An evaluation of self-management outcomes among chronic care patients in community home-based care programmes in rural Malawi: a 12-month follow-up study.

HEARD, 2021.This paper investigates the impact of community home-based care (CHBC) on self-management outcomes for chronically ill patients in rural Malawi. A pre- and post-evaluation survey was administered among 140 chronically ill patients with HIV and non-communicable diseases, newly enrolled in four CHBC programmes. We translated, adapted and administered scales from the Stanford Chronic Disease Self-Management Programme to evaluate patient's self-management outcomes (health status and self-efficacy), at four time points over a 12-month period, between April 2016 and May 2017. The patient's drop-out rate was approximately 8%. Data analysis included descriptive statistics, tests of associations, correlations and pairwise comparison of outcome variables between time points, and multivariate regression analysis to explore factors associated with changes in self-efficacy following CHBC interventions. The results indicate a reduction in patient-reported pain, fatigue and illness intrusiveness, while improvements in general health status and quality of life were not statistically significant. At baseline, the self-efficacy mean was 5.91, which dropped to 5.1 after 12 months. Factors associated with this change included marital status, education, employment and were condition-related; whereby self-efficacy for non-HIV and multimorbid patients was much lower. The odds for self-efficacy improvement were lower for patients with diagnosed conditions of longer duration. CHBC programme support, regularity of contact and proximal location to other services influenced self-efficacy. Programmes maintaining regular home visits had higher patient satisfaction levels. Our findings suggest that there were differential changes in self-management outcomes following CHBC interventions. While self-management support through CHBC programmes was evident, CHBC providers require continuous training, supervision and sustainable funding to strengthen their contribution. Furthermore, sociodemographic and condition-related factors should inform the design of future interventions to optimise outcomes. This study provides a systematic evaluation of self-management outcomes for a heterogeneous chronically ill patient population and highlights the potential and relevant contribution of CHBC programmes in improving chronic care within sub-Saharan Africa

Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi

Since the Alma Ata Declaration in 1978, community health volunteers (CHVs) have been at the forefront, providing health services, especially to underserved communities, in low-income countries. However, consolidation of CHVs position within formal health systems has proved to be complex and continues to challenge countries, as they devise strategies to strengthen primary healthcare. Malawi’s community health strategy, launched in 2017, is a novel attempt to harmonise the multiple health service structures at the community level and strengthen service delivery through a team-based approach. The core community health team (CHT) consists of health surveillance assistants (HSAs), clinicians, environmental health officers and CHVs. This paper reviews Malawi’s strategy, with particular focus on the interface between HSAs, volunteers in community-based programmes and the community health team. Our analysis identified key challenges that may impede the strategy’s implementation: (1) inadequate training, imbalance of skill sets within CHTs and unclear job descriptions for CHVs; (2) proposed community-level interventions require expansion of preexisting roles for most CHT members; and (3) district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is needed on the appropriate forms of CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload, strengthening coordination and communication across all community actors, and financing mechanisms. Policy support through the development of an addendum to the strategy, outlining opportunities for task-shifting between CHT members, CHVs’ expected duties and interactions with paid CHT personnel is recommended

Impacts of Colonial Legacies on the Rights and Security of Sex Workers in Southern Africa

This article will explore the relationship between sex work and the law in four Southern African countries – Madagascar, Mozambique, Zambia and Zimbabwe – to shed light on the persistent barriers to promoting the rights and security of sex workers. In these countries, as across Southern Africa, criminal laws on sex work introduced by colonial powers have profoundly shaped contemporary societal attitudes towards sex work and women who sell sex. More recently, the question of sex work has often been linked to HIV and AIDS and decriminalisation has been promoted as part of a wider strategy to protect ‘key populations’, including sex workers, who are perceived as being at greater risk of HIV infection. Based on our research with young women engaged in selling sex, we found that repression continues in various forms within and outside of the law. Though sex work is no longer fully criminalised in most countries in the region, the relics of the colonial past permeate contemporary norms and attitudes to sex work thus locking the selling of sex within the grey areas of the law and contributing to situations of vulnerability for sex workers. Our four case studies demonstrate that transformations in dominant social norms and representations around sex work have been far slower and less far reaching than many assumed they would be, even in the countries which have adopted more progressive laws and policies. The situations of vulnerability experienced by sex workers also escalated during the COVID-19 crisis, highlighting the critical need for state intervention to improve their legal, economic and social position

Exposed and unprotected: Sex worker vulnerabilities during the COVID-19 health emergency in Mozambique

Measures to contain the spread of COVID-19 have been shown to disproportionately affect the marginalised groups in our societies. We studied the impacts of national restrictions on young adult sex workers in Mozambique, and actions at individual, governmental and civil society level to mitigate against these impacts. The country case study was part of a multi-country qualitative research, including fifty-four semi-structured interviews with female sex workers (N = 38), outreach workers (N = 10) in Maputo and Quelimane, and informants with key positions in national COVID coordination bodies, the Ministry of Health and civil society organisations (N = 7). While restrictions impacted all sex worker participants, the COVID crisis was found to deepen existing class differences and further incite violence against the most visible and economically vulnerable category of street-based sex workers. Parallel enforcement of morals against this group of ‘urban undesirables’ resulted in bodily harm and further degradation of the female sex worker under the guise of COVID emergency decrees, while restrictions weakened protection from peers and outreach workers against abuse by the police and other perpetrators. The State needs to act against unlawful police action and include impact mitigation strategies in its public health response to COVID in order to protect the most vulnerable