Adapting the Community-based Health Planning and Services (CHPS) to engage poor urban communities in Ghana: protocol for a participatory action research study

Introduction: With rapid urbanisation in low-income and middle-income countries, health systems are struggling to meet the needs of their growing populations. Community-based Health Planning and Services (CHPS) in Ghana have been effective in improving maternal and child health in rural areas; however, implementation in urban areas has proven challenging. This study aims to engage key stakeholders in urban communities to understand how the CHPS model can be adapted to reach poor urban communities.Methods and analysis: A Participatory Action Research (PAR) will be used to develop an urban CHPS model with stakeholders in three selected CHPS zones: (a) Old Fadama (Yam and Onion Market community), (b) Adedenkpo and (c) Adotrom 2, representing three categories of poor urban neighbourhoods in Accra, Ghana. Two phases will be implemented: phase 1 (‘reconnaissance phase) will engage and establish PAR research groups in the selected zones, conduct focus groups and individual interviews with urban residents, households vulnerable to ill-health and CHPS staff and key stakeholders. A desk review of preceding efforts to implement CHPS will be conducted to understand what worked (or not), how and why. Findings from phase 1 will be used to inform and co-create an urban CHPS model in phase 2, where PAR groups will be involved in multiple recurrent stages (cycles) of community-based planning, observation, action and reflection to develop and refine the urban CHPS model. Data will be managed using NVivo software and coded using the domains of community engagement as a framework to understand community assets and potential for engagement

Adapting the Community-based Health Planning and Services (CHPS) to engage poor urban communities in Ghana: protocol for a participatory action research study

Introduction: With rapid urbanisation in low-income and middle-income countries, health systems are struggling to meet the needs of their growing populations. Community-based Health Planning and Services (CHPS) in Ghana have been effective in improving maternal and child health in rural areas; however, implementation in urban areas has proven challenging. This study aims to engage key stakeholders in urban communities to understand how the CHPS model can be adapted to reach poor urban communities.Methods and analysis: A Participatory Action Research (PAR) will be used to develop an urban CHPS model with stakeholders in three selected CHPS zones: (a) Old Fadama (Yam and Onion Market community), (b) Adedenkpo and (c) Adotrom 2, representing three categories of poor urban neighbourhoods in Accra, Ghana. Two phases will be implemented: phase 1 (‘reconnaissance phase) will engage and establish PAR research groups in the selected zones, conduct focus groups and individual interviews with urban residents, households vulnerable to ill-health and CHPS staff and key stakeholders. A desk review of preceding efforts to implement CHPS will be conducted to understand what worked (or not), how and why. Findings from phase 1 will be used to inform and co-create an urban CHPS model in phase 2, where PAR groups will be involved in multiple recurrent stages (cycles) of community-based planning, observation, action and reflection to develop and refine the urban CHPS model. Data will be managed using NVivo software and coded using the domains of community engagement as a framework to understand community assets and potential for engagement

Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: a history and systematic review of what works, for whom and why

Background: Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub–Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme. Methods: We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme. Results: N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts. Conclusions: The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214006 , identifier: CRD42020214006

Strategic Leadership in Nursing

Managing the complex healthcare facility in a lower middle-income country (LMIC) such as Ghana can be challenging and demands management principles that would enable the leader to be conscious of the significant role of the environment. Nurses and midwives constitute majority of the health workforce, play pivotal role in healthcare delivery, consuming most of the resources in managing patient care, and promote the corporate image of the facility. Nurse leaders should exhibit practical leadership skills that would enable effective utilization of the capabilities of staff to achieve organizational goals and prominence in the environment. Long-term viability and competitiveness of the healthcare system demands cost-effective strategies using organizational competencies to take advantage of the opportunities within the environment. Leadership, therefore, becomes essential by initiating a vision that harnesses the potential of staff and stakeholders to this commitment. To withstand time and change, strategic leadership principles such as setting high standards of excellence, demonstrating exceptional performance, and constantly delivering value are imminent. Strategic leadership in nursing ensures provision of leadership strategies that would enhance effective teams and mitigate existing challenges confronting the health system. The paper finds that nursing as a profession is incessantly evolving and, hence, requires strong and dynamic leadership

Leadership styles in nursing management: implications for staff outcomes

Introduction: Nursing is a people-centred profession and therefore the issue of leadership is crucial for success. Nurse managers’ leadership styles are believed to be important determinant of nurses’ job satisfaction and retention. In the wake of a global nursing shortage, maldistribution of health workforce, increasing healthcare costs and expanding workload, it has become imperative to examine the role of nurse managers’ leadership styles on their staff outcomes. Using the Path-Goal Leadership theory as an organised framework, this study investigated the leadership styles of nurse managers and how they influence the nursing staff job satisfaction and intentions to stay at their current workplaces. Methods: The study employed a cross-sectional survey design to collect data from a sample of 273 nursing staff in five hospitals in the Eastern Region of Ghana. Descriptive and regression analyses were performed using SPSS version 18.0 Results: Nurse managers used different leadership styles depending on the situation, but were more inclined to the supportive leadership style, followed by the achievement-oriented leadership style and participative leadership style. The nursing staff exhibited moderate levels of job satisfaction. The nurse managers’ leadership styles together explained 29% of the variance in the staff job satisfaction. The intention to stay at the current workplace was low (2.64 out of 5) among the nursing staff. More than half (51.7%) of the nursing staff intended to leave their current workplaces, and 20% of them were actively seeking the opportunities to leave. The nurse managers’ leadership styles statistically explained 13.3% of the staff intention to stay at their current job position. Conclusions: These findings have enormous implications for nursing practice, management, education, and human resource for health policy that could lead to better staff retention and job satisfaction, and ultimately improve patient care. 

Health-seeking experiences of women with obstetric fistula: a qualitative study at two fistula centres in Ghana

Objectives The study explored the health-seeking experiences of women with obstetric fistula from the onset of the condition until surgical treatment was obtained. It also describes their interactions with health staff and traditional healers.Design Exploratory, descriptive qualitative study.Setting Two secondary-level health facilities in the northern and central regions of Ghana; data collection took place in 2018–2019.Participants A purposive sample of 37 women who had experienced fistula resulting from childbirth and were awaiting fistula repair at the two fistula centres in Ghana was obtained.Data analysis Thematic analysis was used to analyse the data.Results Health-seeking experiences and behaviours of women with obstetric fistula were identified. Six major themes were generated: attribution and perceptions of fistula; competing alternatives/multiple sources of care; limited awareness and access to care; financial barriers; psychosocial challenges, and abuse by healers. The results indicate that the health-seeking experiences of women with obstetric fistula were characterised by long delays in care-seeking. The major themes and subthemes are presented with quotes from participants.Conclusion The women experienced winding pathways of treatment-seeking due to lack of awareness and incorrect attribution. The major barriers to health-seeking included poverty, challenges with transportation and inadequate repair centres. Increased awareness of obstetric fistula and access to repair centres could shorten the suffering women go through while awaiting fistula treatment. Improved awareness of obstetric fistula and establishment of more fistula centres would be beneficial

Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana:a history and systematic review of what works, for whom and why

Background: Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub–Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme.Methods: We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme.Results: N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts.Conclusions: The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214006, identifier: CRD42020214006