Motivating and demotivating factors for community health workers engaged in maternal, newborn and child health programs in low and middle-income countries: a systematic review.

This systematic review aimed to synthesize primary research on motivating factors of community health workers (CHWs) for maternal, neonatal, and child health (MNCH) in low and middle-income countries (LMICs). Peer-reviewed literatures were systematically searched in five databases. Identified studies were then screened and selected for inclusion. The eligibility criteria were reported primary qualitative, quantitative, or mixed methods research, with participants being CHWs in LMICs who address MNCH, which investigated motivation or related concepts of retention, attrition, and performance. A thematic synthesis process was used to analyze findings of motivating factors, reported by included studies. Seventeen qualitative, quantitative, or mixed methods studies met inclusion criteria. Two overarching themes were developed: Levels of motivation (i.e. individual, community, and health system) and stages of motivation (i.e. recruitment, retention, and attrition). Nine sub-themes were further developed at the intersection of each level and stage of motivation. Each subtheme comprises the motivating factors that are influential to community health workers at each stage and level. These themes and sub-themes are presented in a Community Health Worker Motivation Model. The motivation model can be used to identify what motivating factors are relevant to community health workers motivation and the stakeholders necessary to address each motivating factor. Recruitment of community health workers for maternal, neonatal, and child health relies largely on individual level of motivation. At retention, individual level motivating factors remain influential; and community and health system begin to influence motivation positively. But, overall health systems in low and middleincome countries are demotivating the health workers rather than motivating them

Comparing risk factors of HIV among hijra sex workers in Larkana and other cities of Pakistan: an analytical cross sectional study

Background In 2005, Pakistan was first labeled as a country with concentrated epidemic of Human Immunodeficiency Virus (HIV). This was revealed through second generation surveillance conducted by HIV/AIDS Surveillance Project (HASP). While injection drug users (IDUs) were driving the epidemic, subsequent surveys showed that Hijra (transgender) sex workers (HSWs) were emerging as the second most vulnerable group with an average national prevalence of 6.4%. An exceptionally high prevalence (27.6%) was found in Larkana, which is a small town on the right bank of river Indus near the ruins of Mohenjo-Daro in the province of Sindh. This paper presents the risk factors associated with high prevalence of HIV among HSWs in Larkana as compared to other cities of the country. Methods Data were extracted for secondary analysis from 2008 Integrated behavioral and biological survey (IBBS) to compare HSWs living in Larkana with those living in other cities including Karachi and Hyderabad in Sindh; Lahore and Faisalabad in Punjab; and Peshawar in Khyber Pakhtunkhwa provinces. After descriptive analysis, univariate and multivariate analyses were performed to identify risk factors. P value of 0.25 or less was used to include factors in multivariate analysis. Results We compared 199 HSWs from Larkana with 420 HSWs from other cities. The average age of HSWs in Larkana was 26.42 (±5.4) years. Majority were Sindhi speaking (80%), uneducated (68%) and unmarried (97%). In univariate analysis, factors associated with higher prevalence of HIV in Larkana included younger age i.e. 20–24 years (OR: 5.8, CI: 2.809–12.15), being unmarried (OR: 2.4, CI: 1.0–5.7), sex work as the only mode of income (OR: 5.5, CI: 3.70–8.2) and longer duration of being involved in sex work 5–10 years (OR: 3.3, CI: 1.7–6.12). In multivariate logistic regression the HSWs from Larkana were more likely to lack knowledge regarding preventive measures against HIV (OR 11.9, CI: 3.4–41.08) and were more prone to use of alcohol during anal intercourse (OR: 6.3, CI: 2.77–17.797). Conclusion Outreach programs focusing on safer sexual practices and VCT are urgently needed to address the upsurge of HIV among HSWs in Larkana

Vaccine effectiveness and risk factors associated with measles among children presenting to the hospitals of Karachi, Pakistan.

OBJECTIVE: To determine the risk factors regarding guardian\u27s practices associated with development of Measles and also find out effectiveness of Measles vaccine among children less than 12 years of age presenting to the hospitals of Karachi. STUDY DESIGN: Matched case control study. PLACE AND DURATION OF STUDY: Multicenter surveillance was conducted in 11 public and private sector hospitals of Karachi from January 2011 to September 2012 in consultation with World Health Organization Measles Surveillance Cell. METHODOLOGY: Cases were children aged less than 12 years with Measles presenting to the hospitals. Controls for cases were enrolled from the same hospitals without Measles, matched for age and gender. Studied variables were analyzed by multivariate conditional logistic regression analysis adjusted for age and gender. RESULTS: Measles cases were more likely to have mothers with \u27lower education\u27 [adjusted matched Odds Ratio or mOR: 3.2 (95% CI: 1.2 - 7.6), for \u3c 5 years of schooling adjusted mOR: 2.2 (95% CI: 1.0 - 5.7) for 6 - 10 years of schooling]. Children with Measles were also more likely to be not given breast milk in initial 2 years of life [adjusted mOR: 2.6, 95% CI 1.0 - 7.0]. Cases were also more likely to have never received vaccination [adjusted mOR: 10.1, 95% CI 4.5 - 22.5] and having no other children vaccinated at home [adjusted mOR: 3, 95% CI 1.5 - 5.3]. Vaccine effectiveness for single dose was found to be 87.4 (95% CI: 76.1 - 93.4), while for two doses it was approximately 93% (95% CI: 86.2 - 96.6). CONCLUSION: For Measles elimination, mother\u27s education on breast feeding and appropriate weaning practices is required

Impact of water and sanitation and health education interventions on health and hygiene behaviors: a study from a northern Pakistani village

Introduction: Water and sanitation interventions were delivered in the northern areas of Pakistan as a joint venture of the Aga Khan University and the Aga Khan Health Systems Oshikhandass Diarrhea and Dysentery Project (1989-96) followed by the Aga Khan Water, Sanitation, Health and Hygiene Studies Program (WSHHSP). Through these interventions water treatment plants, new pit latrines along with a component of health education were introduced. Objectives: To explore perceptions, knowledge and practices of inhabitants of Oshikhandass village in Gilgit related to water quality, latrine use and hand washing following the intervention. Methods: Through a cross-sectional study during June-July 2012, six focus group discussions (FGDs) were conducted in various sectors of Oshikhandass supplied by filtered water (intervention area), piped water and mixed water (piped and channel water). The latter two were designated as the non- intervention areas. Participants included mothers (3 FGDs, 26 participants), LHWs (1 FGD, 5 participants) and youth (2 FGDs, 9 participants each). Results: Irrespective of health education by LHWs, residents of both intervention and non- intervention communities had learnt about proper hygienic practices from daily life experiences, parents, teachers and media. LHWs role at best had been that of a positive reinforcement. Despite uniformly good awareness, intervention communities still had relatively better health and hygiene knowledge and practices as compared to non-intervention areas. Conventional practices of water purification such as using gulk as domestic filter cum refrigerator was prevalent. Non-intervention communities, however, knew that accessibility to safe water makes a difference and they would have practiced better hygiene if they had resources. Inhabitants of intervention area commented that the functionality and coverage of the filtration plant was not enough to cater to the needs of the village. Conclusion: Knowledge alone is ineffective in modifying hygiene related behaviors. Sound context-specific integrated interventions for water and sanitation infrastructure development are much needed

Interventions to reduce neonatal mortality from neonatal tetanus in low and middle income countries - a systematic review

Background In 1988, WHO estimated around 787,000 newborns deaths due to neonatal tetanus. Despite few success stories majority of the Low and Middle Income Countries (LMICs) are still struggling to reduce neonatal mortality due to neonatal tetanus. We conducted a systematic review to understand the interventions that have had a substantial effect on reducing neonatal mortality rate due to neonatal tetanus in LMICs and come up with feasible recommendations for decreasing neonatal tetanus in the Pakistani setting. Methods We systemically reviewed the published literature (Pubmed and Pubget databases) to identify appropriate interventions for reducing tetanus related neonatal mortality. A total of 26 out of 30 studies were shortlisted for preliminary screening after removing overlapping information. Key words used were “neonatal tetanus, neonatal mortality, tetanus toxoid women”. Of these twenty-six studies, 20 were excluded. The pre-defined exclusion criteria was (i) strategies and interventions to reduce mortality among neonates not described (ii) no abstract/author (4 studies) (iii) not freely accessible online (1 study) (iv) conducted in high income countries (2 studies) and (v) not directly related to neonatal tetanus mortality and tetanus toxoid immunization (5). Finally six studies which met the eligibility criteria were entered in the pre-designed data extraction form and five were selected for commentary as they were directly linked with neonatal tetanus reduction. Results Interventions that were identified to reduce neonatal mortality in LMICs were: a) vaccination of women of child bearing age (married and unmarried both) with tetanus toxoid b) community based interventions i.e. tetanus toxoid immunization for all mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; umbilical cord care and management of infections in newborns c) supplementary immunization (in addition to regular EPI program) d) safer delivery practices. Conclusion The key intervention to reduce neonatal mortality from neonatal tetanus was found to be vaccination of pregnant women with tetanus toxoid. In the resource poor countries like Pakistan, this single intervention coupled with regular effective antenatal checkups, clean delivery practices and compliance with the “high- risk” approach can be effective in reducing neonatal tetanus

Building on the health policy analysis triangle: Elucidation of the elements

The health policy triangle first presented in the 20th century by Walt and Gilson has been extensively used at local, national, regional, and international levels to assess health policies related to communicable and non-communicable diseases, physical and mental health, antenatal and postnatal care, and human resources, services, and systems. However, the framework lacks intricate details for the four pillars in the triangle viz: \u27content,\u27 \u27context\u27, \u27actors\u27, and \u27processes. We propose a checklist of elements to be considered for each pillar; to ease and enhance the process of policy analyses for researchers and policymakers across the globe, including low- and middle-income countries. We suggest using Leichter\u27s categorization of situational, structural, cultural, and environmental factors for comprehensive contextual assessment. Kingdon\u27s multiple streams framework can be applied to determine the \u27window of opportunity\u27 allowing the politics, policy, and problem streams to unite, giving birth to the formulation of policies. Lastly, stakeholders\u27 analyses expounding the power, influence, interest, and involvement of intrinsic, extrinsic, implicit, and explicit players should be applied to explore the \u27actors\u27 in policy analyses. Robust policy analyses for generating evidence are of paramount importance for policymakers for informed decision-making. Our approach of dis-entangling and elaborating the pillars of the triangle will be helpful for health systems researchers at sub-national, national, regional and global levels to serve as a basis for evidence-based informed decision-making

Determinants of patient\u27s satisfaction with health care system in Pakistan: a critical review

Patient satisfaction with health care services is considered an important factor of quality health care. Although research on patient satisfaction has become standard in many developed country, in countries such as Pakistan the concept of patient satisfaction is still relatively neglected. This study aimed to find out the determinants of patient satisfaction from existing literature in Pakistan.The literature search was carried out by using the database of Medscape, Medline, PakMedinet and PubMed, without any language restriction using MeSH words as “patient satisfaction AND health care system in Pakistan” and “Determinants of patient satisfaction AND Pakistan”. Twenty-one articles were found which discussed the concept of patient satisfaction and its determinants with health care system in Pakistan and other developing countries. Variable level of patient satisfaction with health care services was identified in literature review, more with private hospitals as compared to public hospitals and health care providers. Patient experiences and their expectations with health care services were found to be important determinant of patient satisfaction in Pakistan. Young age, female gender, literacy and high social class are few patient characteristics influencing level of patient satisfaction. In addition lack of privacy, autonomy, involvement in decision making, poor communication, and sanitation/hygiene leads to bad patient experience hence decreased satisfaction. This review highlights the complex and interrelated determinants of patient satisfaction with health care system in Pakistan. Prompt attention to patients\u27 expectations, enhancing responsiveness of health care system and consideration of patient\u27s perceptions is of utmost importance to increase patient satisfaction outcomes

Relationship between exercise induced dyspnea and functional capacity with doppler-derived diastolic function

Background Dyspnea is the frequent cause of exercise intolerance and physical inactivity among patients referred for exercise tolerance test. Diastolic dysfunction has shown significant correlation with exercise capacity and exercise induced dyspnea. To find out the frequency of diastolic dysfunction (DD) and the relationships between impaired exercise capacity and exercise induced dyspnea with DD by Doppler-derived indices among patients referred for stress test in a tertiary care hospital of Karachi. Methods For this study 135 consecutive patients who were referred for stress test at our non-invasive lab were screened for eligibility. Patients with valvular pathology, atrial fibrillation (AF) and coronary artery disease (CAD) were excluded. Stress test was performed on treadmill using Bruce protocol. Assessment of diastolic function as determined by trans-mitral flow velocity pattern was carried at baseline and at peak exercise. We evaluated impaired exercise capacity and exercise induced dyspnea using validated Borg Scale among study subjects. Results Study subjects 88% were males, mean age was 46 ± 16 years, BMI 27 ± 5 kg/m2, prevalence of diabetes mellitus (DM) 15%, hypertension 28% and smoking 21%. Exercise induced DD occurred among 44.6%. Patients with exercise induced DD had lower exercise capacity (9.2 vs. 10.2 METS; p = 0.04) and higher Borg Scale (5.2 vs. 4.0; p \u3c 0.001). DD at baseline was present in 25(26%) of patients so they were excluded from the study. Five patients develop ischemia during stress test so were also excluded. So final analysis was done on 105 patients. Among patients without DD at baseline, there was significant vicariate linear inverse correlation between post exercise E/A ratio and Borg scale (r = −0.23; p = 0.02) and exercise capacity was assessed by exercise duration and MET (r-0.825; p = 0.04). Multivariate regression analysis revealed post exercise E/A ratio as an independent determinant of severity of exercise induced dyspnea and impaired exercise tolerance. Conclusion DD is significantly associated with impaired functional capacity and dyspnea among patients referred for exercise tolerance test

Research fatigue among injecting drug users in Karachi, Pakistan

Background Karachi is the largest metropolis of Pakistan and its economic hub attracting domestic migrants for economic opportunities. It is also the epicenter of HIV epidemic in the country. Since 2004, one pilot study and four behavioral and biological surveillance rounds have been conducted in Karachi. In addition many student research projects have also focused on key risk groups including injection drug users (IDUs). As a result of this extra ordinary exposure of same kind of questions, IDUs know how to respond to high value questions related to sharing of needles or unsafe sexual practices. The purpose of the study was to explore the element of research fatigue among IDUs in Karachi, Pakistan. Methods The study was conducted on 32 spots in Karachi, selected on the basis of estimate of IDUs at each spot. A trained field worker (recovered IDU) visited each spot; observed sharing behavior of IDUs and asked questions related to practices in January 2009. Verbal consent was obtained from each respondent before asking questions. Results On average 14 IDUs were present at each spot and out of 32 selected spots, 81% were active while more than two groups were present at 69% spots. In each group three to four IDUs were present and everyone in the group was sharing. One dose of injecting narcotics was observed. Sharing of syringes, needles and distilled water was observed at 63% spots while professional injector/street doctor was present at 60% spots. Conclusion There is a need to check internal consistency in surveillance research. It is highly likely that IDUs and other risk groups know how to respond to key questions but their responses do not match with the practices