Systematic review of interventions for improving the performance of community health workers in low-income and middle-income countries

ObjectiveTo systematically review and critically appraise the evidence for the effects of interventions to improve the performance of community health workers (CHWs) for community-based primary healthcare in low- and middle-income countries.DesignSystematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Methods19 electronic databases were searched with a highly sensitive prespecified strategy and the grey literature examined, completed July 2016. Randomised controlled trials evaluating interventions to improve CHW performance in low- and middle-income countries were included and appraised for risk of bias. Outcomes were biological and behavioural patient outcomes (primary), use of health services, quality of care provided by CHWs and CHW retention (secondary).ResultsTwo reviewers screened 8082 records; 14 evaluations were included. Due to heterogeneity and lack of clear outcome data, no meta-analysis was conducted. Results were presented in a narrative summary. The review found one study showing no effect on the biological outcomes of interest, though these moderate quality data may not be indicative of all biological outcomes. It also found moderate quality evidence of the efficacy of performance improvement interventions for (1) improving behavioural outcomes for patients, (2) improving use of services by increasing the absolute number of patients who access services and, perhaps, better identifying those who would benefit from such services and (3) improving CHW quality of care in terms of upstream measures like completion of prescribed activities and downstream measures like adherence to treatment protocols. Nearly half of studies were compound interventions, making it difficult to isolate the effects of individual performance improvement intervention components, though four specific strategies pertaining to recruitment, supervision, incentivisation and equipment were identified.ConclusionsVariations in recruitment, supervision, incentivisation and equipment may improve CHW performance. Practitioners should, however, assess the relevance and feasibility of these strategies in their health setting prior to implementation. Component selection experiments on a greater range of interventions to improve performance ought to be conducted.</jats:sec

Understanding the frustration of academic writers

Have you ever found yourself unable to complete a piece of writing because something else got in the way: a more urgent commitment, a lack of crucial information, an inability to find the right words? If yes, then you are probably well acquainted with frustration, an emotion commonly felt by academic writers but seldom explicitly discussed or examined. When Helen Sword, Evija Trofimova and Madeleine Ballard first set out to write a scholarly article on the topic, they found themselves, well, frustrated. Their experience of writing about writing-related frustration helped them develop strategies for moving beyond it

Implementation Research on Community Health Workers’ Provision of Maternal and Child Health Services in Rural Liberia

OBJECTIVE: To assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme. METHODS: The Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation. FINDINGS: Between 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly. CONCLUSION: We identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes

Oxytocin attenuates phencyclidine hyperactivity and increases social interaction and nucleus accumben dopamine release in rats

The pituitary neuropeptide oxytocin promotes social behavior, and is a potential adjunct therapy for social deficits in schizophrenia and autism. Oxytocin may mediate pro-social effects by modulating monoamine release in limbic and cortical areas, which was investigated herein using in vivo microdialysis, after establishing a dose that did not produce accompanying sedative or thermoregulatory effects that could concomitantly influence behavior. The effects of oxytocin (0.03–0.3 mg/kg subcutaneous) on locomotor activity, core body temperature, and social behavior (social interaction and ultrasonic vocalizations) were examined in adult male Lister-hooded rats, using selective antagonists to determine the role of oxytocin and vasopressin V1a receptors. Dopamine and serotonin efflux in the prefrontal cortex and nucleus accumbens of conscious rats were assessed using microdialysis. 0.3 mg/kg oxytocin modestly reduced activity and caused hypothermia but only the latter was attenuated by the V1a receptor antagonist, SR49059 (1 mg/kg intraperitoneal). Oxytocin at 0.1 mg/kg, which did not alter activity and had little effect on temperature, significantly attenuated phencyclidine-induced hyperactivity and increased social interaction between unfamiliar rats without altering the number or pattern of ultrasonic vocalizations. In the same rats, oxytocin (0.1 mg/kg) selectively elevated dopamine overflow in the nucleus accumbens, but not prefrontal cortex, without influencing serotonin efflux. Systemic oxytocin administration attenuated phencyclidine-induced hyperactivity and increased pro-social behavior without decreasing core body temperature and selectively enhanced nucleus accumbens dopamine release, consistent with activation of mesocorticolimbic circuits regulating associative/reward behavior being involved. This highlights the therapeutic potential of oxytocin to treat social behavioral deficits seen in psychiatric disorders such as schizophrenia

5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting

Introduction: Despite decades of experience with community health workers (CHWs) in a wide variety of global health projects, there is no established conceptual framework that structures how implementers and researchers can understand, study and improve their respective programs based on lessons learned by other CHW programs. Objective: To apply an original, non-linear framework and case study method, 5-SPICE, to multiple sister projects of a large, international non-governmental organization (NGO), and other CHW projects. Design: Engaging a large group of implementers, researchers and the best available literature, the 5-SPICE framework was refined and then applied to a selection of CHW programs. Insights gleaned from the case study method were summarized in a tabular format named the ‘5×5-SPICE chart’. This format graphically lists the ways in which essential CHW program elements interact, both positively and negatively, in the implementation field. Results: The 5×5-SPICE charts reveal a variety of insights that come from a more complex understanding of how essential CHW projects interact and influence each other in their unique context. Some have been well described in the literature previously, while others are exclusive to this article. An analysis of how best to compensate CHWs is also offered as an example of the type of insights that this method may yield. Conclusions: The 5-SPICE framework is a novel instrument that can be used to guide discussions about CHW projects. Insights from this process can help guide quality improvement efforts, or be used as hypothesis that will form the basis of a program's research agenda. Recent experience with research protocols embedded into successfully implemented projects demonstrates how such hypothesis can be rigorously tested

Remoteness and maternal and child health service utilization in rural Liberia: A population–based survey

Background: This study seeks to understand distance from health facilities as a barrier to maternal and child health service uptake within a rural Liberian population. Better understanding the relationship between distance from health facilities and rural health care utilization is important for post–Ebola health systems reconstruction and for general rural health system planning in sub–Saharan Africa. Methods: Cluster–sample survey data collected in 2012 in a very rural southeastern Liberian population were analyzed to determine associations between quartiles of GPS–measured distance from the nearest health facility and the odds of maternal (ANC, facility–based delivery, and PNC) and child (deworming and care seeking for ARI, diarrhea, and fever) service use. We estimated associations by fitting simple and multiple logistic regression models, with standard errors adjusted for clustered data. Findings: Living in the farthest quartile was associated with lower odds of attending 1–or–more ANC checkup (AOR = 0.04, P < 0.001), 4–or–more ANC checkups (AOR = 0.13, P < 0.001), delivering in a facility (AOR = 0.41, P = 0.006), and postnatal care from a health care worker (AOR = 0.44, P = 0.009). Children living in all other quartiles had lower odds of seeking facility–based fever care (AOR for fourth quartile = 0.06, P < 0.001) than those in the nearest quartile. Children in the fourth quartile were less likely to receive deworming treatment (AOR = 0.16, P < 0.001) and less likely (but with only marginal statistical significance) to seek ARI care from a formal HCW (AOR = 0.05, P = 0.05). Parents in distant quartiles more often sought ARI and diarrhea care from informal providers. Conclusions: Within a rural Liberian population, distance is associated with reduced health care uptake. As Liberia rebuilds its health system after Ebola, overcoming geographic disparities, including through further dissemination of providers and greater use of community health workers should be prioritized

Oxytocin attenuates phencyclidine hyperactivity and increases social interaction and nucleus accumben dopamine release in rats

The pituitary neuropeptide oxytocin promotes social behavior, and is a potential adjunct therapy for social deficits in schizophrenia and autism. Oxytocin may mediate pro-social effects by modulating monoamine release in limbic and cortical areas, which was investigated herein using in vivo microdialysis, after establishing a dose that did not produce accompanying sedative or thermoregulatory effects that could concomitantly influence behavior. The effects of oxytocin (0.03-0.3mg/kg s.c.) on locomotor activity, core body temperature and social behavior (social interaction and ultrasonic vocalisations) were examined in adult male Lister-hooded rats, using selective antagonists to determine the role of oxytocin and vasopressin V1A receptors. Dopamine and serotonin (5-HT) efflux in the prefrontal cortex (PFC) and nucleus accumbens (NAc) of conscious rats were assessed using microdialysis. 0.3mg/kg oxytocin modestly reduced activity and caused hypothermia but only the latter was attenuated by the V1A receptor antagonist, SR49059 (1mg/kg i.p.). Oxytocin at 0.1mg/kg, which did not alter activity or temperature, significantly attenuated PCP-induced hyperactivity and increased social interaction between unfamiliar rats without altering the number or pattern of ultrasonic vocalisations. In the same rats, oxytocin (0.1 mg/kg) selectively elevated dopamine overflow in the NAc (F(1, 12)=7.983, P=0.0153), but not PFC, without influencing 5-HT efflux. Systemic oxytocin administration attenuated PCP-induced hyperactivity and increased pro-social behavior without decreasing core body temperature and selectively enhanced NAc dopamine release, consistent with activation of mesocorticolimbic circuits regulating associative/reward behavior being involved. This highlights the therapeutic potential of oxytocin to treat social behavioral deficits seen in psychiatric disorders such as schizophrenia and autism

The feasibility of a strategy for the remote recruitment, consenting and assessment of recent referrals: a protocol for phase 1 of the On-Line Parent Training for the Initial Management of ADHD referrals (OPTIMA)

Background: In the UK, children with high levels of hyperactivity, impulsivity and inattention referred to clinical services with possible attention-deficit/hyperactivity disorder (ADHD) often wait a long time for specialist diagnostic assessment. Parent training (PT) has the potential to support parents during this difficult period, especially regarding the management of challenging and disruptive behaviours that often accompany ADHD. However, traditional face-to-face PT is costly and difficult to organise in a timely way. We have created a low-cost, easily accessible PT programme delivered via a phone app, Structured E-Parenting Support (STEPS), to address this problem. The overall OPTIMA programme will evaluate the efficacy and cost-effectiveness of STEPS as a way of helping parents manage their children behaviour while on the waitlist. To ensure the timely and efficient evaluation of STEPS in OPTIMA, we have worked with children’s health services to implement a remote strategy for recruitment, screening and assessment of recently referred families. Part of this strategy is incorporated into routine clinical practice and part is OPTIMA specific. Here, we present the protocol for Phase 1 of OPTIMA—a study of the feasibility of this remote strategy, as a basis for a large-scale STEPS randomised controlled trial (RCT). Methods: This is a single arm observational feasibility study. Participants will be parents of up to 100 children aged 5-11 years with high levels of hyperactivity/impulsivity, inattention and challenging behaviour who are waiting for assessment in one of five UK child and adolescent mental health or behavioural services. Recruitment, consenting and data collection will occur remotely. The primary outcome will be the rate at which the families, who meet inclusion criteria, agree in principle to take part in a full STEPS RCT. Secondary outcomes include acceptability of remote consenting and online data collection procedures; the feasibility of collecting teacher data remotely within the required timeframe, and technical difficulties with completing online questionnaires. All parents in the study will receive access to STEPS. Discussion: Establishing the feasibility of our remote recruitment, consenting and assessment strategy is a pre-requisite for the full trial of OPTIMA. It can also provide a model for future trials conducted remotely

Building Consensus on Common Features and Interoperability Use Cases for Community Health Information Systems: A Delphi Study

Introduction: Information systems for community health have become increasingly sophistocated and evidence-based in the last decade and they are now the most widely used health information systems in many low- and middle-income countries. This study aimed to establish consensus regarding key features and interoperability priorities for Community Health Information Systems (CHISs). Methods: A Delphi study was conducted among a systematically selected panel of CHIS experts. This impressive pool of experts represented a range of leading global health institutions, with gender and regional balance as well as diversity in their areas of expertise. Through five rounds of iterative surveys and follow-up interviews, the experts established a high degree of consensus. We supplemented the Delphi study findings with a series of Focus Group Discussions with 10 CHW leaders. Results: CHISs today are expected to adapt to a wide range of local contextual requirements and to support and improve care delivery. While once associated with a single role type (CHWs), these systems are now expected to engage other end users, including patients, supervisors, clinicians and data managers. Of 30 World Health Organization-classified digital health interventions for care providers, experts identified 23 (77%) as being important for CHISs. Case management and care coordination features accounted for more than one third (14 of 37, 38%) of the core features expected of CHISs today, a higher proportion than any other category. The highest priority use cases for interoperability include CHIS to HMIS monthly reporting and CHIS to EMR referrals. Conclusion: CHISs today are expected to be feature-rich, to support a range of user roles in community health systems, and to be highly adaptable to local contextual requirements. Future interoperability efforts, like CHISs in general, are expected not only to move data efficiently, but to strengthen community health systems in ways that measurably improve care

Supporting Better Evidence Generation and Use within Social Innovation in Health in Low- and Middle-Income Countries: A Qualitative Study

<div><p>Background</p><p>While several papers have highlighted a lack of evidence to scale social innovations in health, fewer have explored decision-maker understandings of the relative merit of different types of evidence, how such data are interpreted and applied, and what practical support is required to improve evidence generation. The objectives of this paper are to understand (1) beliefs and attitudes towards the value of and types of evidence in scaling social innovations for health, (2) approaches to evidence generation and evaluation used in systems and policy change, and (3) how better evidence-generation can be undertaken and supported within social innovation in health.</p><p>Methods</p><p>Thirty-two one-on-one interviews were conducted between July and November 2015 with purposively selected practitioners, policymakers, and funders from low- and middle- income countries (LMICs). Data were analysed using a Framework Analysis Approach.</p><p>Results</p><p>While practitioners, funders, and policymakers said they held outcome evidence in high regard, their practices only bear out this assertion to varying degrees. Few have given systematic consideration to potential unintended consequences, in particular harm, of the programs they implement, fund, or adopt. Stakeholders suggest that better evidence-generation can be undertaken and supported within social innovation in health by supporting the research efforts of emerging community organizations; creating links between practitioners and academia; altering the funding landscape for evidence-generation; providing responsive technical education; and creating accountability for funders, practitioners, and policymakers.</p><p>Conclusion</p><p>How better evidence-generation can be undertaken and supported within social innovation in health is a previously under-operationalised aspect of the policy-making process that remains essential in order to refrain from causing harm, enable the optimization of existing interventions, and ultimately, to scale and fund what works.</p></div