Evaluating community health workers performance in the prevention and control of malaria in Livingstone District,Zambia: a bottle neck analysis

THESIS MPHCommunity Health Workers (CHWs) are an important human resource in improving community malaria intervention coverages and success in reducing malaria incidence has been attributed to them. However, despite this attribution, malaria resurgence cases have been reported in various countries including Zambia. This study evaluates fidelity of the CHW strategy through evaluation of performance, quality of service and other moderating strategies in malaria prevention and control in Livingstone district highlighting specific factors that are associated with effective implementation of the CHW strategy in malaria programs. A mixed method concurrent cross-sectional study based on quantitative and qualitative approaches was used to evaluate performance and service quality for the two catchment areas of Nakatindi and Libuyu in Livingstone district. For the quantitative approach, 34 CHWs were taken as complete enumeration with evaluation based on CHW knowledge on malaria, report submission, health education, testing and treating. Service quality was assessed based on active detection, diagnosis and treatment, prescription of drugs, follow up and dissemination of malaria preventive messages and actions. A community survey of 464 participants was also done to assess community responsiveness. Two focused group discussions from CHWs and three key informant interviews from the CHW supervisors were done for moderating factors to the CHW strategy for malaria. The study findings indicate that overall implementation fidelity was low with only 5(14.7%) of the CHWs having good performance and least good quality service while 29 (85.3%) performed poorly with substandard service. This however varied with specific indicators being evaluated. For malaria preventive actions by CHWs; 24(70.5%) of the malaria CHWs reported to practice preventive actions and vector control measures. Being married, record for reports, supervision, and work experience were found to be significant factors associated with performance, and no variable was found to be a significant factor for quality service. From the survey, CHWs have poor coverage for malaria index case service response and that a lot more services are rendered by the CHW which are not documented in the CHW records with ITN distribution as the most service received by the community (75%) and 59% for IRS. Lack of supplies, insufficient remuneration and lack of ownership by the supervising district were main moderating factors that were reported to hinder ideal implementation of the CHW strategy. Fidelity to the malaria CHW strategy was low as performance and quality of service was poor and substandard respectively. Strategies to improve responsiveness by the community and improvement in the organizational system with regards to facilitation of the malaria CHW program in terms of supervision, stock supply and recruiting more CHWs on a more standardized level of recognition and remuneration would render an effective quality implementation of the CHW malaria strategy for this setting. Key words: Community Health worker, Performance, Evaluation, Malaria, Assessment, Implementation, fidelity, quality, adherence, polic

A qualitative study of the role of workplace and interpersonal trust in shaping service quality and responsiveness in Zambian primary health centres

Background: Human decisions, actions and relationships that invoke trust are at the core of functional and productive health systems. Although widely studied in high-income settings, comparatively few studies have explored the influence of trust on health system performance in low- and middle-income countries. This study examines how workplace and inter-personal trust impact service quality and responsiveness in primary health services in Zambia. Methods: This multi-case study included four health centres selected for urban, peri-urban and rural characteristics. Case data included provider interviews (60); patient interviews (180); direct observation of facility operations (two weeks/centre) and key informant interviews (14) that were recorded and transcribed verbatim. Case-based thematic analysis incorporated inductive and deductive coding. Results: Findings demonstrated that providers had weak workplace trust influenced by a combination of poor working conditions, perceptions of low pay and experiences of inequitable or inefficient health centre management. Weak trust in health centre managers' organizational capacity and fairness contributed to resentment amongst many providers and promoted a culture of blame-shifting and one-upmanship that undermined teamwork and enabled disrespectful treatment of patients. Although patients expressed a high degree of trust in health workers' clinical capacity, repeated experiences of disrespectful or unresponsive care undermined patients' trust in health workers' service values and professionalism. Lack of patient–provider trust prompted some patients to circumvent clinic systems in an attempt to secure better or more timely care. Conclusion: Lack of resourcing and poor leadership were key factors leading to providers' weak workplace trust and contributed to often-poor quality services, driving a perverse cycle of negative patient–provider relations across the four sites. Findings highlight the importance of investing in both structural factors and organizational management to strengthen providers' trust in their employer(s) and colleagues, as an entry-point for developing both the capacity and a work culture oriented towards respectful and patient-centred care

Evaluating community health workers performance in the prevention and control of malaria in Livingstone District,Zambia: a bottle neck analysis

Community Health Workers (CHWs) are an important human resource in improving community malaria intervention coverages and success in reducing malaria incidence has been attributed to them. However, despite this attribution, malaria resurgence cases have been reported in various countries including Zambia. This study evaluates fidelity of the CHW strategy through evaluation of performance, quality of service and other moderating strategies in malaria prevention and control in Livingstone district highlighting specific factors that are associated with effective implementation of the CHW strategy in malaria programs. A mixed method concurrent cross-sectional study based on quantitative and qualitative approaches was used to evaluate performance and service quality for the two catchment areas of Nakatindi and Libuyu in Livingstone district. For the quantitative approach, 34 CHWs were taken as complete enumeration with evaluation based on CHW knowledge on malaria, report submission, health education, testing and treating. Service quality was assessed based on active detection, diagnosis and treatment, prescription of drugs, follow up and dissemination of malaria preventive messages and actions. A community survey of 464 participants was also done to assess community responsiveness. Two focused group discussions from CHWs and three key informant interviews from the CHW supervisors were done for moderating factors to the CHW strategy for malaria. The study findings indicate that overall implementation fidelity was low with only 5(14.7%) of the CHWs having good performance and least good quality service while 29 (85.3%) performed poorly with substandard service. This however varied with specific indicators being evaluated. For malaria preventive actions by CHWs; 24(70.5%) of the malaria CHWs reported to practice preventive actions and vector control measures. Being married, record for reports, supervision, and work experience were found to be significant factors associated with performance, and no variable was found to be a significant factor for quality service. From the survey, CHWs have poor coverage for malaria index case service response and that a lot more services are rendered by the CHW which are not documented in the CHW records with ITN distribution as the most service received by the community (75%) and 59% for IRS. Lack of supplies, insufficient remuneration and lack of ownership by the supervising district were main moderating factors that were reported to hinder ideal implementation of the CHW strategy. Fidelity to the malaria CHW strategy was low as performance and quality of service was poor and substandard respectively. Strategies to improve responsiveness by the community and improvement in the organizational system with regards to facilitation of the malaria CHW program in terms of supervision, stock supply and recruiting more CHWs on a more standardized level of recognition and remuneration would render an effective quality implementation of the CHW malaria strategy for this setting. Key words: Community Health worker, Performance, Evaluation, Malaria, Assessment, Implementation, fidelity, quality, adherence, polic

Integrating HIV treatment with primary care outpatient services: opportunities and challenges from a scaled-up model in Zambia

Background: Integration of HIV treatment with other primary care services has been argued to potentially improve effectiveness, efficiency and equity. However, outside the field of reproductive health, there is limited empirical evidence regarding the scope or depth of integrated HIV programmes or their relative benefits. Moreover,the body of work describing operational models of integrated service-delivery in context remains thin. Between 2008 and 2011, the Lusaka District Health Management Team piloted and scaled-up a model of integrated HIV and general outpatient department (OPD) services in 12 primary health care clinics. This paper examines the effect of the integrated model on the organization of clinic services, and explores service providers' perceptions of the integrated model. Methods: We used a mixed methods approach incorporating facility surveys and key informant interviews with clinic managers and district officials. On-site facility surveys were carried out in 12 integrated facilities to collect data on the scope of integrated services, and 15 semi-structured interviews were carried out with 12 clinic managers and three district officials to explore strengths and weaknesses of the model. Quantitative and qualitative data were triangulated to inform overall analysis. Findings: Implementation of the integrated model substantially changed the organization of service delivery across a range of clinic systems. Organizational and managerial advantages were identified, including more efficient use of staff time and clinic space, improved teamwork and accountability, and more equitable delivery of care to HIV and non-HIV patients. However, integration did not solve ongoing human resource shortages or inadequate infrastructure, which limited the efficacy of the model and were perceived to undermine service delivery. Conclusion: While resource and allocative efficiencies are associated with this model of integration, a more important finding was the model's demonstrated potential for strengthening organizational culture and staff relationships, in turn facilitating more collaborative and motivated service delivery in chronically under-resourced primary healthcare clinics

How did rapid scale-up of HIV services impact on workplace and interpersonal trust in Zambian primary health centres: a case-based health systems analysis

Background: In sub-Saharan Africa, large amounts of funding continue to be directed towards HIV-specific care and treatment, often with claims of ‘health system strengthening’ effect. Such claims rarely account for the impact on human relationships and decisions that are core to functional health systems. This research examined how establishment of externally funded HIV services influenced trusting relationships in Zambian health centres. Methods: An in-depth, multicase study included four health centres selected for urban, peri-urban and rural characteristics. Case data included healthcare worker (HCW) interviews (60); patient interviews (180); direct observation of facility operations (2 weeks/centre) and key informant interviews (14) which were recorded and transcribed verbatim. Thematic analysis adopted inductive and deductive coding guided by a framework incorporating concepts of workplace trust, patient–provider trust, intrinsic and extrinsic motivation. Results: HIV service scale-up impacted trust in positive and negative ways. Investment in HIV-specific infrastructure, supplies and quality assurance mechanisms strengthened workplace trust, HCW motivation and patient–provider trust in HIV departments in the short-term. In the health centres more broadly and over time, however, non-governmental organisation-led investment and support of HIV departments reinforced HCW's perceptions of the government as uninterested or unable to provide a quality work environment. Exacerbating existing perceptions of systemic workplace inequity and nepotism, uneven distribution of personal and professional opportunities related to HIV service establishment contributed to interdepartmental antagonism and reinforced workplace practices designed to protect individual HCW's interests. Conclusions: Findings illustrate long-term negative effects of the vertical HIV resourcing and support structures which failed to address and sometimes exacerbated HCW (dis)trust with their own government and supervisors. The short-term and long-term effects of weakened workplace trust on HCWs' motivation and performance signal the importance of understanding how such relationships play a role in generating virtuous or perverse cycles of actor interactions, with implications for service outcomes

Factors contributing to the low turn up of HIV exposed children for follow up care between 12 to 18 months in Chongwe, Chipata, Livingstone and Ndola districts

The impact of loss to follow up of HIV exposed children continues to be a challenge that needs to be addressed especially in communities where people think that HIV testing of HIV exposed children can only be done at 6 weeks. There is an increasing impact of loss to follow up despite the efforts by Ministry of Health and collaborating partners to mitigate the loss to follow up of HIV exposed children. This was observed in HMIS report from 2009 to 2011 where out of 18,037 exposed children who were testing at 6 weeks only 4,519 returned for testing at 18 months representing a 25% drop out in 2009. Similarly 2010, out of 22,494 exposed children who tested at 6 weeks, 7,589 returned for testing at 18 months representing a 33.7% drop out. The dropout rate continued to increase in 2011, which was 34.5% where out of 13,655 who were tested at 6 weeks only 4,724 returned for HIV testing at 18 months.This study aimed at determining the factors contributing to low turn up of HIV exposed children at 12 and 18 months in four selected districts namely; Chipata, Chongwe, Livingstone and Ndola.A descriptive study design was used. Data were collected using a structured interview schedule from 200 randomly selected respondents in the four selected districts. Data were entered and analysed using Microsoft office excel and SPSS spreadsheets.The study revealed that the majority 184 (92%) of the respondents had high knowledge on follow up care services, majority 149 (75%) had a positive attitude towards utilisation of follow up care services and 151 (76%) had good utilisation of follow up care services at 6 weeks.Despite the majority having high knowledge and positive attitude towards follow up care, the majority 163 (81%) did not take their children for HIV testing at 12/18 months. The following were the reasons for not taking their children; 50 (31%) of the respondents said that they did not take their children for HIV testing because they were busy, 46 (28%) was due to stigma, 30 (18%) said their children were fine, 23 (14%) was due to being guilty, 8 (5%) was due to long distance while 6 (4%) was due to long waiting time.The study revealed that majority of the respondents had knowledge and positive attitude towards follow up care. Despite the respondents having positive attitude towards follow up care, the level of utilization of follow up care services particularly HIV testing at 12 and 18 months was low since 81% did not take their children for follow up care. The findings show that respondents had various reasons for not taking their children for HIV testing. The main reason for not taking their children for HIV testing was that they have a busy schedule as mothers/caretakers spend most of their time trying to make ends meet.The study targeted the mothers/caretakers as respondents. There is therefore need to conduct an in-depth study from the service providers' point of view which may reveal other factors contributing to low turn up of HIV exposed children at 12 and 18 months

1. Charges for Residential Accommodation - CRAG Amendment no 9 II. National Assistance (Sums for Personal Requirements) and (Assessment of Resources) Regulations 1998

SIGLEAvailable from British Library Document Supply Centre-DSC:5290.0065(98/8) / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Uptake of intermittent preventive treatment for malaria during pregnancy with Sulphadoxine-Pyrimethamine (IPTp-SP) among postpartum women in Zomba District, Malawi: a cross-sectional study

Abstract Background Malaria in pregnancy causes adverse birth outcomes. Intermittent preventive treatment of malaria during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) is recommended as a chemoprevention therapy. Zomba district IPTp uptake falls far below the national average. The study was conducted to assess determinants of IPTp-SP uptake during pregnancy among postpartum women in Zomba district after adoption of new IPTp-SP policy in 2014. Methods This was a cross-sectional survey. Two public health facilities (HFs) were randomly selected from urban and rural areas in Zomba district. Study participants were postpartum women selected by using exit poll method from HFs. A total of 463 postpartum women were interviewed using structured questionnaire. Bivariate and multiple logistic regression was used in data analysis. Results Out of all the enrolled participants (n = 463), 92% women had complete information for analysis. Of these, (n = 426) women, 127 (29.8%, 95% CI: 25.6%–34.3%) received three or more doses of SP, 299 (70.2%, 95% CI: 65.7%–74.4%) received two or less doses. Women receiving SP from rural HF were less likely to get at least three doses of SP than urban women, (AOR = 0.31, 95% CI 0.13–0.70); Others less likely were those with three or few antenatal care (ANC) visits versus four or more visits (AOR = 0.29, 95% CI 0.18–0.48); not taking SP under direct observation therapy (DOT) (AOR = 0.18, 95% CI (0.05–0.63). Conclusions There is low utilisation of at least three doses of SP in this population and this seems to be associated with the number of ANC visits and use of DOTs. These determinants may therefore be important in shaping interventions aimed at increasing the uptake of IPTp in this district. In addition, the rural urban differential suggests the need for further research to understand the barriers and enablers of uptake in each context in order to improve the health of the community