Assessing the Impact of Community Engagement Interventions on Health Worker Motivation and Experiences with Clients in Primary Health Facilities in Ghana:A Randomized Cluster Trial

BackgroundHealth worker density per 1000 population in Ghana is one of the lowest in the world estimated to be 2.3, below the global average of 9.3. Low health worker motivation induced by poor working conditions partly explain this challenge. Albeit the wage bill for public sector health workers is about 90% of domestic government expenditure on health in countries such as Ghana, staff motivation and performance output remain a challenge, suggesting the need to complement financial incentives with non-financial incentives through a community-based approach. In this study, a systematic community engagement (SCE) intervention was implemented to engage community groups in healthcare quality assessment to promote mutual collaboration between clients and healthcare providers, and enhance health worker motivation levels. SCE involves structured use of existing community groups and associations to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements made and rewards given to best performing facilities for closing quality care gaps.Purpose To evaluate the effect of SCE interventions on health worker motivation and experiences with clients.Methods The study is a cluster randomized trial involving health workers in private (n = 38) and public (n = 26) primary healthcare facilities in two administrative regions in Ghana. Out of 324 clinical and non-clinical staff randomly interviewed at baseline, 234 (72%) were successfully followed at end-line and interviewed on workplace motivation factors and personal experiences with clients. Propensity score matching and difference-in-difference estimations were used to estimate treatment effect of the interventions on staff motivation.Results Intrinsic (non-financial) work incentives including cordiality with clients and perceived career prospects appeared to be prime sources of motivation for health staff interviewed in intervention health facilities while financial incentives were ranked lowest. Intervention health facilities that were assessed by female community groups (Coef. = 0.2720, p = 0.0118) and informal groups with organized leadership structures like Artisans (Coef. = 0.2268, p = 0.0368) associated positively with higher intrinsic motivation levels of staff.Conclusion Community-based approach to health worker motivation is a potential complementary strategy that needs policy deliberation to explore its prospects. Albeit financial incentives remain critical sources of staff motivation, innovative non-financial approaches like SCE should complement the latter

Perspectives of frontline health workers on Ghana's National Health Insurance Scheme before and after community engagement interventions

BackgroundBarely a decade after introduction of Ghana’s National Health Insurance Scheme (NHIS), significant successes have been recorded in universal access to basic healthcare services. However, sustainability of the scheme is increasingly threatened by concerns on quality of health service delivery in NHIS-accredited health facilities coupled with stakeholders’ discontentment with the operational and administrative challenges confronting the NHIS. The study sought to ascertain whether or not Systematic Community Engagement (SCE) interventions have a significant effect on frontline health workers’ perspectives on the NHIS and its impact on quality health service delivery.MethodsThe study is a randomized cluster trial involving clinical and non-clinical frontline health workers (n = 234) interviewed at baseline and follow-up in the Greater Accra and Western regions of Ghana. Individual respondents were chosen from within each intervention and control groupings. Difference-in-difference estimations and propensity score matching were performed to determine impact of SCE on staff perceptions of the NHIS. The main outcome measure of interest was staff perception of the NHIS based on eight (8) factor-analyzed quality service parameters.ResultsStaff interviewed in intervention facilities appeared to perceive the NHIS more positively in terms of its impact on “availability and quality of drugs (p < 0.05)” and “workload on health staff/infrastructure” than those interviewed in control facilities (p < 0.1). Delayed reimbursement of service providers remained a key concern to over 70 % of respondents in control and intervention health facilities.ConclusionCommunity engagement in quality service assessment is a potential useful strategy towards empowering communities while promoting frontline health workers’ interest, goodwill and active participation in Ghana’s NHIS

Perspectives of frontline health workers on Ghana's National Health Insurance Scheme before and after community engagement interventions

BackgroundBarely a decade after introduction of Ghana’s National Health Insurance Scheme (NHIS), significant successes have been recorded in universal access to basic healthcare services. However, sustainability of the scheme is increasingly threatened by concerns on quality of health service delivery in NHIS-accredited health facilities coupled with stakeholders’ discontentment with the operational and administrative challenges confronting the NHIS. The study sought to ascertain whether or not Systematic Community Engagement (SCE) interventions have a significant effect on frontline health workers’ perspectives on the NHIS and its impact on quality health service delivery.MethodsThe study is a randomized cluster trial involving clinical and non-clinical frontline health workers (n = 234) interviewed at baseline and follow-up in the Greater Accra and Western regions of Ghana. Individual respondents were chosen from within each intervention and control groupings. Difference-in-difference estimations and propensity score matching were performed to determine impact of SCE on staff perceptions of the NHIS. The main outcome measure of interest was staff perception of the NHIS based on eight (8) factor-analyzed quality service parameters.ResultsStaff interviewed in intervention facilities appeared to perceive the NHIS more positively in terms of its impact on “availability and quality of drugs (p < 0.05)” and “workload on health staff/infrastructure” than those interviewed in control facilities (p < 0.1). Delayed reimbursement of service providers remained a key concern to over 70 % of respondents in control and intervention health facilities.ConclusionCommunity engagement in quality service assessment is a potential useful strategy towards empowering communities while promoting frontline health workers’ interest, goodwill and active participation in Ghana’s NHIS

University students and HIV in Namibia: an HIV prevalence survey and a knowledge and attitude survey

<p>Abstract</p> <p>Background</p> <p>With an overall adult HIV prevalence of 15.3%, Namibia is facing one of the largest HIV epidemics in Africa. Young people aged 20 to 34 years constitute one of the groups at highest risk of HIV infection in Namibia. However, little is known about the impact of HIV on this group and its access to healthcare. The purpose of this study was to estimate HIV prevalence, to assess the knowledge of and attitudes towards HIV/AIDS, and to assess access to healthcare among university students in Namibia.</p> <p>Methods</p> <p>We assessed HIV/AIDS knowledge and attitudes, HIV prevalence and access to healthcare among students at the Polytechnic of Namibia and the University of Namibia. HIV prevalence was tested through anonymous oral fluid-based tests.</p> <p>Results</p> <p>Half (n = 2790/5568) of the university students and 45% (n = 2807/6302) of the Polytechnic students participated in the knowledge and attitudes surveys. HIV/AIDS knowledge was reasonable, except for misperceptions about transmission. Awareness of one's own HIV status and risks was low. In all, 55% (n = 3055/5568) of university students and 58% (n = 3680/6302) of Polytechnic students participated in the HIV prevalence survey; 54 (1.8%) university students and 103 (2.8%) Polytechnic students tested HIV positive. Campus clinics were not the major providers of healthcare to the students.</p> <p>Conclusions</p> <p>Meaningful strategies addressing the gap between knowledge, attitude and young people's perception of risk of HIV acquisition should be implemented. HIV prevalence among Namibian university students appears relatively low. Voluntary counselling and testing should be stimulated. Efforts should be made to increase access to healthcare through the campus clinics.</p

Efficiency of private and public primary health facilities accredited by the National Health Insurance Authority in Ghana

Background: Despite improvements in a number of health outcome indicators partly due to the National HealthInsurance Scheme (NHIS), Ghana is unlikely to attain all its health-related millennium development goals before theend of 2015. Inefficient use of available limited resources has been cited as a contributory factor for this predicament.This study sought to explore efficiency levels of NHIS-accredited private and public health facilities; ascertain factorsthat account for differences in efficiency and determine the association between quality care and efficiency levels.Methods: The study is a cross-sectional survey of NHIS-accredited primary health facilities (n = 64) in two regionsin southern Ghana. Data Envelopment Analysis was used to estimate technical efficiency of sampled health facilitieswhile Tobit regression was employed to predict factors associated with efficiency levels. Spearman correlation testwas performed to determine the association between quality care and efficiency.Results: Overall, 20 out of the 64 health facilities (31 %) were optimally efficient relative to their peers. Out of the20 efficient facilities, 10 (50 %) were Public/government owned facilities; 8 (40 %) were Private-for-profit facilitiesand 2 (10 %) were Private-not-for-profit/Mission facilities. Mission (Coef. = 52.1; p = 0.000) and Public (Coef. = 42.9;p = 0.002) facilities located in the Western region (predominantly rural) had higher odds of attaining the 100 % tech‑nical efficiency benchmark than those located in the Greater Accra region (largely urban). No significant associationwas found between technical efficiency scores of health facilities and many technical quality care proxies, except inoverall quality score per the NHIS accreditation data (Coef. = −0.3158; p &lt; 0.05) and SafeCare Essentials quality scoreon environmental safety for staff and patients (Coef. = −0.2764; p &lt; 0.05) where the association was negative.Conclusions: The findings suggest some level of wastage of health resources in many healthcare facilities, especiallythose located in urban areas. The Ministry of Health and relevant stakeholders should undertake more effective needanalysis to inform resource allocation, distribution and capacity building to promote efficient utilization of limitedresources without compromising quality care standards

Association between health worker motivation and healthcare quality efforts in Ghana

AbstractBackground: Ghana is one of the sub-Saharan African countries making significant progress towards universal accessto quality healthcare. However, it remains a challenge to attain the 2015 targets for the health related MillenniumDevelopment Goals (MDGs) partly due to health sector human resource challenges including low staff motivation.Purpose: This paper addresses indicators of health worker motivation and assesses associations with quality care andpatient safety in Ghana. The aim is to identify interventions at the health worker level that contribute to qualityimprovement in healthcare facilities.Methods: The study is a baseline survey of health workers (n = 324) in 64 primary healthcare facilities in two regions inGhana. Data collection involved quality care assessment using the SafeCare Essentials tool, the National HealthInsurance Authority (NHIA) accreditation data and structured staff interviews on workplace motivating factors. TheSpearman correlation test was conducted to test the hypothesis that the level of health worker motivation is associatedwith level of effort by primary healthcare facilities to improve quality care and patient safety.Results: The quality care situation in health facilities was generally low, as determined by the SafeCare Essentials tooland NHIA data. The majority of facilities assessed did not have documented evidence of processes for continuousquality improvement and patient safety. Overall, staff motivation appeared low although workers in private facilitiesperceived better working conditions than workers in public facilities (P &lt;0.05). Significant positive associations werefound between staff satisfaction levels with working conditions and the clinic’s effort towards quality improvement andpatient safety (P &lt;0.05).Conclusion: As part of efforts towards attainment of the health related MDGs in Ghana, more comprehensive staffmotivation interventions should be integrated into quality improvement strategies especially in government-ownedhealthcare facilities where working conditions are perceived to be the worst

Diabetes, HIV and other health determinants associated with absenteeism among formal sector workers in Namibia

<p>Abstract</p> <p>Background</p> <p>As countries in sub-Saharan Africa develop their economies, it is important to understand the health of employees and its impact on productivity and absenteeism. While previous studies have assessed the impact of single conditions on absenteeism, the current study evaluates multiple health factors associated with absenteeism in a large worker population across several sectors in Namibia.</p> <p>Methods</p> <p>From March 2009 to June 2010, PharmAccess Namibia conducted a series of cross-sectional surveys of 7,666 employees in 7 sectors of industry in Namibia. These included a self-reported health questionnaire and biomedical screenings for certain infectious diseases and non-communicable disease (NCD) risk factors. Data were collected on demographics, absenteeism over a 90-day period, smoking behavior, alcohol use, hemoglobin, blood pressure, blood glucose, cholesterol, waist circumference, body mass index (BMI), HIV status, and presence of hepatitis B antigens and syphilis antibodies. The associations of these factors to absenteeism were ascertained using negative binomial regression.</p> <p>Results</p> <p>Controlling for demographic and job-related factors, high blood glucose and diabetes had the largest effect on absenteeism (IRR: 3.67, 95%CI: 2.06-6.55). This was followed by anemia (IRR: 1.59, 95%CI: 1.17-2.18) and being HIV positive (IRR: 1.47; 95%CI: 1.12-1.95). In addition, working in the fishing or services sectors was associated with an increased incidence of sick days (IRR: 1.53, 95%CI: 1.23-1.90; and IRR: 1.70, 95%CI: 1.32-2.20 respectively). The highest prevalence of diabetes was in the services sector (3.6%, 95%CI:-2.5-4.7). The highest prevalence of HIV was found in the fishing sector (14.3%, 95%CI: 10.1-18.5).</p> <p>Conclusion</p> <p>Both NCD risk factors and infectious diseases are associated with increased rates of short-term absenteeism of formal sector employees in Namibia. Programs to manage these conditions could help employers avoid costs associated with absenteeism. These programs could include basic health care insurance including regular wellness screenings.</p

Effect of Community Engagement Interventions on Patient Safety and Risk Reduction Efforts in Primary Health Facilities:Evidence from Ghana

BackgroundPatient safety and quality care remain major challenges to Ghana’s healthcare system. Like many health systems in Africa, this is largely because demand for healthcare is outstripping available human and material resource capacity of healthcare facilities and new investment is insufficient. In the light of these demand and supply constraints, systematic community engagement (SCE) in healthcare quality assessment can be a feasible and cost effective option to augment existing quality improvement interventions. SCE entails structured use of existing community groups to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements identified and rewards provided if the quality gaps are closed.PurposeThis paper evaluates whether or not SCE, through the assessment of health service quality, improves patient safety and risk reduction efforts by staff in healthcare facilities.MethodsA randomized control trail was conducted in 64 primary healthcare facilities in the Greater Accra and Western regions of Ghana. Patient risk assessments were conducted in 32 randomly assigned intervention and control facilities. Multivariate multiple regression test was used to determine effect of the SCE interventions on staff efforts towards reducing patient risk. Spearman correlation test was used to ascertain associations between types of community groups engaged and risk assessment scores of healthcare facilities.FindingsClinic staff efforts towards increasing patient safety and reducing risk improved significantly in intervention facilities especially in the areas of leadership/accountability (Coef. = 10.4, p&lt;0.05) and staff competencies (Coef. = 7.1, p&lt;0.05). Improvement in service utilization and health resources could not be attributed to the interventions because these were outside the control of the study and might have been influenced by institutional or national level developments between the baseline and follow-up period. Community groups that were gender balanced, religious/faith-based, and had structured leadership appeared to be better options for effective SCE in healthcare quality assessment.ConclusionCommunity engagement in healthcare quality assessment is a feasible client-centered quality improvement option that should be discussed for possible scale-up in Ghana and other resource poor countries in Africa

Incidence of HIV in Windhoek, Namibia: Demographic and Socio-Economic Associations

To estimate HIV incidence and prevalence in Windhoek, Namibia and to analyze socio-economic factors related to HIV infection. In 2006/7, baseline surveys were performed with 1,753 private households living in the greater Windhoek area; follow-up visits took place in 2008 and 2009. Face-to-face socio-economic questionnaires were administrated by trained interviewers; biomedical markers were collected by nurses; GPS codes of household residences were recorded. The HIV prevalence in the population (aged>12 years) was 11.8% in 2006/7 and 14.6% in 2009. HIV incidence between 2007 and 2009 was 2.4 per 100 person year (95%CI = 1.9-2.9). HIV incidence and prevalence were higher in female populations. HIV incidence appeared non-associated with any socioeconomic factor, indicating universal risk for the population. For women a positive trend was found between low per-capita consumption and HIV acquisition. A HIV knowledge score was strongly associated with HIV incidence for both men and women. High HIV prevalence and incidence was concentrated in the north-western part of the city, an area with lower HIV knowledge, higher HIV risk perception and lower per-capita consumption. The HIV incidence and prevalence figures do not suggest a declining epidemic in Windhoek. Higher vulnerability of women is recorded, most likely related to economic dependency and increasing transactional sex in Namibia. The lack of relation between HIV incidence and socio-economic factors confirms HIV risks for the overall urban community. Appropriate knowledge is strongly associated to lower HIV incidence and prevalence, underscoring the importance of continuous information and education activities for prevention of infection. Geographical areas were identified that would require prioritized HIV campaignin

Interrogating the Impact of Intestinal Parasite-Microbiome on Pathogenesis of COVID-19 in Sub-Saharan Africa

Intestinal parasitic infections affect more than 2 billion people throughout the world with disproportionately high prevalence rates in Low- and Middle-Income Countries (LMICs) (Herricks et al., 2017). Multicellular and highly complex parasites such as Ascaris, hook worm, Trichuris, Enterobius and Schistosoma, as well as unicellular organisms including Entamoeba, Giardia, Toxoplasma, Cyclospora, and Cryptosporidium are among major pathogens that contribute to the global intestinal parasitic disease burden. Parasites can cause persistent infection due to their ability to resist immune-mediated expulsion by modulating the host's immune response (McSorley and Maizels, 2012; Wammes et al., 2014; Chabé et al., 2017; Burrows et al., 2019; Ryan et al., 2020). There is a complex interaction between parasites and human microbiota which can triangulate with host's immune homeostasis and host responses to bystander antigens, vaccines or other unrelated diseases, both infectious and non-communicable diseases (McSorley and Maizels, 2012; Wammes et al., 2014). Recently, the world has grappled with an unprecedented pandemic due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that causes coronavirus disease 2019 (COVID-19) (WHO, 2020). The pathogenesis of severe disease in COVID-19 has been linked to the phenomenon of immune hyperactivation (Sinha et al., 2020; Tay et al., 2020). Here, we propose that the interplay between intestinal parasites and microbiome may have a potential direct or indirect effects on the pathogenesis of SARS-CoV-2 infection, in particular in the context of LMICs