Protecting small and sick newborn care in the COVID-19 pandemic: multi-stakeholder qualitative data from four African countries with NEST360

Background: Health system shocks are increasing. The COVID-19 pandemic resulted in global disruptions to health systems, including maternal and newborn healthcare seeking and provision. Yet evidence on mitigation strategies to protect newborn service delivery is limited. We sought to understand what mitigation strategies were employed to protect small and sick newborn care (SSNC) across 65 facilities Kenya, Malawi, Nigeria and Tanzania, implementing with the NEST360 Alliance, and if any could be maintained post-pandemic. Methods: We used qualitative methods (in-depth interviews n=132, focus group discussions n=15) with purposively sampled neonatal health systems actors in Kenya, Malawi, Nigeria and Tanzania. Data were collected from September 2021 - August 2022. Topic guides were co-developed with key stakeholders and used to gain a detailed understanding of approaches to protect SSNC during the COVID-19 pandemic. Questions explored policy development, collaboration and investments, organisation of care, human resources, and technology and device innovations. Interviews were conducted by experienced qualitative researchers and data were collected until saturation was reached. Interviews were digitally recorded and transcribed verbatim. A common coding framework was developed, and data were coded via NVivo and analysed using a thematic framework approach. Findings: We identified two pathways via which SSNC was strengthened. The first pathway, COVID-19 specific responses with secondary benefit to SSNC included: rapid policy development and adaptation, new and collaborative funding partnerships, improved oxygen systems, strengthened infection prevention and control practices. The second pathway, health system mitigation strategies during the pandemic, included: enhanced information systems, human resource adaptations, service delivery innovations, e.g., telemedicine, community engagement and more emphasis on planned preventive maintenance of devices. Chronic system weaknesses were also identified that limited the sustainability and institutionalisation of actions to protect SSNC. Conclusion: Innovations to protect SSNC in response to the COVID-19 pandemic should be maintained to support resilience and high-quality routine SSNC delivery. In particular, allocation of resources to sustain high quality and resilient care practices and address remaining gaps for SSNC is critical

Building Forward Better: Inclusive Livelihood Support in Nairobi’s Informal Settlements

For the large population living in Nairobi’s informal settlements, the long-term effects of Covid-19 pose a threat to livelihoods, health, and wellbeing. For those working in the informal sector, who are the lifeblood of the city, livelihoods have been severely supressed by Covid-19 restrictions such as curfews, pushing many into further poverty. This article draws on community data, meetings, and authors’ observations as community organisers, to explore the challenges posed by existing government responses from a community development perspective. We found that poor accountability structures and targeted income support only for the ‘most vulnerable’ exacerbates tensions, mistrust, and insecurity among already vulnerable communities. We draw on a rapid desk review of existing literature to argue that community-led enumeration to validate entitlement claims, improved accountability for distribution, and widening income support is required to build solidarity and improve the future resilience of these communities.Irish Ai

Community participation and maternal health service utilization: lessons from the health extension programme in rural southern Ethiopia

Background Health extension workers (HEWs) are the implementers of the unique primary health care programme of Ethiopia. They facilitate community participation in maternal health service delivery via the health development army (HDA) and pregnant women forums (PWFs). As part of a quality improvement intervention, HEWs received training, guidance and supervision focused on facilitation of HDA meetings and PWFs. We aimed to assess the effect of the intervention on maternal health service utilization and explore the perceptions of stakeholders regarding efforts to enhance community participation in maternal health. Methods We conducted a mixed method study in Shebedino woreda (district), Sidama Zone, southern Ethiopia. The research team observed HDA meetings and PWFs (15), conducted in-depth interviews with 32 HEWs, 8 HEW supervisors and maternal health program managers, and conducted 8 focus group discussions (FGDs) with community members. The interviews and FGDs were recorded, transcribed, translated, coded in Nvivo and thematically analysed. We also collected quantitative data on HDA and PWF participation, antenatal care attendance and skilled delivery and analysed using Excel (Microsoft Inc, Seattle, WA, USA). Results The proportion of HDA leaders and pregnant women who attended the HDA and PWF meetings increased by 30.6% and 36% respectively, over 18 months of the intervention. The percentage of pregnant women identified and referred by HDA leaders increased from 42% to 85%, the antenatal care utilization increased from 73.4% to 77.6% and skilled delivery increased from 76.7% to 83.3%,) (p<0.05). From interviews with stakeholders, we found improved awareness about maternal health services and increased health seeking behaviour. However, lack of incentives and reporting formats for HDA leaders, absenteeism and limited support from kebele administrators constrained community participation in maternal health. Conclusion With focused training, guidance and regular supportive supervision, HEWs were able to stimulate and enhance community participation, resulting in better maternal health service utilization in rural communities. HEWs, volunteer HDAs, pregnant women and the wider community have a role to play in quality improvement of maternal health services

Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique’s community health workforce

Background: Mozambique’s community health programme has a disproportionate number of male community health workers (known as Agentes Polivalentes Elementares (APEs)). The government of Mozambique is aiming to increase the proportion of females to constitute 60% to improve maternal and child health outcomes. To understand the imbalance, this study explored current recruitment processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience, and retention of APEs in Maputo province, Mozambique. Methods: We employed qualitative methods with APEs, APE supervisors, community leaders, and a government official in two districts within Maputo province. Interviews were recorded, transcribed and translated. A coding framework was developed in accordance with thematic analysis to synthesise findings. Findings: In-depth interviews (n=30), key informant interviews (n=1) and focus group discussions (n=3) captured experiences and perceptions of employment processes. Intra-household decision-making structures mean women may experience additional barriers to join the APE programme, often requiring their husband’s consent. Training programmes outside of the community were viewed positively, as an opportunity to build a cohort. However, women reported difficulty leaving family responsibilities behind, and men reported challenges in providing for their families during training as other income generating opportunities were not available to them. These dynamics were particularly acute in the case of single mothers, serving both a provider and primary carer role. Differences in attrition by gender were reported: women are likely to leave the programme when they marry, whereas men tend to leave when offered another job with higher salary. Age and geographic location were also important intersecting factors: younger male and female APEs seek employment opportunities in neighbouring South Africa, whereas older APEs are more content to remain. Conclusion: Gender norms, roles and power dynamics intersect with other axes of inequity such as marital status, age and geographic location to impact recruitment and retention of APEs in Maputo province, Mozambique. Responsive policies to support gender equity within APE recruitment processes are required to support and retain a gender-equitable APE cadre. Resumo O programa de saúde comunitária de Moçambique tem um número desproporcional de agentes comunitários de saúde – Agentes Polivalentes Elementares (APEs) – do sexo masculino. O governo pretende aumentar a proporção de mulheres para 60%, para melhorar indicadores de saúde materna e infantil. Este estudo explora os processos de recrutamento dos APEs e como estes são moldados por normas de gênero; e como os papéis e relações de gênero influenciam a experiência e retenção dos APEs na província de Maputo, Sul de Moçambique. Recorreu-se a métodos qualitativos para selecionar de forma propositada APEs, supervisores dos APE e líderes comunitários. As entrevistas foram gravadas, transcritas e traduzidas. Uma grelha de codificação foi desenvolvida de acordo com a análise temática para sintetizar os resultados. Realizamos entrevistas em profundidade (n=30), informante chave (n=1) e discussões em grupos focais (n=3) para captar as experiências e percepções dos processos de recrutamento. As estruturas decisórias intrafamiliares, implicam que as mulheres podem experienciar barreiras na adesão ao programa dos APE, exigindo frequentemente anuência dos esposos. Os treinamentos fora das comunidades representam aprendizagem em ambiente diferente, todavia, as mulheres relataram dificuldades em deixar as suas responsabilidades familiares, e os homens desafios em prover assistência as suas famílias. Estas dinâmicas agudizaram-se para mães solteiras com o papel de provedoras e de principais cuidadoras. A atracão do programa por gênero revelou que as mulheres tendem a abandonar o programa quando se casam, e os homens a abandonarem quando são oferecidos melhores empregos. A idade e a localização geográfica demonstram que os APEs mais jovens buscam oportunidades de emprego na vizinha África do Sul, e os mais velhos tendem permanecer no programa. Sugerimos que as normas de gênero e a dinâmica de poder se cruzam com outros eixos de desigualdade, como estado civil, idade e localização geográfica, para influenciarem o recrutamento e a retenção dos trabalhadores comunitários de saúde. O fortalecimento dos sistemas de saúde requer políticas mais equitativas e sensíveis para apoiarem a equidade de gênero nos processos de recrutamento e manter dos APEs

Safeguarding in practice: anticipating, minimising and mitigating risk in teenage pregnancy research in urban informal settlements in Nairobi, Kenya

Safeguarding challenges in global health research include sexual abuse and exploitation, physical and psychological abuse, financial exploitation and neglect. Intersecting individual identities (such as gender and age) shape vulnerability to risk. Adolescents, who are widely included in sexual and reproductive health research, may be particularly vulnerable. Sensitive topics like teenage pregnancy may lead to multiple risks. We explored potential safeguarding risks and mitigation strategies when studying teenage pregnancies in informal urban settlements in Nairobi, Kenya. Risk mapping was initiated by the research team that had prolonged engagement with adolescent girls and teen mothers. The team mapped potential safeguarding risks for both research participants and research staff due to, and unrelated to, the research activity. Mitigation measures were agreed for each risk. The draft risk map was validated by community members and coresearchers in a workshop. During implementation, safeguarding risks emerged across the risk map areas and are presented as case studies. Risks to the girls included intimate partner violence because of a phone provided by the study; male participants faced potential disclosure of their perceived criminal activity (impregnating teenage girls); and researchers faced psychological and physical risks due to the nature of the research. These cases shed further light on safeguarding as a key priority area for research ethics and implementation. Our experience illustrates the importance of mapping safeguarding risks and strengthening safeguarding measures throughout the research lifecycle. We recommend co-developing and continuously updating a safeguarding map to enhance safety, equity and trust between the participants, community and researchers

Cultural Norms Create a Preference for Traditional Birth Attendants and Hinder Health Facility-based Childbirth in Indonesia and Ethiopia: A Qualitative Inter-country Study

Cultural barriers to health facility-based childbirth are a common experience worldwide despite wide variations in context. Close-to-community (CTC) maternal health providers play an important role in bridging communities and health systems and their role in maternal health are particularly key. This study explored the views of CTC maternal health providers and other community members on the cultural barriers to health facility-based childbirth in two districts in Indonesia and six districts of Sidama Zone, southern Ethiopia. Employing a qualitative approach, we conducted 110 semi-structured interviews (SSIs) and 7 focus group discussions (FGDs) in Indonesia; 44 SSIs and 14 FGDs in Ethiopia. Participants in both contexts included mothers, husbands, male community members, traditional birth attendants (TBAs), village heads, local administrators, district health officials, maternal health-care workers and CTC maternal health providers. Despite significant geographical and cultural differences, the main findings were similar in the two countries’ study areas. These included: strong cultural-religious beliefs; culture of shyness and privacy around pregnancy; highly gendered decision-making related to pregnancy and childbirth; and preference for the TBA care. TBAs’ close proximity at the time of childbirth and their adherence to traditional practices were important factors influencing preference for TBAs. These cultural barriers interplay with geographical, transportation and financial factors hindering pregnant women from giving birth at a health facility. Intensifying health promotion on health facility-based childbirth, increasing collaboration among CTC maternal health workers e.g. midwives, health extension workers and TBAs, and enhancing responsiveness to traditional practices may overcome cultural barriers to institutional childbirth in Indonesia and Ethiopia

Leaving No One Behind: A Photovoice Case Study on Vulnerability and Wellbeing of Children Heading Households in Two Informal Settlements in Nairobi

Children heading households (CHH) in urban informal settlements face specific vulnerabilities shaped by limitations on their opportunities and capabilities within the context of urban inequities, which affect their wellbeing. We implemented photovoice research with CHHs to explore the intersections between their vulnerabilities and the social and environmental context of Nairobi’s informal settlements. We enrolled and trained four CHHs living in two urban informal settlements—Korogocho and Viwandani—to utilise smartphones to take photos that reflected their experiences of marginalisation and what can be done to address their vulnerabilities. Further, we conducted in-depth interviews with eight more CHHs. We applied White’s wellbeing framework to analyse data. We observed intersections between the different dimensions of wellbeing, which caused the CHHs tremendous stress that affected their mental health, social interactions, school performance and attendance. Key experiences of marginalisation were lack of adequate food and nutrition, hazardous living conditions and stigma from peers due to the limited livelihood opportunities available to them. Despite the hardships, we documented resilience among CHH. Policy action is required to take action to intervene in the generational transfer of poverty, both to improve the life chances of CHHs who have inherited their parents’ marginalisation, and to prevent further transfer of vulnerabilities to their children. This calls for investing in CHHs’ capacity for sustaining livelihoods to support their current and future independence and wellbeing

Supporting community health workers in fragile settings from a gender perspective: a qualitative study

Objective To explore how gender influences the way community health workers (CHWs) are managed and supported and the effects on their work experiences. Setting Two districts in three fragile countries. Sierra Leone—Kenema and Bonthe districts; Liberia—two districts in Grand Bassa county one with international support for CHW activities and one without: Democratic Republic of Congo (DRC)—Aru and Bunia districts in Ituri Province. Participants and methods Qualitative interviews with decision-makers and managers working in community health programmes and managing CHWs (n=36); life history interviews and photovoice with CHWs (n=15, in Sierra Leone only). Results While policies were put in place in Sierra Leone and Liberia to attract women to the newly paid position of CHW after the Ebola outbreak, these good intentions evaporated in practice. Gender norms at the community level, literacy levels and patriarchal expectations surrounding paid work meant that fewer women than imagined took up the role. Only in DRC, there were more women than men working as CHWs. Gender roles, norms and expectations in all contexts also affected retention and progression as well as safety, security and travel (over long distance and at night). Women CHWs also juggle between household and childcare responsibilities. Despite this, they were more likely to retain their position while men were more likely to leave and seek better paid employment. CHWs demonstrated agency in negotiating and challenging gender norms within their work and interactions supporting families. Conclusions Gender roles and relations shape CHW experiences across multiple levels of the health system. Health systems need to develop gender transformative human resource management strategies to address gender inequities and restrictive gender norms for this critical interface cadre

Community Engagement, Co-Production or Citizen Action? Lessons from COVID-19 Responses in India and Bangladesh’s Informal Urban Settlements

Government COVID-19 disease control efforts in many contexts have been critiqued as simultaneously inadequate and authoritarian, causing widespread suffering. “Top-down,” bio-security focused approaches aimed at achieving behavioral change through information dissemination and legal measures have often been ineffective in informal urban settlements, for a range of reasons related to the nature of citizen-state relationships. Community engagement, participation, “co-production,” and citizen- and civil-society-led efforts have variously been identified as important to pandemic responses. However, to date, there have been few examinations of the ways in which social, political, and economic environments shape community actions during the COVID-19 pandemic, and the extent to which these have reached the most marginalized. Drawing on data and experiences of collaborative research and action from four cities in Bangladesh and India, we argue that citizen and community responses in informal settlements have often emerged from the necessity to survive in the absence of effective state interventions and support to guarantee the basic rights of citizens. They therefore represent neither engagement of the state with citizens nor genuine “co-production.” Community action emerging from inadequacies in state responses merely pushes the responsibilities of the state to poor and marginalized communities, many of which are fractured by axes of disadvantage such as length of residence, class, caste, religion, and gender. Effective community engagement or co-production requires the willingness of the state to recognize the rights of informal urban residents as urban citizens, trusting relationships within systems and structures built over time prior to a crisis, and the willingness of the state to share resources and cede power over decision making. Multi-sectoral, multi-scalar and multi-stakeholder collaborations that balance “top-down” public health policy implementation with community organization, through communication and accountability channels that privilege the perspectives of the marginalized, are required. Community engagement and co-production cannot be a standardized intervention but require ongoing processes of political, social, economic, and cultural negotiation and will play out in varied ways across different contexts

How are Research for Development Programmes Implementing and Evaluating Equitable Partnerships to Address Power Asymmetries?

The complexity of issues addressed by research for development (R4D) requires collaborations between partners from a range of disciplines and cultural contexts. Power asymmetries within such partnerships may obstruct the fair distribution of resources, responsibilities and benefits across all partners. This paper presents a cross-case analysis of five R4D partnership evaluations, their methods and how they unearthed and addressed power asymmetries. It contributes to the field of R4D partnership evaluations by detailing approaches and methods employed to evaluate these partnerships. Theory-based evaluations deepened understandings of how equitable partnerships contribute to R4D generating impact and centring the relational side of R4D. Participatory approaches that involved all partners in developing and evaluating partnership principles ensured contextually appropriate definitions and a focus on what partners value