Understanding community health worker employment preferences in Malang district, Indonesia using a discrete choice experiment

BACKGROUND: Community health workers (CHWs) play a critical role in supporting health systems, and in improving accessibility to primary healthcare. In many settings CHW programmes do not have formalised employment models and face issues of high attrition and poor performance. This study aims to determine the employment preferences of CHWs in Malang district, Indonesia, to inform policy interventions. METHODS: A discrete choice experiment was conducted with 471 CHWs across 28 villages. Attributes relevant to CHW employment were identified through a multistage process including literature review, focus group discussions and expert consultation. Respondents’ choices were analysed with a mixed multinomial logit model and latent class analyses. RESULTS: Five attributes were identified: (1) supervision; (2) training; (3) monthly financial benefit; (4) recognition; and (5) employment structure. The most important influence on choice of job was a low monthly financial benefit (US$~2) (β=0.53, 95$~20) was most unappealing to respondents (β=−0.13, 95% CI=−0.23 to −0.03). Latent class analysis identified two groups of CHWs who differed in their willingness to accept either job presented and preferences over specific attributes. Preferences diverged based on respondent characteristics including experience, hours’ worked per week and income. CONCLUSION: CHWs in Malang district, Indonesia, favour a small monthly financial benefit which likely reflects the unique cultural values underpinning the programme and a desire for remuneration that is commensurate with the limited number of hours worked. CHWs also desire enhanced methods of performance feedback and greater structure around training and their rights and responsibilities. Fulfilling these conditions may become increasingly important should CHWs work longer hours

Observations of a noctilucent cloud above Logan, Utah (41.7oN, 111.8oW) in 1995

A Rayleigh-scatter lidar has been operated at the Atmospheric Lidar Observatory (ALO) on the Utah State University (USU) campus (41.7°N, 111.8°W) since August 1993. During the morning of 22 June 1995, lidar returns from a noctilucent cloud (NLC) were observed for approximately 1 hr, well away from the twilight periods when NLCs are visible. This detection of an NLC at this latitude shows that the first reported sighting, in 1999 (Wickwar et al., 2002), was not a unique occurrence. This 1995 observation differs from the 1999 one in that temperatures could be deduced. Near the 83-km NLC altitude the temperatures were found to be up to ∼23 K cooler than the 11-year June climatology for ALO. This analysis shows that these cool temperatures arose, not because the whole profile was cooler, but because of a major temperature oscillation or wave with a 22-km vertical wavelength and a ∼0.9 km/hr downward phase speed. This large-amplitude wave has many of the characteristics of the diurnal tide. However, the amplitude would have to be enhanced considerably. These lidar observations were supplemented by OH rotational temperature observations from approximately 87 km. These NLC observations equatorward of 50° have been suggested to be significant harbingers of global change. However, if that were the case, the mechanism is more complicated than a simple overall cooling or an increase in water vapor. Accordingly, we propose enhanced generation of gravity waves that would interact with the diurnal tide to produce a large-amplitude wave, the cold phase of which would give rise to low enough temperatures to produce the NLC. The gravity wave source might be orographic in the Mountain West or convective far to the east or south

Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project

Background and objectives: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. Methods: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. Results: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. Conclusion: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia

The design of incentives for community health workers in Indonesia during the COVID-19 pandemic

In many low- and middle-income countries, community health workers (CHWs) play a crucial role in extending the reach of primary health care systems. Typically, CHWs provide basic health services to their own community, for which they receive limited training, support and remuneration. Financial and non-financial incentives play an important role in supporting the retention, motivation and performance of CHWs yet the acceptability of incentives is largely context dependent. Indonesia is home to one of the largest and longest-standing CHW programs yet these areas of research have received relatively limited attention. In this thesis I assess the design of appropriate incentive strategies for kaders, the Indonesian community workforce through a range of studies conducted in Malang district, East Java, Indonesia. Chapter 1 introduces the CHW program in Indonesia and outlines the scope of this thesis. Chapter 2 systematically reviews the impact of incentives for CHWs. Chapter 3 reports a pilot study that tested the feasibility of financial and non-financial incentives for kaders. In chapter 4, kaders’ preferences for their working conditions are examined through a discrete choice experiment. The emergence of the COVID-19 pandemic disrupted plans for a trial of incentives yet provided an opportunity to examine tangential areas of research. In chapter 5, for instance, the kaders’ role in pandemic response efforts in Malang district was assessed, including the influence of social capital. Lastly, in chapter 6 an evaluation is reported that assessed decentralised decision-making during the pandemic, specifically related to the design incentives for kaders. In chapter 7, I synthesise all study findings and discuss the policy implications for the CHW program in Indonesia, decentralised decision-making in Malang district and the country’s attainment of universal health coverage. Kaders are a critical part of the primary health workforce in Indonesia and have the potential to play a larger role in contributing to progress towards universal health coverage. Appropriately incentivising and providing further support to kaders will be fundamental to realising their often untapped capacity but doing so requires addressing health system governance challenges at the village level