Every year six million children die worldwide due to diseases that are easily preventable or curable. Interventions to reduce the number of deaths are offered by health facilities, yet many children continue to die at home without receiving any type of health care. Expansion of the strategy for the Integrated Management of Childhood Illness (IMCI), promoted by WHO and UNICEF, provides a unique opportunity to improve health care for young children at the household level. This thesis examines the potential role for community health workers (CHWs) in extending the IMCI strategy from health facilities to the community. A review of the literature on CHWs and IMCI is followed by a description of two state-wide questionnaire surveys and a qualitative study carried out in Sergipe, Northeastern Brazil, aimed at evaluating child health care with particular emphasis on the role ofCHWs. In the first survey, children less than five years of age were investigated regarding morbidity patterns, utilization of health services, socioeconomic and household conditions. A two-stage process led to a representative sample of caretakers of 1,785 children (response rate of 98%). About one third of the families with children were living below the poverty line and under unfavourable environmental conditions. Of all the children studied, 39% had been ill in the two weeks preceding the survey, mostly with acute lower respiratory infections which is the main reason for medical consultations and hospital admissions in the State. Co-morbidity was frequent and 85% of all reported illness episodes were covered by the IMCI strategy. Nine out of 10 children were fully immunized, and 69% had had their growth monitored in the last month. Almost all children who sought care were seen by a health worker. Despite high access to health care, essential drugs were often unavailable in health facilities. Overprescribing was also common with two thirds of children, seen by a doctor, having received an antibiotic. The median duration of total and exclusive breastfeeding were very short at 5.4 months and 2.1 months, respectively. Complementary feeding was also inappropriate with a median number of three meals in the previous 24 hours when, at least, five meals are recommended. There is therefore a potentially significant role for IMCI in improving the quality of care and nutritional management of children under five years of age. CHWs were regularly visiting 81% of all children under five years of age in the State. There was a clear trend towards higher coverage among the poor. Coverage was highest among children living in municipalities in the interior of the State (86.9% against 58.1% in the capital) and in rural areas (88.5% against 76.3% in urban areas). CHWs were also more 8 likely to visit children whose mothers did not attend school (86.3% against 69.3% with nine years or more of schooling) and those belonging to families earning less than one minimum wage (89.2% against 69.4% of families receiving four minimum wages or more). This suggests that CHWs are contributing to reducing inequities in access to basic health care and may explain the high coverage of immunization and growth monitoring activities as CHWs playa major role in delivering these activities. In the second representative survey, 311 CHWs were asked about their knowledge on child survival issues as well as about the support and supervision they received from their local health teams. Again, a two-stage sampling process (municipalities and CHWs) was used with a response rate of 96%. CHWs from Sergipe state were usually female, young and married. Their educational level was substantially higher than that of mothers of young children. Yet, CHWs were inadequately trained, supervised and supported. They were overloaded having to deliver 26 different tasks and usually worked alone in the community. In addition, their professional standing was negatively affected by low salaries, a lack of job security and few fringe benefits. A comparison of families who were regularly visited by CHWs and those that were not, showed a positive effect on maternal knowledge about oral rehydration therapy, breastfeeding and kind of delivery. Children who were visited were also more likely to receive vitamin A and be weighed regularly. The positive impact of CHW visits remained after adjustment for confounding variables. These findings suggest that CHWs are already effective in improving maternal knowledge as well as in providing several interventions that are part of the IMCI strategy. In order to investigate perceptions and beliefs regarding health care, the qualitative study included expert interviews with doctors, nurses and heads of municipal departments of health as well as in-depth interviews with a sample of CHWs. Mothers of children under five years old were enrolled in the qualitative study through focus groups discussions. A total of 90 qualitative interviews and six focus groups were carried out by the author of this thesis and an anthropologist. These data showed that the relationships between facility workers, CHWs and community mothers were often conflicting. Facility workers did not take part in community activities and, in tum, mothers did not participate in group activities in the health facilities. As a result, integration was poor or non-existent. Mothers, especially those from rural areas, wanted a greater availability of doctors and nurses. Most facility workers, in contrast, judged mothers to be highly demanding, making excessive use of health services by seeking health care for mild illnesses, and making inappropriate demands because they 9 lacked knowledge about the roles of the different cadres of health workers. The role of CHWs in the health team was unclear and their tasks were not properly defined. Their relationship with facility workers, especially doctors, was often conflicting. They also did not relate well to urban mothers, who wanted direct access to doctors and who did not feel that CHWs had greater knowledge than themselves. Rural mothers had a generally positive view of CHWs. Currently the main task of CHWs is to act as messengers between the community and the health facility. While this is a positive role per se, CHWs could have a greater impact if their roles in urban and rural areas were more specialized. In urban areas, they should be better trained to deliver educational messages, whereas in rural areas they should also be allowed to perform simple curative tasks to improve their professional standing as well as to deliver key interventions in areas with poor access to health facilities. Almost all respondents stated that extending the activities related to IMCI - such as identifying pneumonia and dysentery at household level through CHWs - would be highly appropriate and desirable. However, to effectively extend IMCI to the community through CHWs, substantial changes would have to occur in their selection, training, supervision, support and professional standing. Several policy recommendations for improving child health in Sergipe are presented. These include improving the performance and professional standing of CHWs and redefining their tasks in the light of the IMCI strategy. Recommendations are also given for improving the integration between communities, facility-based health workers and CHWs, and on how to extend IMCI more effectively to the community through an enhanced role for CHWs.

This Chapter introduces the key issues addressed by this Thesis, and the method by which they are explored, The Thesis was stimulated by experiences of statutory carers as a volunteer supporting elderly people living in the community, My observations of these carers (such as social workers, district nurses, home helps and G.P.s) and the support they provided to elderly people in the community suggested .that there as a fundamental contradiction between, on the one hand, their avowal of the virtue of maintaining elderly people at home for as long as possible (in the 'spirit' of community care policy) and, on the other hand, their ability and willingness to collaborate to achieve this end, To explain this situation, this Thesis explores three aspects of the theory and practice of community care for elderly people: I the historical and conceptual diversity of community care policies in England and Wales as revealed by government publications over the period 1800-1982 and a range of professional and academic literature; I the degree to which community care policies have been officially regarded as dependent upon inter-agency and inter-professional collaboration, and whether in practice community care practitioners have lent such policies their support and agreed on their meaning and implications

This thesis considers the quantitative synthesis of evidence from different study types in order to assess the effectiveness of health interventions. Bayesian MCMC methodology is used extensively, but not exclusively, for the analyses described herein. The thesis commences with consideration of different study designs used in health and related disciplines together with consideration of the validity of these sources. Existing synthesis methods for combining information, first, from a single study design (often referred to as meta-analysis), and then from multiple sources of evidence are then reviewed. A meta-analysis of the randomised evidence on cholesterol lowering observations is presented. This analysis is then extended to a more generalised synthesis by including data from aetiological cohort studies in the analysis using hierarchical modelling methods. Such models allow for heterogeneity between study types. A second generalised synthesis considers evidence from three sources relating to the use of electronic fetal heart rate monitoring during labour. The particular problem of publication bias, and how it can be addressed in a generalised synthesis framework, where there are potentially differential levels of publication bias for the different sources of evidence, is discussed. Adverse events from interventions are often rare, and hence, difficult to detect and quantify using randomised controlled trials. The use of generalised synthesis to quantify adverse events is illustrated using data relating to adverse events of hormone replacement therapy and breast implants. The sparseness of the event data in these examples presents specific statistical problems which are explored. A sensitivity analysis framework for assessing the robustness of results to under-reported adverse events is outlined. A final example, the use of warfarin to prevent strokes in patients with atrial fibrillation, illustrates how disparate sources of data can be synthesised to construct a net-clinical-benefit model where potential benefits of treatment are weighed up against potential harm due to adverse events. This analysis synthesises clinical event data from randomised controlled trials, observational cohort studies for both benefit and harms as well as quality of life data. The net-clinical-benefit of the treatment is expressed, together with corresponding uncertainty measures, for patients with different underlying risks. This thesis illustrates that with the increase in computer power and development of software to fit complex models using Bayesian MCMC methodology, it is now possible to think beyond the models currently used to synthesise medical data. It is hoped that such efforts will be seen as tentative first steps in a future where quantitative models are created routinely to summarise the totality of evidence, and inform models to make decisions for future patients.

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The aim of this study was to develop a video intervention and to determine whether it could be successful in increasing patient participation in medical interviews. The efficacy of the intervention was evaluated by examining the effects of the video on the process of communication and on patient outcomes. The secondary aims of the study were to investigate the role of individual patient differences and the doctor on the consultation. This study was experimental, with patients allocated to one of three groups, experimental, placebo control and control. The experimental group watched a video designed to improve their communication with the doctor, the placebo group saw a neutral video and the control group no video. All patients completed questionnaires assessing anxiety, health related cognitions and health status immediately prior to their consultation. The consultations were audiotaped and subsequently analysed using the Verbal Response Mode coding system (Stiles, 1992). Post-consultation, further questionnaires were completed to assess anxiety, satisfaction, perceived control over recovery and ability to communicate. Data from 206 participants were analysed. The results demonstrated that the video intervention did not result in significant increases in patient participation or improved outcomes. Individual patient differences accounted for a small proportion of the variance in patient participation and satisfaction. Significant differences were found in patient participation and satisfaction according to the doctor seen. Individual patient differences and the doctor seen predicted the patients' verbal contribution to the consultation and patient satisfaction. A significant interaction was found between the experimental group and doctor on the measure of patient satisfaction, in that experimental group patients of one doctor were more satisfied than controls. The findings suggested that targeting an intervention exclusively at patients was insufficient to produce improvements in participation and outcomes, except where circumstances within the consultation were favourable to patient participation. The evidence indicated that doctors play an influential role in the consultation and interventions may be more successful if directed at doctors and patients simultaneously.

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The financial remuneration of health workers (HWs) is a key concern to address human resources challenges in many low-income countries. Analyzing the entire set of payments available to HWs is critical to understand the incentives they face, their motivation and performance, and ultimately to devise effective health workforce reforms. In this thesis, I investigate these issues by exploring the complex remuneration of HWs in Sierra Leone, defined as all income sources, both formal (salary, allowances, performance bonus) and informal (per diems, top-ups, private practice, nonhealth activities and illegal incomes). The study adopts a mixed-method approach. At central level, 23 key informants were conducted along with a stakeholder mapping workshop and a documentary review. At district level, 18 key informants were interviewed. Quantitative data were collected through a cross-sectional survey of 266 public HWs at primary healthcare level in three districts. Additionally, HWs were given a logbook to daily record their activities and incomes. Quantitative data at individual level were complemented with 39 in-depth interviews with a sub-sample of the same HWs. The analysis carried out in this thesis, first, sets the background to the complex remuneration by describing the incentive environment available to HWs as it developed during the post-conflict period, through policy-making processes at macro (central) level. It then investigates how the political economy dynamics between District Health Teams and NGOs at meso (district) level contribute to re-shape the incentive package. Moving to the micro (HW) level, I estimate the absolute and relative contribution of each income and I find that, while earnings from salary represent the largest share, HWs’ income is fragmented and composed of a variety of payments. Further data analysis shows that the determinants of the incomes are not in line with policies defined at national level and are influenced by the district of posting. Furthermore, the HWs’ narratives reveal the relevance of the features of each of their incomes (e.g., amount, regularity, reliability, ease of access, etc.) and the income use strategies through which HWs ‘manage’. Finally, I investigate whether the complex remuneration affects what HWs do or if there are other factors which constrain and/or influence HWs’ activities and service delivery. Findings from this research have important implications for how we go about (re)thinking financial incentive strategies. HWs’ income comes from a variety of sources, which they use differently. This questions the assumption of the fungibility of payments and highlights the potential consequences of increasing one rather than another of HWs’ incomes. Moreover, it is shown that the alignment of policies and incentive packages at central level may not be sufficient as dynamics at district level play a key role in influencing both HWs’ incomes as well as the activities they perform, thus effectively modifying incentive package and service delivery. From a methodological perspective, this thesis contributes to developing data collection and analysis techniques on the complex remuneration of HWs, which are relevant for a potential cross-country research agenda.

Abstract Aim: To describe the processes involved which encourage or inhibit the pursuit of community health within one environmental justice event. To contribute to nursing theory regarding nurses' environmental role, within the provision of holistic care. Method: Mixed methods within an interpretive approach drawing upon critical social theory. It focuses on one critical situation as a case study, namely the development of a local waste strategy that includes a proposarfor a waste incinerator. The sample was derived from documentation related to the case, members of the public, members of local and national government, expert informants and community nurses. Data collection included individual and focus group interviews, observation, local media and policy documentation. Findings: The pursuit of community environmental health requires a framework for dialogue between stakeholders. In the context of this critical study, the meaning of nursing advocacy has become the examination ofthe multiple agendas of stakeholders involved in. decisions that affect communities. The emergence of the community environmental health model demonstrates how community nurses can support a community with envirornnental health concerns and the emergence ofthe community engagement model reveals a cross-sector strategy. Community nurses need to be able to participate as partners in community environmental health without feeling restricted by organisational policies or fear ofconflict. It is argued that the adoption of a community environmental ethic will strengthen any nursing response. Conclusions: Within the proposed framework, nurses can become involved in environmental decision-making and environmental advocacy in partnership with the community. Ultimately nurses can act as a resource to communities and to policymakers. This role demands that nurses challenge professional ideologies in order to partake in the social dimensions of community nursing. It will also require working within defmed geographical boundaries, a clear environmental health agenda and the development of an environmental information base from which to draw. Keywords: community health, community nurses, environmental justice, environmental health, community environmental ethic, nursing advocacy.