A research report submitted to the Faculty of Health Sciences, University of The Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Science Epidemiology in the Field of Implementation Sciences. May 2018 Johannesburg, South Africa. / Background: Surveillance structures for tuberculosis (TB) contact tracing are not well integrated into routine national reporting structures. The implementation of reingineering of primary health care through ward based outreach teams (WBOTs) is a step towards equitable primary health care. Data and information collected by WBOTs for household TB contact tracing is an integral part of the implementation model of primary health care reengineering. The quality of patient record documentation becomes even more vital in light of the increased focus on process and outcome measures in health programmes and as a result, careful consideration be given to the WBOT data collection system used by community health workers (CHWs). In order to contribute to efforts of developing an optimised model for household contact tracing, the acceptability of the current paper-based data collection system needs to be assessed in order to develop a comprehensive monitoring & evaluaiton (M&E) framework for an optimsed model for household tuberculosis contact tracing. Methods: The current cross sectional research project is nested within a project that aims to develop an optimised model for household TB contact tracing. In this nested mixed methods study; the exploratory sequential design was used to explore the facilitators and barriers to completing the current data collection tools used by CHWs. The study had two components, firstly three focus group discussions (FGDs) were conducted in the three Ekurhuleni health sub-districts (Northern, Eastern and Southern) in three purposively selected primary health clinics and secondary data analysis of the main study`s FGDs was also conducted. Manual coding and QDA Miner software was used for coding and all qualitative analysis. Emerging themes were identified through inductive thematic analysis using the constant comparison analysis framework. The results informed the quantitative data collection and analysis. Following qualitative analysis; a close ended questionnaire was refined and informed by the results of the qualitative inquiry. CHWs were recruited using targetted sampling techniques from 6 primary health care facilities located in the different sub-districts in order to administer the questionnaire. The four point Likert Scale questionnaire was developed using theoritical framework for acceptability (TFA) constructs to asses the level of acceptability of the current data collection tools used to document tuberculosis contact tracing activities. Univariate and multivariate linear regression models were fitted to examine significant relationships between the composite acceptability scores and several predictors. All quantitative analysis was perforned on STATA version 14 (StataCorp College Station, Texas 77845 USA). Results: A total of five FGDs were conducted; two that were conducted as part of the main study supplemented the data from the three that were conducted (one in each Ekurhuleni health Sub-district). The total of 54 CHWs participated in all the five FGDs with 89% being female. Average age of all CHWs was 34.41 years [mean (sd): 34.41(8.16)]. Five broad themes emerged including inadequate CHW training, WBOT programme integration with other health and social care service providers, challenges with the WBOT data collection system, community access issues and preference for a digital based data collection system. Data related barriers identified included limitations with the current paper based data collection system such as insufficient competency assessments about the different data collection tools, lack of a specific tool to capture TB contact tracing activities, incomplete referral forms due to clinic staff not completing them, patients providing wrong information, too many papers to complete. Those that were related to the WBOT actvities included lack of community acceptance, resource constraints, violent patients and community members, community members that are not welcoming . Facilitators included motivated CHWs. 94 CHWs were enrolled for the quantitative survey with 90 (95.74%) females. From the total, 35% of the CHWs were from the Ekurhuleni health southern subdistrict, 34% and 31% were from the eastern and northern sub-districts respectively. The overall median (IQR) composite acceptability scores from all sub-districts was 48 (45 51), with the highest scores observed in the Eastern sub-district 49 (45 46) . In the overall study population, the acceptability of the current WBOT data collection tools was low. Conclusions: Main findings pertaining to CHW training indicate that the different phases of the Primary Health Care (PHC) reingeering WBOT trainings were inconsistent. There is also a lack of acknowledgement of attendance as CHW expressed their dissatisfaction in not receiving certifications which resulted in low morale for conducting outreach activities. The sub-optimal integration of the WBOT programme into the primary health care system results in a patchy referral system characterised by incomplete back referrals resulted as referral forms remain incomplete. Communication between the primary health care facility staff and WBOT CHWs needs to be strengthened in order to strengthen the referral linkages with other health and social care service providers. Funding models for WBOT programme need to be reviewed to ensure that resources needed for optimal WBOT functioning are secured. Restricted access to some communities, patients providing wrong addresses, violent and unwelcoming household members and lack of WBOT safety were barriers to accessing TB patients during outreach activities; thus leading to incomplete and innacurate data. The limitations posed by the current paper-based data collection system have been acknowledged and the CHWs preference for a digital based system highlights the need for the evaluation of the current mobile data collection technologies in other regions in order to inform nationwide scale-up. Recommendations: The implementation of the WBOT programme is still in its infancy and in order to improve the data collection processes of the programme, more research on CHW post-training competence is needed to determine the effectiveness of the wide array of training programs. Moreover, the implementation of CHW program should be coordinated among the different training providers including government, civil society organizations and NGOs. To improve the quality of the CHW training delivery and content, CHW feedback should be sought through pre-and post-assessments. There is a need to focus efforts on coordinating and strengthening the different PHC reengineering streams and integrate them into the primary health care system. This will likely strengthen the referral system between the WBOT programme and PHC facilities. The current M&E policy needs to be reviewed and special consideration should be given to TB contact tracing related indicators. This should also be accompanied by an adjustment of the current WBOT data collection tools to better reflect the agreed upon TB contact tracing indicators. The study further recommends further research in the form of economic evaluations to determine the cost effectiveness of scaling up current digital based data collection methods to inform nationwide scale up. Key words: Ward Based Outreach Teams, data collection system, data collection tools, community health workers, TB contact tracing, Community Based Information System, acceptabiltity, mHealth / LG2018

Indiana University-Purdue University Indianapolis (IUPUI) / Community Health Workers (CHW) are trusted frontline members of the public health workforce with a unique understanding of the communities they serve. CHW interventions have been shown effective and economical in improving certain health outcomes, including diabetes-related complications and self-management. The ability of CHWs to relate to patients in a culturally appropriate manner positions them to better address social determinants of health and inequities than many allied health professionals. State-level CHW legislation varies by jurisdiction and can direct CHW processes including definitions, funding, and scope of practice. The Diabetes Project – Indianapolis Neighborhoods (DIP-IN) intervention employs clinic-based CHWs to work with high-risk patients with diabetes in three Indianapolis communities with disproportionately high diabetes prevalence rates. DIP-IN CHWs are based in select Eskenazi Health Federally Qualified Health Centers and deliver services to patients primarily through home visits or phone calls. This dissertation examines CHW policies and the impact of the DIP-IN CHW intervention on patient outcomes in relation to a comparison group. This dissertation includes three studies 1) a state-level policy surveillance exploring legislation that includes best practices for CHW policy, 2) a study using a difference-in-difference approach through the application of generalized linear mixed models to estimate the effect of DIP-IN on A1C and hospital outcomes, and 3) a study using multivariat regression and negative binomial modeling to estimate the impact of DIP-IN on COVID-19 hospitalization and length of stay. As financing influences duration and application of CHW interventions, this dissertation aims to explore the landscape over time of CHW legislation and evaluate a privately funded CHW program model intended to improve health outcome among high-risk patients with diabetes. It also aims to strengthen the knowledge base for CHW involvement in improving clinical-community linkages to support diabetes management. / 2024-07-03

Background: Task shifting provision of basic health care services to lay health workers (LHWs) is increasingly employed to combat the global shortage of skilled health workers, particularly in low and middle income countries, where the shortage is greatest. Despite evidence for the effectiveness of LHWs in improving access to basic health services and positively impacting a variety of health outcomes, questions remain as to how recognized weaknesses in training and supervision are best addressed. This thesis employed a sequential-concurrent mixed-methods design and is composed of 3 studies with the objective of designing and rigorously evaluating a knowledge translation (KT) intervention tailored to address identified barriers to LHWs ability to function optimally as TB adherence supporters in Zomba district, Malawi. Methods & Findings: The first study utilized the qualitative methods of focus groups and interviews conducted with LHWs routinely involved in provision of care to TB patients. Lack of TB knowledge and job-specific training were identified as the key barriers to LHWs in their role as TB adherence supporters. Based on these findings, a KT intervention was developed and tailored to the identified training gaps. The second study, evaluated the effectiveness of the intervention in improving TB treatment adherence in a cluster randomized controlled trial, which showed no evidence for effectiveness of the intervention. The third study, conducted concurrently with the cluster trial, employed qualitative interviews to explore LHWs experiences with the intervention to identify ii aspects of the intervention found to be helpful and areas in need of improvement. Study 3 found that the intervention was well received and valued, with reported benefits to LHWs through improved knowledge and skills, and increased confidence. Suggestions for improvement varied considerably, with an anticipated concern with the lack of stipends and conduct of training on-site, raised as an issue by a minority of participants. Conclusion: This thesis suggests that a multi-component KT strategy tailored to address local barriers, was well received and valued by LHWs, and may represent a cost-effective approach to LHW training. However, given the trend for effectiveness did not reach significance in this underpowered study, further research is needed.

Background: Task shifting provision of basic health care services to lay health workers (LHWs) is increasingly employed to combat the global shortage of skilled health workers, particularly in low and middle income countries, where the shortage is greatest. Despite evidence for the effectiveness of LHWs in improving access to basic health services and positively impacting a variety of health outcomes, questions remain as to how recognized weaknesses in training and supervision are best addressed. This thesis employed a sequential-concurrent mixed-methods design and is composed of 3 studies with the objective of designing and rigorously evaluating a knowledge translation (KT) intervention tailored to address identified barriers to LHWs ability to function optimally as TB adherence supporters in Zomba district, Malawi. Methods & Findings: The first study utilized the qualitative methods of focus groups and interviews conducted with LHWs routinely involved in provision of care to TB patients. Lack of TB knowledge and job-specific training were identified as the key barriers to LHWs in their role as TB adherence supporters. Based on these findings, a KT intervention was developed and tailored to the identified training gaps. The second study, evaluated the effectiveness of the intervention in improving TB treatment adherence in a cluster randomized controlled trial, which showed no evidence for effectiveness of the intervention. The third study, conducted concurrently with the cluster trial, employed qualitative interviews to explore LHWs experiences with the intervention to identify ii aspects of the intervention found to be helpful and areas in need of improvement. Study 3 found that the intervention was well received and valued, with reported benefits to LHWs through improved knowledge and skills, and increased confidence. Suggestions for improvement varied considerably, with an anticipated concern with the lack of stipends and conduct of training on-site, raised as an issue by a minority of participants. Conclusion: This thesis suggests that a multi-component KT strategy tailored to address local barriers, was well received and valued by LHWs, and may represent a cost-effective approach to LHW training. However, given the trend for effectiveness did not reach significance in this underpowered study, further research is needed.

Objectives. A community health worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. While natural leadership may incline individuals to the CHW profession, they do not always have skills to address broad social issues. We describe evaluation of the Women’s Health Leadership Institute (WHLI), a 3-year training initiative to increase the capacity of CHWs as change agents. Methods. Pre-/postquestionnaires measured the confidence of 254 participants in mastering WHLI leadership competencies. In-depth interviews with CHW participants 6 to 9 months after the training documented application of WHLI competencies in the community. A national CHW survey measured the extent to which WHLI graduates used leadership skills that resulted in concrete changes to benefit community members. Multivariate logistic regressions controlling for covariates compared WHLI graduates’ leadership skills to the national sample. Results. Participants reported statistically significant pre-/post improvements in all competencies. nterviewees credited WHLI with increasing their capacity to listen to others, create partnerships, and initiate efforts to address community needs. Compared to a national CHW sample, WHLI participants were more likely to engage community members in attending public meetings and organizing events. These activities led to community members taking action on an issue and a concrete policy change. Conclusions. Leadership training can increase the ability of experienced CHWs to address underlying issues related to community health across different types of organizational affiliations and job responsibilities.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Public Health Johannesburg June 2016 / Background: The work of Community Health Workers is appreciated in most setups in both developing and developed countries. In Zimbabwe there are a number of cadres who are working to bridge the health services and the community. There has however been limited documentation on the perspectives of Community Health Workers on what enables them to do their work and also barriers they face in providing their services. Aim: The study aimed to explore the perceptions of CHWs on the enablers and barriers to providing services in Nyanga district in Zimbabwe. Method: The study used a qualitative methods of in-depth interviews with Community Health Workers and key informants and document reviews. A thematic content analysis was used to identify key themes. The themes were then further analysed to identify the enablers and barriers to community health work. Results and Conclusion: The major enablers of the CHW work were perceived to be the benefits which have accrued to the communities the CHWs were working with, the benefits which the CHWs had gained and the support given by the hospital, NGO and the community leadership. The following were perceived to be the major barriers to CHW work: limited access to health services by the communities from the health facilities driven by the weak macroeconomic conditions in the country, gaps in support services, workload and geographical coverage. The recommendations include improving the motivation of the CHWs through efficient payment system, improving on quality of care and processes in the service provision. The results provide insights into CHW work which can assist policy makers and managers in making informed decisions on the investments they make for the CHW programmes in Nyanga district and Zimbabwe in general. / MT2016

How do health workers understand population health as a concept and as it relates to their practice? How does an accreditation of a health region lead to an understanding of a population health approach? <p>The purpose of this study was to explore the extent to which health region staff understands population health and to determine how the Canadian Council on Health Services Accreditation (CCHSA) accreditation process addresses population health perspectives. The goal was to ascertain the knowledge, practices, and attitudes of the staff with respect to population health in general and with respect to an accreditation process in order to see how a health region integrates a population health component into its services. A case study of the Saskatoon Health Region (SHR) was used to determine how a health region can integrate a population health component into the design and delivery of its services. The case study was comprised of a literature review, secondary data review from the 2001 Accreditation Survey Report, and primary data collection from people involved in the 2004 accreditation self-assessment which took place in the health region from March through June, 2004, which was facilitated by the Canadian Council on Health Services Accreditation (CCHSA). Primary data was captured through the use of key informant interviews of twenty employees in the health region. The participants were selected from the sponsors and leads of the accreditation teams that are most connected to a population health perspective; other participants were invited from those teams. These teams were selected by the author after reviewing the results of the CCHSA 2001 Accreditation Report that highlighted areas for improvement. This variety of input from across the teams triangulated the responses. In addition, key informants representing senior management, (i.e. the medical health officer(s) and the Chief Executive Officer for SHR), were also interviewed. These people were included in order to capture the knowledge practices and attitudes of the visionaries and leaders of the region and their ideas with respect to the direction for population health. <p>The thesis closes with a discussion on implications for the policy arena and opportunities for the CCHSA to improve the population health content in their accreditation documents.

How do health workers understand population health as a concept and as it relates to their practice? How does an accreditation of a health region lead to an understanding of a population health approach? <p>The purpose of this study was to explore the extent to which health region staff understands population health and to determine how the Canadian Council on Health Services Accreditation (CCHSA) accreditation process addresses population health perspectives. The goal was to ascertain the knowledge, practices, and attitudes of the staff with respect to population health in general and with respect to an accreditation process in order to see how a health region integrates a population health component into its services. A case study of the Saskatoon Health Region (SHR) was used to determine how a health region can integrate a population health component into the design and delivery of its services. The case study was comprised of a literature review, secondary data review from the 2001 Accreditation Survey Report, and primary data collection from people involved in the 2004 accreditation self-assessment which took place in the health region from March through June, 2004, which was facilitated by the Canadian Council on Health Services Accreditation (CCHSA). Primary data was captured through the use of key informant interviews of twenty employees in the health region. The participants were selected from the sponsors and leads of the accreditation teams that are most connected to a population health perspective; other participants were invited from those teams. These teams were selected by the author after reviewing the results of the CCHSA 2001 Accreditation Report that highlighted areas for improvement. This variety of input from across the teams triangulated the responses. In addition, key informants representing senior management, (i.e. the medical health officer(s) and the Chief Executive Officer for SHR), were also interviewed. These people were included in order to capture the knowledge practices and attitudes of the visionaries and leaders of the region and their ideas with respect to the direction for population health. <p>The thesis closes with a discussion on implications for the policy arena and opportunities for the CCHSA to improve the population health content in their accreditation documents.

Occupational stress of nurses has been widely researched, for example in specific health care units - intensive care, specific conditions - cancer. Personal characteristics like emotional involvement and depersonalisation of patients are also suggested as stressors for nurses. In South Africa the Department of Health has made a number of changes since 1994. One of the changes involved the restructuring of the different departments to unify the fragmented health services. No comparison study was found for professional and enrolled nurses. The objectives of this study were to determine the construct validity and internal consistency of the Nursing Stress Indicator (NSI) and to identify differences between occupational stressors of professional and enrolled nurses. A cross-sectional survey design was used. An random sample of professional nurses (N = 980) and enrolled (N = 800) nurses of seven of the nine provinces of South Africa were used. The NSI was developed as measuring instrument and administrated together with a biographical questionnaire. Descriptive statistics and inferential statistics were used to analyse the data. Five internally consistent factors were extracted. The first factor was labelled Stress: Patient Care. It relates to stress because of the care nursing staff provide to patients. The second factor was labelled Stress: Job Demands, and refer to the demands associated with the work of the nurse. The third factor indicated a lack of support in the organisation as well as from supervisors and colleagues, and was labelled Stress: Lack of Support. The fourth factor was labelled Stress: Staff Issues, because it included item loadings on things like shortage of staff, and fellow workers not doing their job. The fifth factor contains items concerning working hours, especially overtime, and was labelled Stress: Overtime. The results indicated that a difference in stress levels exists between professional and enrolled nurses. Professional nurses' severity for the different stressors are higher on all five the extracted factors than those of the enrolled nurses. The sources of occupational stress for professional and enrolled nurses were almost the same. One source of stress for professional nurses that the enrolled nurses did not experience is management of staff. Professional nurses (compared with enrolled nurses) obtained practically significant higher scores on two stressors, namely stress because of making a mistake when treating a patient and stress because of disagreement with medical practitioners or colleagues concerning the treatment of a patient. Recommendations for future research were made. / Thesis (M.A. (Industrial Psychology))--North-West University, Potchefstroom Campus, 2004.

In this thesis, the relevance and practical value of discourses about reproductive rights to women living in a rural area of Zimbabwe are examined. Policy documents indicate that the Zimbabwe National Family Planning Council's (ZNFPC's) community based distribution service is based on principles of respect for particular definitions of reproductive rights and, concomitantly, a degree of women's reproductive self determination. In contrast, recent analyses of post Independence government action suggest that, as citizens of Zimbabwe, women are generally defined as dependants of men. This raises questions about the impact of the context of women's citizenship on the interpretation and realisation of reproductive rights through the family planning programme. Field work data focuses on the interpretation of policy and the consequent practices of local level health workers as well as women's interactions with health workers and their implications for reproductive self determination within household relations. It is suggested that health workers' actions result in the differential realisation of reproductive rights for particular social groups. Health worker relations with clients, in turn, reinforce differences between women in terms of the extent to which they are able to exercise reproductive self-determination within household relations. State employed health workers, in effect, act as policemen of private reproductive decision making. The use of an analytical framework of rights and citizenship highlights the relatively neglected issue of the political system in which family planning programmes are embedded. It is argued that health worker accountability to village populations is as important as the content of policy in determining the realisation and practical value of discourses about reproductive rights to rural women.