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Improving the performance of community health workers in Swaziland: findings from a qualitative study

Lun, 18/09/2017 - 00:00
Abstract Background

The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre.

Methods

The CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance.

Results

Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: (i) increased monetary compensation of CHWs, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance.

Conclusions

While this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers.

Categorías: Investigaciones

Physicians’ perceptions on the impact of telemedicine on recruitment and retention in underserved areas: a descriptive study in Senegal

Lun, 18/09/2017 - 00:00
Abstract Background

Similar to many places, physicians in Senegal are unevenly distributed. Telemedicine is considered a potential solution to this problem. This study investigated the perceptions of Senegal’s physicians of the impact of telemedicine on their recruitment to and retention in underserved areas.

Methods

We conducted individual interviews with a random sample of 60 physicians in Senegal, including 30 physicians working in public hospitals and 30 physicians working in district health centres between January and June 2014, as part of a mixed methods study. Data were collected using a semi-structured interview guide comprising both open- and close-ended questions. Interviews were recorded, transcribed and coded thematically using NVivo 10 software using a priori and emergent codes. Participants’ characteristics were analyzed descriptively using SPSS 23.

Results

The impact of telemedicine on physicians’ recruitment and retention in underserved areas was perceived with some variability. Among the physicians who were interviewed, most (36) thought that telemedicine could have a positive impact on their recruitment and retention but many (24) believed the opposite. The advantages noted by the first included telemedicine’s ability to break their professional isolation and reduce the stress related to this, facilitate their distance learning and improve their working conditions. They did acknowledge that it is not sufficient in itself, an opinion also shared by physicians who did not believe that telemedicine could affect their recruitment and retention. Both identified contextual, economic, educational, family, individual, organizational and professional factors as influential.

Conclusion

Based on these opinions of physicians, telemedicine promotion is one intervention that, alongside others, could be promoted to assist in addressing the multiple factors that influence physicians’ recruitment and retention in underserved areas.

Categorías: Investigaciones

Professional fulfillment and parenting work-life balance in female physicians in Basic Sciences and medical research: a nationwide cross-sectional survey of all 80 medical schools in Japan

Vie, 15/09/2017 - 00:00
Abstract Background

In Japan, the field of Basic Sciences encompasses clinical, academic, and translational research, as well as the teaching of medical sciences, with both an MD and PhD typically required. In this study, it was hypothesized that the characteristics of a Basic Sciences career path could offer the professional advancement and personal fulfillment that many female medical doctors would find advantageous. Moreover, encouraging interest in Basic Sciences could help stem shortages that Japan is experiencing in medical fields, as noted in the three principal contributing factors: premature resignation of female clinicians, an imbalance of female physicians engaged in research, and a shortage of medical doctors in the Basic Sciences. This study examines the professional and personal fulfillment expressed by Japanese female medical doctors who hold positions in Basic Sciences. Topics include career advancement, interest in medical research, and greater flexibility for parenting.

Methods

A cross-sectional questionnaire survey was distributed at all 80 medical schools in Japan, directed to 228 female medical doctors whose academic rank was assistant professor or higher in departments of Basic Sciences in 2012. Chi-square tests and the binary logistic regression model were used to investigate the impact of parenthood on career satisfaction, academic rank, salary, etc.

Results

The survey response rate of female physicians in Basic Sciences was 54.0%. Regardless of parental status, one in three respondents cited research interest as their rationale for entering Basic Sciences, well over twice other motivations. A majority had clinical experience, with clinical duties maintained part-time by about half of respondents and particularly parents. Only one third expressed afterthoughts about relinquishing full-time clinical practice, with physicians who were parents expressing stronger regrets. Parental status had little effect on academic rank and income within the Basic Sciences,

Conclusion

Scientific curiosity and a desire to improve community health are hallmarks of those choosing a challenging career in medicine. Therefore, it is unsurprising that interest in research is the primary motivation for a female medical doctor to choose a career in Basic Sciences. Additionally, as with many young professionals with families, female doctors seek balance in professional and private lives. Although many expressed afterthoughts relinquishing a full-time clinical practice, mothers generally benefited from greater job flexibility, with little significant effect on career development and income as Basic Scientists.

Categorías: Investigaciones

Devolution and its effects on health workforce and commodities management – early implementation experiences in Kilifi County, Kenya

Vie, 15/09/2017 - 00:00
Abstract Background

Decentralisation is argued to promote community participation, accountability, technical efficiency, and equity in the management of resources, and has been a recurring theme in health system reforms for several decades. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous county governments, with substantial transfer of responsibility for health service delivery from the central government to these counties. Focusing on two key elements of the health system, Human Resources for Health (HRH) and Essential Medicines and Medical Supplies (EMMS) management, we analysed the early implementation experiences of this major governance reform at county level.

Methods

We employed a qualitative case study design, focusing on Kilifi County, and adapted the decision space framework developed by Bossert et al., to guide our inquiry and analysis. Data were collected through document reviews, key informant interviews, and participant and non-participant observations between December 2012 and December 2014.

Results

As with other county level functions, HRH and EMMS management functions were rapidly transferred to counties before appropriate county-level structures and adequate capacity to undertake these functions were in place. For HRH, this led to major disruptions in staff salary payments, political interference with HRH management functions and confusion over HRH management roles. There was also lack of clarity over specific roles and responsibilities at county and national government, and of key players at each level. Subsequently health worker strikes and mass resignations were witnessed. With EMMS, significant delays in procurement led to long stock-outs of essential drugs in health facilities. However, when the county finally managed to procure drugs, health facilities reported a better order fill-rate compared to the period prior to devolution.

Conclusion

The devolved government system in Kenya has significantly increased county level decision-space for HRH and EMMS management functions. However, harnessing the full potential benefits of this increased autonomy requires targeted interventions to clarify the roles and responsibilities of different actors at all levels of the new system, and to build capacity of the counties to undertake certain specific HRH and EMMS management tasks. Capacity considerations should always be central when designing health sector decentralisation policies.

Categorías: Investigaciones

Postings and transfers in the Ghanaian health system: a study of health workforce governance

Vie, 15/09/2017 - 00:00
Abstract Background

Decision-making on postings and transfers – that is, the geographic deployment of the health workforce – is a key element of health workforce governance. When poorly managed, postings and transfers result in maldistribution, absenteeism, and low morale. At stake is managing the balance between organisational (i.e., health system) and individual (i.e., staff preference) needs. The negotiation of this potential convergence or divergence of interests provides a window on practices of postings and transfers, and on the micro-practices of governance in health systems more generally. This article explores the policies and processes, and the interplay between formal and informal rules and norms which underpin postings and transfers practice in two rural districts in the Greater Accra Region of Ghana.

Methods

Semi-structured interviews were conducted with eight district managers and 87 frontline staff from the district health administration, district hospital, polyclinic, health centres and community outreach compounds across two districts. Interviews sought to understand how the postings and transfers process works in practice, factors in frontline staff and district manager decision-making, personal experiences in being posted, and study leave as a common strategy for obtaining transfers.

Results

Differential negotiation-spaces at regional and district level exist and inform postings and transfers in practice. This is in contrast to the formal cascaded rules set to govern decision-making authority for postings and transfers. Many frontline staff lack policy clarity of postings and transfers processes and thus ‘test’ the system through informal staff lobbying, compounding staff perception of the postings and transfers process as being unfair. District managers are also challenged with limited decision-space embedded in broader policy contexts of systemic hierarchy and resource dependence. This underscores the negotiation process as ongoing, rather than static.

Conclusions

These findings point to tensions between individual and organisational goals. This article contributes to a burgeoning literature on postings and transfers as a distinct dynamic which bridges the interactions between health systems governance and health workforce development. Importantly, this article helps to expand the notion of health systems governance beyond ‘good’ governance towards understanding governance as a process of negotiation.

Categorías: Investigaciones

Time for action: key considerations for implementing social accountability in the education of health professionals

Mar, 12/09/2017 - 00:00
Abstract

Within health professional education around the world, there exists a growing awareness of the professional duty to be socially responsible, being attentive to the needs of all members of communities, regions, and nations, especially those who disproportionately suffer from the adverse influence of social determinants. However, much work still remains to progress beyond such good intentions. Moving from contemplation to action means embracing social accountability as a key guiding principle for change. Social accountability means that health institutions attend to improving the performance of individual practitioners and health systems by directing educational and practice interventions to promote the health of all the public and assessing the systemic effects of these interventions. In this Reflection, the authors (1) review the reasons why health professional schools and their governing bodies should codify, in both curricular and accreditation standards, norms of excellence in social accountability, (2) present four considerations crucial to successfully implementing this codification, and (3) discuss the challenges such changes might entail. The authors conclude by noting that in adopting socially accountable criteria, schools will need to expand their philosophical scope to recognize social accountability as a vitally important part of their institutional professional identity.

Categorías: Investigaciones

Forecasting the regional distribution and sufficiency of physicians in Japan with a coupled system dynamics—geographic information system model

Mar, 12/09/2017 - 00:00
Abstract Background

In Japan, the shortage of physicians has been recognized as a major medical issue. In our previous study, we reported that the absolute shortage will be resolved in the long term, but maldistribution among specialties will persist. To address regional shortage, several Japanese medical schools increased existing quota and established “regional quotas.” This study aims to assist policy makers in designing effective policies; we built a model for forecasting physician numbers by region to evaluate future physician supply–demand balances.

Methods

For our case study, we selected Hokkaido Prefecture in Japan, a region displaying disparities in healthcare services availability between urban and rural areas. We combined a system dynamics (SD) model with geographic information system (GIS) technology to analyze the dynamic change in spatial distribution of indicators. For Hokkaido overall and for each secondary medical service area (SMSA) within the prefecture, we analyzed the total number of practicing physicians. For evaluating absolute shortage and maldistribution, we calculated sufficiency levels and Gini coefficient. Our study covered the period 2010–2030 in 5-year increments.

Results

According to our forecast, physician shortage in Hokkaido Prefecture will largely be resolved by 2020. Based on current policies, we forecast that four SMSAs in Hokkaido will continue to experience physician shortages past that date, but only one SMSA would still be understaffed in 2030.

Conclusion

The results show the possibility that diminishing imbalances between SMSAs would not necessarily mean that regional maldistribution would be eliminated, as seen from the sufficiency levels of the various SMSAs. Urgent steps should be taken to place doctors in areas where our forecasting model predicts that physician shortages could occur in the future.

Categorías: Investigaciones

The impact of austerity on the health workforce and the achievement of human resources for health policies in Ireland (2008–2014)

Lun, 11/09/2017 - 00:00
Abstract Background

The global economic crisis saw recessionary conditions in most EU countries. Ireland’s severe recession produced pro-cyclical health spending cuts. Yet, human resources for health (HRH) are the most critical of inputs into a health system and an important economic driver. The aim of this article is to evaluate how the Irish health system coped with austerity in relation to HRH and whether austerity allowed and/or facilitated the implementation of HRH policy.

Methods

The authors employed a quantitative longitudinal trend analysis over the period 2008 to 2014 with Health Service Executive (HSE) staff database as the principal source. For the purpose of this study, heath service employment is defined as directly employed whole-time equivalent public service staffing in the HSE and other government agencies. The authors also examined the heath sector pay bill and sought to establish linkages between the main staff database and pay expenditure, as given in the HSE Annual Accounts and Financial Statements (AFS), and key HRH policies.

Results

The actual cut in total whole-time equivalent (WTE) of directly employed health services human resources over the period 2008 to 2014 was 8027 WTE, a reduction of 7.2% but substantially less than government claims. There was a degree of relative protection for frontline staffing decreasing by 2.9% between 2008 and 2014 and far less than the 18.5% reduction in other staff. Staff exempted from the general moratorium also increased by a combined 12.6%. Counter to stated policy, the decline in staffing of non-acute care was over double than in acute care. Further, the reduction in directly employed staff was to a great extent matched by a marked increase in agency spending.

Conclusions

The cuts forced substantial HRH reductions and yet there was some success in pursuing policy goals, such as increasing the frontline workforce while reducing support staff and protection of some cadres. Nevertheless, other policies failed such as moving staff away from acute settings and the claimed financial savings were substantially offset by overtime payments and the need to hire more expensive agency workers. There was also substantial demotivation of staff as a consequence of the changes.

Categorías: Investigaciones

The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review

Lun, 11/09/2017 - 00:00
Abstract Background

The prevalence of chronic illness and multimorbidity rises with population aging, thereby increasing the acuity of care. Consequently, the demand for emergency and critical care services has increased. However, the forecasted requirements for physicians have shown a continued shortage. Among efforts underway to search for innovations to strengthen the workforce, there is a heightened interest to have nurses in advanced practice participate in patient care at a great extent. Therefore, it is of interest to evaluate the impact of increasing the autonomy of nurses assuming advanced practice roles in emergency and critical care settings on patient outcomes.

Objectives

The objectives of this study are to present, critically appraise, and synthesize the best available evidence on the impact of advanced practice nursing on quality of care, clinical outcomes, patient satisfaction, and cost in emergency and critical care settings.

Review methods

A comprehensive and systematic search of nine electronic databases and a hand-search of two key journals from 2006 to 2016 were conducted to identify studies evaluating the impact of advanced practice nursing in the emergency and critical care settings. Two authors were involved selecting the studies based on the inclusion criteria. Out of the original search yield of 12,061 studies, 15 studies were chosen for appraisal of methodological quality by two independent authors and subsequently included for analysis. Data was extracted using standardized tools.

Results

Narrative synthesis was undertaken to summarize and report the findings. This review demonstrates that the involvement of nurses in advanced practice in emergency and critical care improves the length of stay, time to consultation/treatment, mortality, patient satisfaction, and cost savings.

Conclusions

Capitalizing on nurses in advanced practice to increase patients’ access to emergency and critical care is appealing. This review suggests that the implementation of advanced practice nursing roles in the emergency and critical care settings improves patient outcomes. The transformation of healthcare delivery through effective utilization of the workforce may alleviate the impending rise in demand for health services. Nevertheless, it is necessary to first prepare a receptive context to effect sustainable change.

Categorías: Investigaciones

Obstetric care providers’ knowledge, practice and associated factors towards active management of third stage of labor in Sidama Zone, South Ethiopia

Jue, 07/09/2017 - 00:00
Abstract Background

Active management of third stage of labor played a great role to prevent child birth related hemorrhage. However, maternal morbidity and mortality related to hemorrhage is high due to lack of knowledge and skill of obstetric care providers ‘on active management of third stage of labor.

Our study was aimed to assess knowledge, practice and associated factors of obstetric care providers (Midwives, Nurses and Health officers) on active management of third stage of labor in Sidama Zone, South Ethiopia.

Methods

An institution based cross sectional study design was conducted from December 1–30 /2015 among midwives, nurses and health officers. Simple random sampling technique was used to get the total of 528 participants. Data entry was done using EPI Info 3.5.1 and exported to SPSS version 20.0 software package for analysis. The presence of association between independent and dependent variables was assessed using odds ratio with 97% confidence interval by applying logistic regression model.

Results

Of the 528 obstetric care providers 37.7% and 32.8% were knowledgeable and skilled to manage third stage of labor respectively. After controlling for possible confounding factors, the result showed that pre/in service training, being midwife and graduation year were found to be the major predictors of proper active management of third stage of labor.

Conclusion

The knowledge and practice of obstetric care providers towards active management of third stage of labor can be improved with appropriate interventions like in-service trainings. This study also clearly showed that the level of knowledge and practice of obstetric care providers to wards active management of third stage of labor needs immediate attention of Universities and health science colleges better to revise their obstetrics course contents, health institutions and zonal health bureau should arrange trainings for their obstetrics care providers to enhance skill.

Categorías: Investigaciones

Unifying a fragmented effort: a qualitative framework for improving international surgical teaching collaborations

Jue, 07/09/2017 - 00:00
Abstract Background

Access to adequate surgical care is limited globally, particularly in low- and middle-income countries (LMICs). To address this issue, surgeons are becoming increasingly involved in international surgical teaching collaborations (ISTCs), which include educational partnerships between surgical teams in high-income countries and those in LMICs. The purpose of this study is to determine a framework for unifying, systematizing, and improving the quality of ISTCs so that they can better address the global surgical need.

Methods

A convenience sample of 68 surgeons, anesthesiologists, physicians, residents, nurses, academics, and administrators from the U.S., Canada, and Norway was used for the study. Participants all had some involvement in ISTCs and came from multiple specialties and institutions. Qualitative methodology was used, and participants were interviewed using a pre-determined set of open-ended questions. Data was gathered over two months either in-person, over the phone, or on Skype. Data was evaluated using thematic content analysis.

Results

To organize and systematize ISTCs, participants reported a need for a centralized/systematized process with designated leaders, a universal data bank of current efforts/progress, communication amongst involved parties, full-time administrative staff, dedicated funds, a scholarly approach, increased use of technology, and more research on needs and outcomes.

Conclusion

By taking steps towards unifying and systematizing ISTCs, the quality of ISTCs can be improved. This could lead to an advancement in efforts to increase access to surgical care worldwide.

Categorías: Investigaciones

Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania

Mié, 06/09/2017 - 00:00
Abstract Background

Option B+ for the prevention of mother-to-child transmission (PMTCT) of HIV (i.e., lifelong antiretroviral treatment for all pregnant and breastfeeding mothers living with HIV) was initiated in Tanzania in 2013. While there is evidence that this policy has benefits for the health of the mother and the child, Option B+ may also increase the workload for health care providers in resource-constrained settings, possibly leading to job dissatisfaction and unwanted workforce turnover.

Methods

From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and PMTCT services in Dar es Salaam, Tanzania. Multivariable logistic regression models were used to identify factors associated with job dissatisfaction and intention to quit one’s job.

Results

Slightly over half (54%, 114/213) of the providers were dissatisfied with their current job, and 35% (74/213) intended to leave their job. Most of the providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The odds of reporting to be globally dissatisfied with one’s job were high if the provider was dissatisfied with salary (adjusted odds ratio (aOR) 5.6, 95% CI 1.2–26.8), availability of protective gear (aOR 4.0, 95% CI 1.5–10.6), job description (aOR 4.3, 95% CI 1.2–14.7), and working hours (aOR 3.2, 95% CI 1.3–7.6). Perceiving clients to prefer PMTCT Option B+ reduced job dissatisfaction (aOR 0.2, 95% CI 0.1–0.8). The following factors were associated with providers’ intention to leave their current job: job stability dissatisfaction (aOR 3.7, 95% CI 1.3–10.5), not being recognized by one’s superior (aOR 3.6, 95% CI 1.7–7.6), and poor feedback on the overall unit performance (aOR 2.7, 95% CI 1.3–5.8).

Conclusion

Job dissatisfaction and turnover intentions are comparatively high among nurses in Dar es Salaam’s public-sector maternal care facilities. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback will be key to retaining satisfied PMTCT providers and thus to sustain successful implementation of Option B+ in Tanzania.

Categorías: Investigaciones

Changes in catastrophic health expenditure in post-conflict Sierra Leone: an Oaxaca-blinder decomposition analysis

Lun, 04/09/2017 - 00:00
Abstract Background

At the end of the eleven-year conflict in Sierra Leone, a wide range of policies were implemented to address both demand- and supply-side constraints within the healthcare system, which had collapsed during the conflict. This study examines the extent to which households’ exposure to financial risks associated with seeking healthcare evolved in post-conflict Sierra Leone.

Method

This study uses the 2003 and 2011 cross-sections of the Sierra Leone Integrated Household Survey to examine changes in catastrophic health expenditure between 2003 and 2011. An Oaxaca-Blinder decomposition approach is used to quantify the extent to which changes in catastrophic health expenditure are attributable to changes in the distribution of determinants (distributional effect) and to changes in the impact of these determinants on the probability of incurring catastrophic health expenditure (coefficient effect).

Results

The incidence of catastrophic health expenditure decreased significantly by 18% from approximately 50% in 2003 t0 32% in 2011. The decomposition analysis shows that this decrease represents net effects attributable to the distributional and coefficient effects of three determinants of catastrophic health expenditure – ill-health, the region in which households reside and the type of health facility used. A decrease in the incidence of ill-health and changes in the regional location of households contributed to a decrease in catastrophic health expenditure. The distributional effect of health facility types observed as an increase in the use of public health facilities, and a decrease in the use of services in facilities owned by non-governmental organizations (NGOs) also contributed to a decrease in the incidence of catastrophic health expenditure. However, the coefficient effect of public health facilities and NGO-owned facilities suggests that substantial exposure to financial risk remained for households utilizing both types of health facilities in 2011.

Conclusion

The findings support the need to continue expanding current demand-side policies in Sierra Leone to reduce the financial risk of exposure to ill health.

Categorías: Investigaciones

Understanding the factors affecting the attraction and retention of health professionals in rural and remote areas: a mixed-method study in Niger

Lun, 04/09/2017 - 00:00
Abstract Background

The critical shortage of human resources in health is a critical public health problem affecting most low- and middle-income countries, particularly in sub-Saharan Africa. In addition to the shortage of health professionals, attracting and retaining them in rural areas is a challenge. The objective of the study was to understand the factors that influence the attraction and retention of health professionals working in rural areas in Niger.

Methods

A mixed-method study was conducted in Tillabery region, Niger. A conceptual framework was used that included five dimensions. Three data collection methods were employed: in-depth interviews, documentary analysis, and concept mapping. In-depth interviews were conducted with three main actor groups: policy-makers and Ministry of Health officials (n = 15), health professionals (n = 102), and local health managers (n = 46). Concept mapping was conducted with midwifery students (n = 29). Multidimensional scaling and cluster analysis were performed to analyse the data from the concept mapping method. A content analysis was conducted for the qualitative data.

Results

The results of the study showed that the local environment, which includes living conditions (no electricity, lack of availability of schools), social factors (isolation, national and local insecurity), working conditions (workload), the lack of financial compensation, and individual factors (marital status, gender), influences the attraction and retention of health professionals to work in rural areas. Human resources policies do not adequately take into account the factors influencing the retention of rural health professionals.

Conclusion

Intersectoral policies are needed to improve living conditions and public services in rural areas. The government should also take into account the feminization of the medical profession and the social and cultural norms related to marital status and population mobility when formulating human resources management policies.

Categorías: Investigaciones

Performance of community health workers: situating their intermediary position within complex adaptive health systems

Sáb, 02/09/2017 - 00:00
Abstract

Health systems are social institutions, in which health worker performance is shaped by transactional processes between different actors.

This analytical assessment unravels the complex web of factors that influence the performance of community health workers (CHWs) in low- and middle-income countries. It examines their unique intermediary position between the communities they serve and actors in the health sector, and the complexity of the health systems in which they operate. The assessment combines evidence from the international literature on CHW programmes with research outcomes from the 5-year REACHOUT consortium, undertaking implementation research to improve CHW performance in six contexts (two in Asia and four in Africa). A conceptual framework on CHW performance, which explicitly conceptualizes the interface role of CHWs, is presented. Various categories of factors influencing CHW performance are distinguished in the framework: the context, the health system and intervention hardware and the health system and intervention software. Hardware elements of CHW interventions comprise the supervision systems, training, accountability and communication structures, incentives, supplies and logistics. Software elements relate to the ideas, interests, relationships, power, values and norms of the health system actors. They influence CHWs’ feelings of connectedness, familiarity, self-fulfilment and serving the same goals and CHWs’ perceptions of support received, respect, competence, honesty, fairness and recognition.

The framework shines a spotlight on the need for programmes to pay more attention to ideas, interests, relationships, power, values and norms of CHWs, communities, health professionals and other actors in the health system, if CHW performance is to improve.

Categorías: Investigaciones

The impact of a supportive supervision intervention on health workers in Niassa, Mozambique: a cluster-controlled trial

Sáb, 02/09/2017 - 00:00
Abstract Background

Regular supportive supervision is critical to retaining and motivating staff in resource-constrained settings. Previous studies have shown the particular contribution that supportive supervision can make to improving job satisfaction amongst over-stretched health workers in such settings.

Methods

The Support, Train and Empower Managers (STEM) study designed and implemented a supportive supervision intervention and measured its’ impact on health workers using a controlled trial design with a three-arm pre- and post-study in Niassa Province in Mozambique. Post-intervention interviews with a small sample of health workers were also conducted.

Results

The quantitative measurements of job satisfaction, emotional exhaustion and work engagement showed no statistically significant differences between end-line and baseline. The qualitative data collected from health workers post the intervention showed many positive impacts on health workers not captured by this quantitative survey.

Conclusions

Health workers perceived an improvement in their performance and attributed this to the supportive supervision they had received from their supervisors following the intervention. Reports of increased motivation were also common. An unexpected, yet important consequence of the intervention, which participants directly attributed to the supervision intervention, was the increase in participation and voice amongst health workers in intervention facilities.

Categorías: Investigaciones

Knowledge of standard precautions and barriers to compliance among healthcare workers in the Lower Manya Krobo District, Ghana

Mié, 30/08/2017 - 00:00
Abstract Background

Implementing standard precautions (SP) has been a major challenge for health care workers (HCWs) especially those in developing countries thereby compromising their safety and increasing their exposure to blood-related pathogens. Compliance with safety precautions and occupational accidents among health workers are often unreported. The literature on knowledge and compliance to SP in Ghana is scanty. We report findings of a study that examined knowledge of SP, compliance and barriers to compliance with SP among HCWs in two health facilities in Ghana.

Methods

This is a facility-based cross-sectional study involving 100 HCWs from two health facilities in the Lower Manya Krobo District of the Eastern region. Statistical analysis summarised data on socio-demographic characteristics of respondents, knowledge of SP and compliance and barriers to SP in frequencies and percentages.

Results

Most respondents had been working as health staff for 0–5 years (65.0%). Generally, knowledge of the basic concepts of SP was low; only 37.0% of HCWs knew that SP includes hand washing before and after any direct contact with the patient, 39.0% knew about cough etiquettes and 40.0% knew about aseptic techniques which involve infection prevention strategies to minimise the risks of infection. Fifty percent of respondents always protect themselves against BBFs of patients. About a quarter of the respondents do not recap needles after use and 28.0% of respondents sometimes promptly wipe all blood spills. HCWs were of the opinion that wearing PPEs—such as gloves, aprons, gowns and goggles—might cause patients to panic sometimes (63.0%) and complying with SP sometimes interferes with the ability to provide care (38.0%). Sometimes, because of the demands of patient care, HCWs do not have enough time to comply with the rigours of SP (44.0%) and sometimes PPEs are not available.

Conclusion

Education programmes on the benefits of SP should be organised frequently. The OHS national policy together with the application of the IPC training manual in all health care facilities must be enforced. Communities of practice should be established and sanctions and rewards should be introduced to limit negative behavior and reinforce positive attitudes as regards SP.

Categorías: Investigaciones

The impact of a human resource management intervention on the capacity of supervisors to support and supervise their staff at health facility level

Mié, 30/08/2017 - 00:00
Abstract Background

A systematic and structured approach to the support and supervision of health workers can strengthen the human resource management function at the district and health facility levels and may help address the current crisis in human resources for health in sub-Saharan Africa by improving health workers’ motivation and retention.

Methods

A supportive supervision programme including (a) a workshop, (b) intensive training and (c) action learning sets was designed to improve human resource management in districts and health facilities in Tanzania. We conducted a randomised experimental design to evaluate the impact of the intervention. Data on the same measures were collected pre and post the intervention in order to identify any changes that occurred (between baseline and end of project) in the capacity of supervisors in intervention a + b and intervention a + b + c to support and supervise their staff. These were compared to supervisors in a control group in each of Tanga, Iringa and Tabora regions (n = 9). A quantitative survey of 95 and 108 supervisors and 196 and 187 health workers sampled at baseline and end-line, respectively, also contained open-ended responses which were analysed separately.

Results

Supervisors assessed their own competency levels pre- and post-intervention. End-line samples generally scored higher compared to the corresponding baseline in both intervention groups for competence activities. Significant differences between baseline and end-line were observed in the total scores on ‘maintaining high levels of performance’, ‘dealing with performance problems’, ‘counselling a troubled employee’ and ‘time management’ in intervention a + b. In contrast, for intervention a + b + c, a significant difference in distribution of scores was only found on ‘counselling a troubled employee’, although the end-line mean scores were higher than their corresponding baseline mean scores in all cases. Similar trends to those in the supervisors’ reports are seen in health workers data in terms of more efficient supervision processes, although the increases are not as marked.

Conclusion

A number of different indicators were measured to assess the impact of the supportive supervision intervention on the a + b and a + b + c intervention sites. The average frequency of supervision visits and the supervisors’ competency levels across the facilities increased in both intervention types. This would suggest that the intervention proved effective in raising awareness of the importance of supervision and this understanding led to action in the form of more supportive supervision.

Categorías: Investigaciones

Sowing the seeds of transformative practice to actualize women’s rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research

Mié, 30/08/2017 - 00:00
Abstract Background

Despite years of growing concern about poor provider attitudes and women experiencing mistreatment during facility based childbirth, there are limited interventions that specifically focus on addressing these issues. The Heshima project is an evidence-based participatory implementation research study conducted in 13 facilities in Kenya. It engaged a range of community, facility, and policy stakeholders to address the causes of mistreatment during childbirth and promote respectful maternity care.

Methods

We used the consolidated framework for implementation research (CFIR) as an analytical lens to describe a complex, multifaceted set of interventions through a reflexive and iterative process for triangulating qualitative data. Data from a broad range of project documents, reports, and interviews were collected at different time points during the implementation of Heshima. Assessment of in-depth interview data used NVivo (Version 10) and Atlas.ti software to inductively derive codes for themes at baseline, supplemental, and endline. Our purpose was to generate categories of themes for analysis found across the intervention design and implementation stages.

Results

The implementation process, intervention characteristics, individual champions, and inner and outer settings influenced both Heshima’s successes and challenges at policy, facility, and community levels. Implementation success stemmed from readiness for change at multiple levels, constant communication between stakeholders, and perceived importance to communities. The relative advantage and adequacy of implementation of the Respectful Maternity Care (RMC) resource package was meaningful within Kenyan politics and health policy, given the timing and national promise to improve the quality of maternity care.

Conclusion

We found the CFIR lens a promising and flexible one for understanding the complex interventions. Despite the relatively nascent stage of RMC implementation research, we feel this study is an important start to understanding a range of interventions that can begin to address issues of mistreatment in maternity care; replication of these activities is needed globally to better understand if the Heshima implementation process can be successful in different countries and regions.

Categorías: Investigaciones

Primary care clinical practice guidelines in South Africa: qualitative study exploring perspectives of national stakeholders

Mar, 29/08/2017 - 00:00
Abstract Background

Clinical practice guidelines (CPGs) are common tools in policy and clinical practice informing clinical decisions at the bedside, governance of health facilities, health insurer and government spending, and patient choices. South Africa’s health sector is transitioning to a national health insurance system, aiming to build on other primary health care initiatives to transform the previously segregated, inequitable services. Within these plans CPGs are an integral tool for delivering standardised and cost effective care. Currently, there is no accepted standard approach to developing, adapting or implementing CPGs efficiently or effectively in South Africa. We explored the current players; drivers; and the context and processes of primary care CPG development from the perspective of stakeholders operating at national level.

Methods

We used a qualitative approach. Sampling was initially purposeful, followed by snowballing and further sampling to reach representivity of primary care service providers. Individual in-depth interviews were recorded and transcribed verbatim. We used thematic content analysis to analyse the data.

Results

We conducted 37 in-depth interviews from June 2014–July 2015. We found CPG development and implementation were hampered by lack of human and funding resources for technical and methodological work; fragmentation between groups, and between national and provincial health sectors; and lack of agreed systems for CPG development and implementation. Some CPG contributors steadfastly work to improve processes aiming to enhance communication, use of evidence, and transparency to ensure credible guidance is produced. Many interviewed had shared values, and were driven to address inequity, however, resource gaps were perceived to create an enabling environment for commercial interests or personal agendas to drive the CPG development process.

Conclusions

Our findings identified strengths and gaps in CPG development processes, and a need for national standards to guide CPG development and implementation. Based on our findings and suggestions from participants, a possible way forward would be for South Africa to have a centrally coordinated CPG unit to address these needs and aspects of fragmentation by devising processes that support collaboration, transparency and credibility across sectors and disciplines. Such an initiative will require adequate resourcing to build capacity and ensure support for the delivery of high quality CPGs for South African primary care.

Categorías: Investigaciones

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