| 1. |
- Hernández, Alison, 1978-, et al.
(författare)
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Supporting the performance of rural nurses : a concept mapping study with regional health system actors in Guatemala
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Background: The performance of front-line health workers is critical for improving the health of vulnerable populations. Performance is a complex behavior generated through interactions between health workers, the health system and communities served. In Guatemala, where front-line nurses serve rural communities with great health needs, a concept mapping study was carried out with actors from different levels of a regional health system to develop an integrated view on how performance can be supported in this setting.Methods: The concept mapping process began with four sessions engaging a total of 93 regional and district managers, and primary and secondary care health workers in generating ideas on actions needed to support nurses’ performance. Ideas were consolidated into 30 action items, which were sorted by 12 managers and rated by a total of 135 managers and health workers from different levels. Maps depicting domains of action and dynamics in sub-groups’ interests were generated using a sequence of multivariate statistical analyses and were interpreted by regional managers.Results: The combined input of regional health system actors provided a multi-faceted view of actions needed to support performance, which were organized in six domains, including: Communication and coordination, Tools to orient work, Organizational climate of support, Motivation through recognition, Professional development and Skills development. The nature of relationships across hierarchical levels was identified as a crosscutting theme. Pattern matching and go-zone maps depicted dynamics in the interests of sub-groups of actors, indicating directions for action based on areas of consensus and difference.Conclusions: This study indicates that rural nurses’ performance is interconnected with the performance of other actors in the regional health system who require support, including managers and community-level collaborators. Organizational climate is critical for making rural nurses feel supported, and the nature of relationships across levels shapes the way actions to support performance are implemented and received. The participatory nature of the conceptmapping process enables regional health system actors to collaborate in co-production of context-specific knowledge needed to guide efforts to strengthen performance.
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| 2. |
- Gebrehiwet, Tesfay Gebregzabher, 1966-
(författare)
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No woman should die while giving life : Does the Health Extension Program improveaccess to maternal health services in Tigray, Ethiopia?
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Ensuring access to universal primary health care is essential to secure a safe and pleasant motherhood and to provide compassionate care for mothers and newborns.However, inequalities in the access to maternal health services still remain a prominent problem in many countries. As part of reducing inequalities, Ethiopia launched the Health Extension Program (HEP) in 2003. The HEP is a community based program designed with a defined package of essential promotive, preventive and basic curative services targeting households, particularly mothers and children. Despite the construction of over 600 health posts and deploying more than 1200 Health Extension Workers (HEWs), preliminary data suggests a low utilization of maternal health care services. This thesis explores the HEP contribution in improving women’s access to maternal health care, and the reasons for the low use of maternal health care services from the perspectives of the involved actors in the Tigray region in Ethiopia. The five dimensions of access were used as a framework to explore the access to maternal health care utilization in this setting.Methods: A total of four districts were included in the study. Both quantitative and qualitative methods were applied. In the first sub-study, we assessed the HEP and its association with change in the utilization of antenatal, delivery and postnatal care services. Retrospective longitudinal data for 10 years was extracted from three selected districts and checked for accuracy. Segmented linear regression technique was used to control the secular trends adjusted for correlation of the data. For the second sub-study, we conducted a cross sectional survey with 1115 women (aged 15-49 years who had given birth within five years prior to the survey period) to determine the prevalence of antenatal care and institutional delivery utilization and explore their determinant factors of low utilization. For the third sub-study, we conducted six focus group discussions (FGDs) with a total of 51 women to explore women’s experiences of childbirth and maternal care. An interview with eight HEWs and four midwives were carried out to capture health workers’ perspective on access to maternal health care services in the fourth sub-study. Grounded theory for the former, and thematic analysis for the latter were used for the analysis.Main findings: The finding of the first sub-study showed a statistically significant upward trend for delivery care (DC) and postnatal care (PNC) in all facilities during the HEP late implementation period (July 2008-June 2012). In addition, a substantial trend of antenatal care (ANC) service use was observed at health centres after the intervention. In the second sub-study, the determinant predictors for ANC utilization were: proximity to health facilities, to be married, ≥5 years of education and having non-farming husbands. The last three factors were also significantly associated with institutional delivery, but also lower parity, previous history of obstructed/prolonged labour and ANC counselling. Findings from the qualitative studies pointed out that elderly women influenced women’s decision making about where to give birth. Women were mostly positive about giving birth at health facilities, but were concerned about the poor quality of care, inaccessibility and unavailability of transport. From the health workers’ perspective: specialized performance of hospital services, community assistance during referral and an increased awareness among women regarding the benefits of giving birth at a health facility were perceived as facilitators for institutional deliveries. Poor perceived competence of HEWs, poor conditions of health care facilities and inaccessibility of transportation, among others, were perceived as barriers for giving birth at health facilities.Conclusion: Overall, this research revealed a considerable contribution of the HEP in improving the access and coverage of maternal health services (ANC, DC and PNC). However, cultural traditions, scattered localities, mountainous roads without adequate transportation and low quality of care are still the major obstacles to accessing the services. Mechanisms need to be designed to enable health facility access of safe delivery for women in hard to reach areas, improving the proficiency of health workers and introducing a women centered approach that enhances acceptability of the services.
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| 3. |
- Lemma, Hailemariam, 1966-
(författare)
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Improving efficiency, access to and quality of the rural health extension programme in Tigray, Ethiopia : the case of malaria diagnosis and treatment
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Ensuring universal access to primary health care (PHC) is a key component of the Ethiopian nationalhealth policy. The policy also emphasises promoting and enhancing national self-reliance in health development bymobilizing and efficiently utilizing resources including community participation. To this end, the government introducedthe accelerated expansion of the PHC strategy through a comprehensive health extension programme (HEP). HEP is afamily and community-based health care delivery system institutionalised at health post level which combines carefullyselected high impact promotive, preventive and basic curative interventions. All HEP interventions are promotive and preventive except the malaria intervention which, in addition, incorporates a curative service. In the country, malaria is a leading disease. Unlike most Sub-Saharan African countries where P. falciparum accounts for almost all malaria infections, in Ethiopia both P. falciparum and P. vivax are co-dominant. Considering this peculiar epidemiological nature, the national guideline recommends alternative diagnosis and treatment strategies. Rationale: The lack of adequate resources and the efficiency with which available resources are being utilised are the main challenges in any health care setting. Therefore, if the HEP which consumes consideral amount of resource desires to reach its intended goal, monitoring and improving its efficiency is of great public heath importance. HEP has been successful in improving access to PHC including the malaria diagnosis and treatment service. Though this is a crucial measure, its quality ought to be considered. For the malaria curative service, studying the cost-effectiveness of the available strategy and patients’ adherence to the treatment regimen can be considered as proxy measures of quality for which local evidence is lacking. However, none of the existing studies in this field of research has addressed the Ethiopian malaria epidemiological context and its diagnosis and treatment guideline. In Tigray, for more than two decades, access to malaria early diagnosis and prompt treatment was facilitated by volunteer community healthworkers (CHWs). However, with the introduction of artemether-lumefantrine (AL) the service was compromised mainly for reasons of cost, safety and logistic. Therefore, it was important to explore the feasibility and the impact of community deployment of AL with rapid diagnostic tests (RDTs). The aim: to explore the overall performance of HEP and particularly the access to and quality of malaria early diagnosis and prompt treatment in the Tigray region of Ethiopia. Methods: Different study designs and populations were used for each of the four specific objectives. Data envelop analysis (DEA) was applied to assess the HEP efficiency. For this, register data for the output variables and primary data for the input and the environmental factors were collected. A health provider perspective cost-effectiveness analysis was used to determine which among the currently available diagnostic and treatment strategies is best for the country. Effectiveness data were generated from a stratified cross-sectional survey and secondary data were used to calculate the cost. For measuring adherence to the six-dose AL regimen, an assessment questionnaire and pill count was employed at patients´ home. To determine whether deploying AL with RDT at community level was feasible and effective, a number of designs were used: longitudinal follow-up, cross-sectional surveys, cost analysis, verbal autopsyquestionnaires and focal group discussions. Main findings: More than three-quarters of the health posts were found to be technically inefficient with an average score of 42%, which implies potentially they could improve their efficiency by 58%. Scale of operation was not a cause of inefficiency. None of the considered environmental factors was associated with efficiency. The Parascreen-based strategy (multispecies RDT-BS) was found to be the most cost-effective strategy, which allowed treating correctly an additional 65% of patients with less cost than the paracheck-BS. Presumptive-BS was highly dominated. Among P.falciparum positive patients to whom AL was prescribed, more than a quarter did not finish their treatment. The main reasons for interrupting the dose were ‘too many tablets’ and ‘felt better before finishing the dose’. The ownership of aradio, the belief that malaria cannot be treated traditionally and a delay of more than one day in seeking treatment after the onset of fever were significantly associated with being adherent. Deploying AL with RDT at community level was demonstrated to be effective and feasible. In the intervention district, almost 60% of suspected cases were managed by CHWs. Malaria transmission was lower at least threefold and malaria mortality risk by around 40% compared to the control district. The use of RDTs reduced cost and possibly the risk of drug resistance development. Conclusion: Though improving access to health care is important, it should be considered a means, not an end. Themore accessible a system is the more people could utilise it to improve their health. Thus, ensuring the access obtainedthrough HEP is maintained, its quality is improved and efficiently utilised to its optimal productivity level is a necessarytask. The DEA study revealed a high level of inefficiency where majority of the health posts needed improvement.This thesis also found parascreen-BS to be the most cost-effective strategy and that there is no epidemiological andeconomical contextual justification to keep both, the presumptive-BS and the RDT-BS specific only to P.falciparum.The high poor adherence levels raises great concern as it leads to recurrent malaria attacks of the patient, speed upthe development and spread of drug resistance strains and reduces the effect of the drug on the transmission. Therefore,providing effective drug alone is not sufficient; assessing and monitoring adherence to the treatment is by faressential. Deployment of AL with RDT through a community-based service has shown an enormous impact in termsof cost, transmission, morbidity and mortality. However, it is worth noting that this results came from an area wherea community-based service has been involved in the PHC system for more than three decades.
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| 4. |
- Mathias, Kaaren, 1969-, et al.
(författare)
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Cross-sectional study of depression and help-seeking in Uttarakhand, North India
- 2015
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Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 5:11
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: This study sought to use a population-based cross-sectional survey to describe depression prevalence, healthcare seeking and associations with socioeconomic determinants in a district in North India.SETTING: This study was conducted in Sahaspur and Raipur, administrative blocks of Dehradun district, Uttarakhand, in July 2014.PARTICIPANTS: A population-based sample of 960 people over the age of 18 years was selected in 30 randomised clusters after being stratified by rural:urban census ratios.PRIMARY OUTCOME MEASURES: The survey used a validated screening tool, Patient Health Questionnaire, to identify people with depression, and collected information regarding socioeconomic variables and help-seeking behaviours. Depression prevalence and health seeking behaviours were calculated, and multivariable logistic regression was used to assess associations between risk factors and depression.RESULTS: Prevalence of depression was 6% (58/960), with a further 3.9% (37/960) describing a depressive episode of over 2 weeks in the past 12 months. Statistically significant adjusted OR for depression of more than 2 were found for people who were illiterate, classified as Scheduled Caste/Tribe or Other Backward Castes, living in temporary material housing and who had recently taken a loan. While over three quarters of people with depression (79%) had attended a private or government general medical practitioner in the past 3 months, none had received talking therapy (100% treatment gap) and two people (3.3%) had been prescribed antidepressants.CONCLUSIONS: There are clear associations between social, educational and economic disadvantage and depression in this population. Strategies that address the social determinants of depression, such as education, social exclusion, financial protection and affordable housing for all are indicated. To address the large treatment gap in Uttarakhand, we must ensure access to primary and secondary mental health providers who can recognise and appropriately manage depression.
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| 5. |
- Mosquera, Paola A, 1979-, et al.
(författare)
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Income-related inequalities in cardiovascular disease from mid-life to old age in a Northern Swedish cohort : a decomposition analysis
- 2016
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Ingår i: Social Science and Medicine. - : Elsevier. - 0277-9536 .- 1873-5347. ; 149, s. 135-144
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Tidskriftsartikel (refereegranskat)abstract
- While the social determinants of cardiovascular disease (CVD) are fairly well-known, the determinants of socioeconomic inequalities in CVD are scarcely studied and almost completely based on cross-sectional designs in which the changing circumstances across the life course are not taken into account. The present study seeks to incorporate a life course approach to the social determinants of socioeconomic inequalities in CVD. The specific aims were to 1) examine how income-related inequalities in CVD change over two decades of the mid-late life course, and 2) identify the key social determinants of the inequalities at each time period. The cohort (N = 44,039) comprised all individuals aged 40-60 years in 1990 who during 1990-2010 were enrolled in the county-wide preventive effort :"Västerbotten Intervention Program" (VIP). The cohort was followed over these two decades by Swedish population register data linked within the Umeå SIMSAM Lab micro data infrastructure. First-time hospitalization for CVD and mean earned income were used to calculate the concentration index (C) during four periods of 5-6 years. The C for each period was decomposed by sociodemographic factors, using Wagstaff-type decomposition analysis. Results suggest that inequalities in CVD increase gradually from mid-life to old age; from initially non-significant to particularly marked among the elderly. The decomposition showed that, from middle to old age, educational and employment inequalities underwent a transition from initially dominant to a moderate role in explaining the health inequalities, coupled with an increasing importance of age and a stable role of income. In conclusion, the study illustrates the need for incorporating a dynamic life course perspective into research, policy and practice concerned with equity in health.
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