Implementation research and human-centred design: how theory driven human-centred design can sustain trust in complex health systems, support measurement and drive sustained community health volunteer engagement

Abstract Human-centred design (HCD) can support complex health system interventions by navigating thorny implementation problems that often derail population health efforts. HCD is a pragmatic, ‘practice framework’, not an intervention protocol. It can build empathy by bringing patient voice, user perspective and innovation to construct and repair pieces of the intervention or health system. However, its emphasis on product development and process change with fixed end points has left it as an approach lacking explanatory power and reproducible measurement. Yet when informed by theory, the tremendous innovation potential of HCD can be harnessed to drive sustainability, mediate implementation problems, frame measurement constructs and ultimately improve population-level health outcomes. In attempting to mine, the potential of HCD we move beyond the pragmatic ‘how it works’, to the theoretical question, ‘why it works’. In doing so, we explore a more fundamental human question, ‘How can participation and engagement be sustained for impact in close to the community health systems?’ In this exploration, we illustrate the power of HCD by linking it to our theory of trust building. The research method we utilize is that of a longitudinal process evaluation. We leverage the heterogeneity of five community health units from the diverse setting (rural, peri-urban slum) to better understand what works for whom and in what context by tracking 21 groups of community health volunteers (CHVs) over 12 months. We report results with a focus on the outlier case failure to illustrate the contrast with common features of sustained CHV engagement, where recurrent reciprocal cycles of trust building are demonstrated in the successful implementation of action plans in plan-do-study-act cycles for improvement. All was accomplished by CHVs with no external funding. We conclude by discussing how HCD could be unleashed if linked to theoretical frameworks, increasing ability to address implementation challenges in complex health systems.

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Exploring health system readiness for adopting interventions to address intimate partner violence: a case study from the occupied Palestinian Territory

Health Policy and Planning ◽

10.1093/heapol/czz151 ◽

2019 ◽

Vol 35 (3) ◽

pp. 245-256 ◽

Cited By ~ 3

Author(s):

Manuela Colombini ◽

Abdulsalam Alkaiyat ◽

Amira Shaheen ◽

Claudia Garcia Moreno ◽

Gene Feder ◽

...

Keyword(s):

Health Care ◽

Health System ◽

Health Systems ◽

Partner Violence ◽

Scale Up ◽

Successful Implementation ◽

Occupied Palestinian Territory ◽

System Readiness ◽

Palestinian Territory

Abstract Domestic violence (DV) against women is a widespread violation of human rights. Adoption of effective interventions to address DV by health systems may fail if there is no readiness among organizations, institutions, providers and communities. There is, however, a research gap in our understanding of health systems’ readiness to respond to DV. This article describes the use of a health system’s readiness assessment to identify system obstacles to enable successful implementation of a primary health-care (PHC) intervention to address DV in the occupied Palestinian Territory (oPT). This article describes a case study where qualitative methods were used, namely 23 interviews with PHC providers and key informants, one stakeholder meeting with 19 stakeholders, two health facility observations and a document review of legal and policy materials on DV in oPT. We present data on seven dimensions of health systems. Our findings highlight the partial readiness of health systems and services to adopt a new DV intervention. Gaps were identified in: governance (no DV legislation), financial resources (no public funding and limited staff and infrastructure) and information systems (no uniform system), co-ordination (disjointed referral network) and to some extent around the values system (tension between patriarchal views on DV and more gender equal norms). Additional service-level barriers included unclear leadership structure at district level, uncertain roles for front-line staff, limited staff protection and the lack of a private space for identification and counselling. Findings also pointed to concrete actions in each system dimension that were important for effective delivery. This is the first study to use an adapted framework to assess health system readiness (HSR) for implementing an intervention to address DV in low- and middle-income countries. More research is needed on HSR to inform effective implementation and scale up of health-care-based DV interventions.

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Community Health Workers as Influential Health System Actors and not "Just Another Pair Of Hands"

International Journal of Health Policy and Management ◽

10.34172/ijhpm.2020.58 ◽

2020 ◽

Cited By ~ 2

Author(s):

Sumit Kane ◽

Anjali Radkar ◽

Mukta Gadgil ◽

Barbara McPake

Keyword(s):

Health System ◽

Community Health ◽

Community Health Workers ◽

Health Systems ◽

Work Experience ◽

Health Workers ◽

Human Resources For Health ◽

Research Question ◽

Large Body ◽

Optimal Strategies

Background: Over the last 20 years, community health workers (CHWs) have become a mainstay of human resources for health in many low- and middle-income countries (LMICs). A large body of research chronicles CHWs’ experience of their work. In this study we focus on 2 narratives that stand out in the literature. The first is the idea that social, economic and health system contexts intersect to undermine CHWs’ experience of their work, and that a key factor underpinning this experience is that LMIC health systems tend to view CHWs as just an ‘extra pair of hands’ to be called upon to provide ‘technical fixes.’ In this study we show the dynamic and evolving nature of CHW programmes and CHW identities and the need, therefore, for new understandings. Methods: A qualitative case study was carried out of the Indian CHW program (CHWs are called accredited social health activists: ASHAs). It aimed to answer the research question: How do ASHAs experience being CHWs, and what shapes their experience and performance? In depth interviews were conducted with 32 purposively selected ASHAs and key informants. Analysis was focused on interpreting and on developing analytical accounts of ASHAs’ experiences of being CHWs; it was iterative and occurred throughout the research. Interviews were transcribed verbatim and transcripts were analysed using a framework approach (with Nvivo 11). Results: CHWs resent being treated as just another pair of hands at the beck and call of formal health workers. The experience of being a CHW is evolving, and many are accumulating substantial social capital over time – emerging as influential social actors in the communities they serve. CHWs are covertly and overtly acting to subvert the structural forces that undermine their performance and work experience. Conclusion: CHWs have the potential to be influential actors in the communities they serve and in frontline health services. Health systems and health researchers need to be cognizant of and consciously engage with this emerging global social dynamic around CHWs. Such an approach can help guide the development of optimal strategies to support CHWs to fulfil their role in achieving health and social development goals.

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Challenges with Scale-up of GeneXpert MTB/RIF® in Uganda: a Health Systems Perspective

10.21203/rs.2.10689/v1 ◽

2019 ◽

Author(s):

Talemwa Nalugwa ◽

Priya B. Shete ◽

Mariam Nantale ◽

Katherine Farr ◽

Christopher Ojok ◽

...

Keyword(s):

Health System ◽

Community Health ◽

Health Systems ◽

Community Health Centers ◽

Scale Up ◽

Health Centers ◽

Data Sources ◽

Cross Sectional ◽

Hub And Spoke ◽

System Factors

Abstract Background Many high burden countries are scaling-up GeneXpert® MTB/RIF (Xpert) testing for tuberculosis (TB) using a hub-and-spoke model. However, the effect of scale up on reducing TB has been limited. We sought to characterize variation in implementation of referral-based Xpert TB testing across Uganda, and to identify health system factors that may enhance or prevent high-quality implementation of Xpert testing services. Methods We conducted a cross-sectional study triangulating quantitative and qualitative data sources at 23 community health centers linked to one of 15 Xpert testing sites between November 2016 and May 2017 to assess health systems infrastructure for hub-and-spoke Xpert testing. Data sources included a standardized site assessment survey, routine TB notification data, and field notes from site visits. Results Challenges with Xpert implementation occurred at every step of the diagnostic evaluation process, leading to low overall uptake of testing. Of 2,241 patients eligible for TB testing, only 580 (26%) were referred for Xpert testing. Of those, 57 (9.6%) were Xpert confirmed positive just over half initiated treatment within 14 days (n=33, 58%). Gaps in required infrastructure at 23 community health centers to support the hub-and-spoke system included lack of refrigeration (n=14, X%) for sputum testing and lack of telephone/mobile communication (n=21, 91%). Motorcycle riders responsible for transporting sputum to Xpert sites operated variable with trips once a week, 2x/week or 3x/week at 10 (43%), 9 (39%) and 4 (17%) health centers, respectively. Staff recorded Xpert results in the TB laboratory register at only one health center and called patients with positive results at only 2 health centers. Of the 15 Xpert testing sites, 5 (33%) had at least one non-functioning module. The median number of tests per day was 3.57 (IQR 2.06-4.54), and 10 (67%) sites had error/invalid rates >5%. Conclusions Although Xpert devices are now widely distributed throughout Uganda, health system factors across the continuum from test referral to results reporting and treatment initiation preclude effective implementation of Xpert testing for patients presenting to peripheral health centers. Support for scale up of innovative technologies should include support for communication, coordination and health systems integration.

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Psychological treatments delivered by community health workers in low-resource government health systems: effectiveness of group interpersonal psychotherapy for caregivers of children affected by nodding syndrome in Uganda

Psychological Medicine ◽

10.1017/s0033291718000193 ◽

2018 ◽

Vol 48 (15) ◽

pp. 2573-2583 ◽

Cited By ~ 14

Author(s):

Byamah B. Mutamba ◽

Jeremy C. Kane ◽

Joop T. V. M. de Jong ◽

James Okello ◽

Seggane Musisi ◽

...

Keyword(s):

Health System ◽

Community Health ◽

Community Health Workers ◽

Health Systems ◽

National Health ◽

Health Workers ◽

Interpersonal Psychotherapy ◽

Post Intervention ◽

Psychological Treatments ◽

Low Resource

BackgroundDespite increasing evidence for the benefits of psychological treatments (PTs) in low- and middle-income countries, few national health systems have adopted PTs as standard care. We aimed to evaluate the effectiveness of a group interpersonal psychotherapy (IPT-G) intervention, when delivered by lay community health workers (LCHWs) in a low-resource government health system in Uganda. The intended outcome was reduction of depression among caregivers of children with nodding syndrome, a neuropsychiatric condition with high morbidity, mortality and social stigma.MethodsA non-randomized trial design was used. Caregivers in six villages (n = 69) received treatment as usual (TAU), according to government guidelines. Caregivers in seven villages (n = 73) received TAU as well as 12 sessions of IPT-G delivered by LCHWs. Primary outcomes were caregiver and child depression assessed at 1 and 6 months post-intervention.ResultsCaregivers who received IPT-G had a significantly greater reduction in the risk of depression from baseline to 1 month [risk ratio (RR) 0.25, 95% confidence interval (CI) 0.10–0.62] and 6 months (RR 0.33, 95% CI 0.11–0.95) post-intervention compared with caregivers who received TAU. Children of caregivers who received IPT-G had significantly greater reduction in depression scores than children of TAU caregivers at 1 month (Cohen's d = 0.57, p = 0.01) and 6 months (Cohen's d = 0.54, p = 0.03). Significant effects were also observed for psychological distress, stigma and social support among caregivers.ConclusionIPT-G delivered within a low-resource health system is an effective PT for common mental health problems in caregivers of children with a severe neuropsychiatric condition and has psychological benefits for the children as well. This supports national health policy initiatives to integrate PTs into primary health care services in Uganda.

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Working Towards Inclusive, Socially Accountable and Resilient Community Health Systems: An Introduction to a Special Issue

International Journal of Health Policy and Management ◽

10.34172/ijhpm.2021.166 ◽

2021 ◽

Vol 11 (1) ◽

pp. 1-4

Author(s):

Charles Michelo ◽

Anna-Karin Hurtig ◽

Helen Schneider

Keyword(s):

South Africa ◽

Health System ◽

Community Health ◽

Health Systems ◽

Special Issue ◽

Community Health Systems

This editorial introduces the eleven papers in the special issue titled: The multiple lenses on the community health system: implications for research and action. Our editorial begins by describing the collaboration that led to the special issue, and then gives an overview of the contents of the special issue, which include two framing papers and nine empirical contributions from researchers in Zambia, Tanzania, Sweden, South Africa, India, and Australia. We conclude by considering how these papers collectively speak to the theme of resilience.

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Trust is the engine of change: A conceptual model for trust building in health systems

10.21203/rs.2.21935/v1 ◽

2020 ◽

Author(s):

Mary B. Adam ◽

Angela Joy Donelson

Keyword(s):

Community Health ◽

Health Systems ◽

Process Model ◽

Theory Development ◽

Building Blocks ◽

Trust Building ◽

Community Health Volunteers ◽

Systems Research ◽

Community Health Systems ◽

Building Process

Abstract Background: Physicians, health care organizations, governments and communities are increasingly interested in how trust is built throughout the health system. Current science on building trust draws on diverse literature from business and consumer science to healthcare, and theory development has predominately focused on factor based models. We propose a process based theoretical model for trust building which may better reflect the complex and dynamic nature of trust itself. In doing so, we propose a new measurable dimension of the trust building process: reciprocity cycles. Cooperative reciprocal relationships are its building blocks, enabling stakeholders to “try out” their interactions with less risk, and to calibrate their level of effort, time and emotional investment. Reciprocity cycles includes three measurable elements: common goals, self-interests and gratitude/indebtedness.Methods: We applied the model, developing outcomes and measures in close-to-community health partnerships in Kenya. A 3-day workshop designed to stimulate problem solving and collaborative teamwork using human centered design principles was offered in 2 community health units in diverse contexts (rural agrarian and peri-urban flower farm slum), each with about 30 community health volunteers (CHVs) serving a population of approximately 5,000. Each unit formed separate teams representing specific villages; we followed these 9 teams between 18 to 24 months.Results: All 9 volunteer CHV teams delivered on self-directed public health outcomes across the spectrum of social determinants of health over the follow up period, with no funding, only using their own locally available resources. Projects were diverse, including immunization, composting toilets, hygiene, neonatal and reproductive health and public gardening. All 9 teams demonstrated trust building reciprocity cycles with articulation of common goal, self-interest, and gratitude/indebtedness. Conclusion: A process model of trust building, defined by reciprocity cycles, can be stimulated with a short intervention (illustrated here in close-to-community health systems) resulting in trusting relationships that drive agency and co-production of positive outcomes for health systems. In addition, it offers a simpler, more useful framework for trust building and measurement than traditional models of trust in health systems research. Early findings illustrate reciprocity cycles are scalable and adaptable, with potential utility at multiple levels of health systems.

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Why Community Health Systems Have Not Flourished in High Income Countries: What the Australian Experience Tells Us

International Journal of Health Policy and Management ◽

10.34172/ijhpm.2021.42 ◽

2021 ◽

Author(s):

Fran Baum ◽

Toby Freeman

Keyword(s):

Health Promotion ◽

Health Services ◽

Health System ◽

Community Health ◽

Health Systems ◽

The United States ◽

Community Health Services ◽

High Income ◽

Community Health Systems ◽

Effective Community

Background: Despite the value of community health systems, they have not flourished in high income countries and there are no system-wide examples in high income countries where community health is regarded as the mainstream model. Those that do exist in Australia, Canada, the United States and the United Kingdom provide examples of comprehensive primary healthcare (PHC) but are marginal to bio-medical primary medical care. The aim of this paper is to examine the factors that account for the absence of strong community health systems in high income countries, using Australia as an example. Methods: Data are drawn from two Australian PHC studies led by the authors. One examined seven case studies of community health services over a five-year period which saw considerable health system change. The second examined regional PHC organisations. We conducted new analysis using the ‘three I’s’ framework (interests, institutions, ideas) to examine why community health systems have not flourished in high-income countries. Results: The elements of the community health services that provide insights on how they could become the basis of an effective community health system are: a focus on equity and accessibility, effective community participation/control; multidisciplinary teamwork; and strategies from care to health promotion. Key barriers identified were: when general practitioners (GPs) were seen to lead rather than be part of a team; funding models that encourage curative services rather than disease prevention and health promotion; and professional and medical dominance so that community voices are drowned out. Conclusion: Our study of the community health system in Australia indicates that instituting such a system in high income countries will require systematic ideological, political and institutional change to shift the overarching government policy environment, and health sector policies and practices towards a social model of health which allows community control, and multidisciplinary service provision.

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Challenges with Scale-up of GeneXpert MTB/RIF® inUganda: a Health Systems Perspective

10.21203/rs.2.10689/v4 ◽

2020 ◽

Author(s):

Talemwa Nalugwa ◽

Priya B. Shete ◽

Mariam Nantale ◽

Katherine Farr ◽

Christopher Ojok ◽

...

Keyword(s):

Health System ◽

Community Health ◽

Health Systems ◽

Community Health Centers ◽

Scale Up ◽

Health Centers ◽

Data Sources ◽

Cross Sectional ◽

Hub And Spoke ◽

System Factors

Abstract Background: Many high burden countries are scaling-up GeneXpert MTB/RIF (Xpert) testing for tuberculosis (TB) using a hub-and-spoke model. However, the effect of scale up on reducing TB has been limited. We sought to characterize variation in implementation of referral-based Xpert TB testing across Uganda, and to identify health system factors that may enhance or prevent high-quality implementation of Xpert testing services. Methods: We conducted a cross-sectional study triangulating quantitative and qualitative data sources at 23 community health centers linked to one of 15 Xpert testing sites between November 2016 and May 2017 to assess health systems infrastructure for hub-and-spoke Xpert testing. Data sources included a standardized site assessment survey, routine TB notification data, and field notes from site visits. Results: Challenges with Xpert implementation occurred at every step of the diagnostic evaluation process, leading to low overall uptake of testing. Of 2,192 patients eligible for TB testing, only 574 (26%) who initiated testing were referred for Xpert testing. Of those, 54 (9.4%)were Xpert confirmed positive just under half initiated treatment within 14 days (n=25, 46%). Gaps in required infrastructure at 23 community health centers to support the hub-and-spoke system included lack of refrigeration (n=14, 61%) for sputum testing and lack of telephone/mobile communication (n=21, 91%). Motorcycle riders responsible for transporting sputum to Xpert sites operated variable with trips once, twice, or three times a week at 10 (43%), nine (39%) and four (17%) health centers, respectively. Staff recorded Xpert results in the TB laboratory register at only one health center and called patients with positive results at only two health centers. Of the 15 Xpert testing sites, five (33%) had at least one non-functioning module. The median number of tests per day was 3.57 (IQR 2.06-4.54), and 10 (67%) sites had error/invalid rates >5%. Conclusions: Although Xpert devices are now widely distributed throughout Uganda, health system factors across the continuum from test referral to results reporting and treatment initiation preclude effective implementation of Xpert testing for patients presenting to peripheral health centers. Support for scale up of innovative technologies should include support for communication, coordination and health systems integration.

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Selection of patient-reported outcome measures (PROMs) for use in health systems

Journal of Patient-Reported Outcomes ◽

10.1186/s41687-021-00374-2 ◽

2021 ◽

Vol 5 (S2) ◽

Author(s):

Fatima Al Sayah ◽

Xuejing Jin ◽

Jeffrey A. Johnson

Keyword(s):

Health System ◽

Health Systems ◽

Outcome Measures ◽

Outcome Measurement ◽

Patient Reported Outcome Measures ◽

Patient Reported Outcome ◽

Measurement Properties ◽

Successful Implementation ◽

Patient Reported ◽

Selection Of

AbstractMany healthcare systems around the world have been increasingly using patient-reported outcome measures (PROMs) in routine outcome measurement to enhance patient-centered care and incorporate the patient’s perspective in health system performance evaluation. One of the key steps in using PROMs in health systems is selecting the appropriate measure(s) to serve the purpose and context of measurement. However, the availability of many PROMs makes this choice rather challenging. Our aim was to provide an integrated approach for PROM(s) selection for use by end-users in health systems.The proposed approach was based on relevant literature and existing guidebooks that addressed PROMs selection in various areas and for various purposes, as well as on our experience working with many health system users of PROMs in Canada. The proposed approach includes the following steps: (1) Establish PROMs selection committee; (2) Identify the focus, scope, and type of PROM measurement; (3) Identify potential PROM(s); (4) Review practical considerations for each of the identified PROMs; (5) Review measurement properties of shortlisted PROMs; (6) Review patient acceptance of shortlisted PROMs; (7) Recommend a PROM(s); and (8) Pilot the selected PROM(s). The selection of appropriate PROMs is one step in the successful implementation of PROMs within health systems, albeit, an essential step. We provide guidance for the selection of PROMs to satisfy all potential usages at the micro (patient-clinician), meso (organization), and macro (system) levels within the health system. Selecting PROMs that satisfy all these purposes is essential to ensure continuity and standardization of measurement over time. This is an iterative process and users should consider all the available information from all presented steps in selecting PROMs. Each of these considerations has a different weight in diverse clinical contexts and settings with various types of patients and resources.

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Antimicrobial Stewardship Programs in Community Health Systems Perceived by Physicians and Pharmacists: A Qualitative Study with Gap Analysis

Antibiotics ◽

10.3390/antibiotics8040252 ◽

2019 ◽

Vol 8 (4) ◽

pp. 252 ◽

Cited By ~ 1

Author(s):

Sohyun Park ◽

Ji Eun Kang ◽

Hee Jung Choi ◽

Chung-Jong Kim ◽

Eun Kyoung Chung ◽

...

Keyword(s):

Health System ◽

Community Health ◽

Antimicrobial Stewardship ◽

Gap Analysis ◽

Interdisciplinary Collaboration ◽

Working Environment ◽

Successful Implementation ◽

Specific Information ◽

Good Communication ◽

Stewardship Program

Antimicrobial stewardship program (ASP) is one of the most important strategies for managing infectious disease treatment and preventing antimicrobial resistance. The successful implementation of ASP in the community health system (CHS) has been challenging. We evaluated perceptions of current ASP, potential setbacks of ASP implementation, and future demands on ASP services among physicians and pharmacists in the CHS. The qualitative research was conducted through in-depth individual interviews and focus group discussions with 11 physicians and 11 pharmacists. In addition, a quantitative gap analysis was conducted to assess the different awareness and demands on services of ASP and preferred antimicrobial-related problems (ARP). In overall, perceptions of ASP varied by profession. The identified setbacks were unorganized institutional leadership, the undefined roles of healthcare professionals, a lack of reimbursement, the hierarchical structure of the health system, and the labor-intensive working environment of pharmacy services. Although demands for ASP improvement were similar among professionals, they had different preferences in prioritizing each service item of ASP/ARP development and the profession responsible for each service. Continuous administrative and financial investments, understanding ASP contents, ASP-specific information technology, and interdisciplinary collaboration with good communication among healthcare professions are needed to continue the progression of ASP.

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