scholarly journals Implementation and Scale Up of Tobacco Cessation Within TB Programmes: Findings from a Multi-Country, Mixed-Methods Implementation Study

2021 ◽  
Author(s):  
Helen Elsey ◽  
Zunayed Al Azdi ◽  
Shophika Regmi ◽  
Sushil Baral ◽  
Razia Fatima ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Health System ◽  
Tobacco Cessation ◽  
Health Workers ◽  
Scale Up ◽  
Deep Understanding ◽  
Routine Data ◽  
System Level ◽  
Horizontal Scale ◽  
Vertical Scale

Abstract Background: Brief behavioural support can effectively help TB patients to quit smoking and improve their outcomes. In collaboration with TB programmes in Bangladesh, Nepal and Pakistan, we evaluated implementation and scale-up of cessation support using four strategies: i) brief tobacco cessation intervention ii) integration of tobacco cessation within routine training iii) inclusion of tobacco indicators in routine records and iv) embedding research within TB programmes.Methods: We used mixed methods of observation, interviews and routine data within WHO’s ExpandNet framework for scale-up. We aimed to understand the extent of, and strategies which facilitated vertical scale-up (institutionalisation) within 59 health facility learning sites in Pakistan, 18 in Nepal and 15 in Bangladesh and horizontal scale-up (increased coverage beyond learning sites). We observed training and surveyed 169 TB health workers to measure changes in their confidence to deliver cessation. Routine TB data from the learning sites was analysed to assess delivery of the intervention and use of TB forms revised to report smoking status and cessation support provided. A purposive sample of TB health workers, managers and policymakers were interviewed (Bangladesh: n=12; Nepal n=13; Pakistan n=19;). Costs of scale-up were estimated using activity-based cost-analysis. Results: Routine data indicated health workers in learning sites asked all TB patients about tobacco use and offered them cessation support. Qualitative data showed use of intervention materials, often with adaptation and partial implementation in busy clinics. Short (1-2 hours) training integrated within existing programmes increased mean confidence to deliver cessation by 17% (95% CI: 14% to 20%). A focus on health system changes (reporting, training, supervision) facilitated vertical scale-up. Dissemination of materials beyond learning sites and changes to national reporting forms and training indicated horizontal scale-up. Embedding research within TB health systems was crucial for horizontal scale-up and required dynamic use of tactics e.g. alliance-building, engagement in wider policy process, use of insider-researchers, and deep understanding of health system actors and processes. Conclusions: System-level changes within TB programmes may enable routine delivery of cessation support to TB patients. These strategies are inexpensive and, with concerted efforts from TB programmes and donors, tobacco cessation can be institutionalised at-scale.

scholarly journals Scaling Up Tobacco Cessation within TB Programmes: Findings from a Multi-Country, Mixed-Methods, Implementation Study.

2021 ◽  
Author(s):  
Helen Elsey ◽  
Zunayed Al Azdi ◽  
Shophika Regmi ◽  
Sushil Baral ◽  
Razia Fatima ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Health System ◽  
Tobacco Cessation ◽  
Health Workers ◽  
Scale Up ◽  
Deep Understanding ◽  
Routine Data ◽  
System Level ◽  
Horizontal Scale ◽  
Vertical Scale

Abstract Background: Brief behavioural support can effectively help TB patients to quit smoking and improve their outcomes. In collaboration with TB programmes in Bangladesh, Nepal and Pakistan, we evaluated implementation and scale-up of cessation support using four strategies: i) brief tobacco cessation intervention ii) integration of tobacco cessation within routine training iii) inclusion of tobacco indicators in routine records and iv) embedding research within TB programmes.Methods: We used mixed methods of observation, interviews and routine data within WHO’s ExpandNet framework for scale-up. We aimed to understand the extent of, and strategies which facilitated vertical scale-up (institutionalisation) within 59 health facility learning sites in Pakistan, 18 in Nepal and 15 in Bangladesh and horizontal scale-up (increased coverage beyond learning sites). We observed training and surveyed 169 TB health workers to measure changes in their confidence to deliver cessation. Routine TB data from the learning sites was analysed to assess delivery of the intervention and use of TB forms revised to report smoking status and cessation support provided. A purposive sample of TB health workers, managers and policymakers were interviewed (Bangladesh: n=12; Nepal n=13; Pakistan n=19;). Costs of scale-up were estimated using activity-based cost-analysis. Results: Routine data indicated health workers in learning sites asked all TB patients about tobacco use and offered them cessation support. Qualitative data showed use of intervention materials, often with adaptation and partial implementation in busy clinics. Short (1-2 hours) training integrated within existing programmes increased mean confidence to deliver cessation by 17% (95% CI: 14% to 20%). A focus on health system changes (reporting, training, supervision) facilitated vertical scale-up. Dissemination of materials beyond learning sites and changes to national reporting forms and training indicated horizontal scale-up. Embedding research within TB health systems was crucial for horizontal scale-up and required dynamic use of tactics e.g. alliance-building, engagement in wider policy process, use of insider-researchers, and deep understanding of health system actors and processes. Conclusions: System-level changes within TB programmes may enable routine delivery of cessation support to TB patients. These strategies are inexpensive and, with concerted efforts from TB programmes and donors, tobacco cessation can be institutionalised at-scale.

scholarly journals Who could be One Health Activist at the community level?: A case for India

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Sandul Yasobant ◽  
Walter Bruchhausen ◽  
Deepak Saxena ◽  
Farjana Zakir Memon ◽  
Timo Falkenberg
Keyword(s):  
Health System ◽  
Work Experience ◽  
Financial Incentives ◽  
One Health ◽  
Health Workers ◽  
Structured Interview ◽  
Communicable Diseases ◽  
Community Level ◽  
System Level

Abstract Background Community health workers (CHWs) are the mainstay of the public health system, serving for decades in low-resource countries. Their multi-dimensional work in various health care services, including the prevention of communicable diseases and health promotion of non-communicable diseases, makes CHWs, the frontline workers in their respective communities in India. As India is heading towards the development of One Health (OH), this study attempted to provide an insight into potential OH activists (OHA) at the community level. Thus, this case study in one of India’s western cities, Ahmedabad, targeted identifying OHA by exploring the feasibility and the motivation of CHWs in a local setting. Methods This case study explores two major CHWs, i.e., female (Accredited Social Health Activists/ASHA) health workers (FHWs) and male (multipurpose) health workers (MHWs), on their experience and motivation for becoming an OHA. The data were collected between September 2018 and August 2019 through a mixed design, i.e., quantitative data (cross-sectional structured questionnaire) followed by qualitative data (focus group discussion with a semi-structured interview guide). Results The motivation of the CHWs for liaisoning as OHA was found to be low; however, the FHWs have a higher mean motivation score [40 (36–43)] as compared to MHWs [37 (35–40)] out of a maximum score of 92. Although most CHWs have received zoonoses training or contributed to zoonoses prevention campaigns, their awareness level was found to be different among male and female health workers. Comparing the female and male health workers to act as OHA, higher motivational score, multidisciplinary collaborative work experience, and way for incentive generation documented among the female health workers. Conclusion ASHAs were willing to accept the additional new liaison role of OHAs if measures like financial incentives and improved recognition are provided. Although this study documented various systemic factors at the individual, community, and health system level, which might, directly and indirectly, impact the acceptance level to act as OHA, they need to be accounted for in the policy regime.

scholarly journals Health system readiness for innovation scale-up: the experience of community-based distribution of injectable contraceptives in Nigeria

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Oluwaseun Akinyemi ◽  
Bronwyn Harris ◽  
Mary Kawonga
Keyword(s):  
Health System ◽  
Community Health ◽  
Health Workers ◽  
Scale Up ◽  
Task Shifting ◽  
Policy Framework ◽  
Framework Analysis ◽  
Community Based ◽  
System Readiness ◽  
Injectable Contraceptives

Abstract Background Following the successful pilot of the community-based distribution of injectable contraceptives (CBDIC) by community health extension workers (CHEWs) in Gombe, northern Nigeria in 2010, there was a policy decision to scale-up the innovation to other parts of the country. However, there is limited understanding of health system factors that may facilitate or impede the successful scale-up of this innovation beyond the pilot site. Thus, this study assessed the health system readiness to deliver CBDIC in Nigeria and how this may influence the scale-up process. Methods This study was conducted in two Local Government Areas in Gombe State in September 2016. Seven key informant interviews were held with purposively sampled senior officials of the ministries of health at the federal and state levels as well as NGO program managers. Also, 10 in-depth interviews were carried out with health workers. All transcripts were analyzed using the thematic framework analysis approach. Result The availability of a policy framework that supports task-shifting and task-sharing, as well as application of evidence from the pilot programme and capacity building programmes for health workers provided a favourable environment for scale-up. Health system challenges for the scale-up process included insufficient community health workers, resistance to the task-shifting policy from professional health groups (who should support the CHEWs), limited funding and poor logistics management which affected commodity distribution and availability. However, there were also a number of health worker innovations which kept the scale-up going. Health workers sometimes used personal resources to make up for logistics failures and poor funding. They often modify the process in order to adapt to the realities on the ground. Conclusion This study shows health system weaknesses that may undermine scale-up of CBDIC. The study also highlights what happens when scale-up is narrowly focused on the intervention without considering system context, capacity and readiness. However, agency and discretionary decision-making among frontline health workers facilitated the process of scaling up, although the sustainability of this is questionable. Benefits observed during the pilot may not be realised on a larger scale if health system challenges are not addressed.

scholarly journals Community Dialogue Approach for addressing the drivers of antibiotic resistance in Bangladesh: a mixed methods study on developing a sustainable and scalable approach to community engagement

2020 ◽  
Author(s):  
Rebecca King ◽  
Joseph Hicks ◽  
Christian Rassi ◽  
Muhammad Shafique ◽  
Deepa Barua ◽  
...  
Keyword(s):  
Antibiotic Resistance ◽  
Mixed Methods ◽  
Health System ◽  
Community Engagement ◽  
Cultural Context ◽  
Scale Up ◽  
International Standards ◽  
Mixed Methods Study ◽  
Small Scale ◽  
Engagement Interventions

Abstract Background Community engagement approaches that have impacted on health outcomes are often time intensive, small-scale and require high levels of financial and human resources. They can be difficult to sustain and scale-up in low resource settings. Given the reach of health services into communities in low income countries, the health system provides a valuable and potentially sustainable entry point that would allow for scale-up of community engagement interventions. This study explores the process of developing an embedded approach to community engagement taking the global challenge of antibiotic resistance as an example. Methods The intervention was developed using a sequential mixed methods study design. This consisted of: exploring the evidence base through an umbrella review, and identifying key international standards on the appropriate use of antibiotics; undertaking detailed exploratory research through a) a qualitative study to explore the most appropriate mechanisms through which to embed the intervention within the existing health system and community infrastructure, and to understand patterns of knowledge, attitudes and practice regarding antibiotics and antibiotic resistance; and b) a household survey – which drew on the qualitative findings - to quantify knowledge, and reported attitudes and practice regarding antibiotics and antibiotic resistance within the target population; and c) drawing on appropriate theories regarding change mechanisms and experience of implementing community engagement interventions to co-produce the intervention processes and materials with key stakeholders at policy, health system and community level. Results A community engagement intervention was co-produced and was explicitly designed to link into existing health system and community structures and be appropriate for the cultural context, and therefore have the potential to be implemented at scale. We anticipate that taking this approach increases local ownership, as well as the likelihood that the intervention will be sustainable and scalable. Conclusions This study demonstrates the value of ensuring that a range of stakeholders co-produce the intervention, and ensuring that the intervention is designed to be appropriate for the health system, community and cultural context.

Abstract MP64: Estimated Impact Of Public Health System Reforms To Increase Hypertension Treatment Coverage In India

Hypertension ◽  
2021 ◽  
Vol 78 (Suppl_1) ◽  
Author(s):  
Matti Marklund ◽  
Rajeev Cherukupalli ◽  
Priya Pathak ◽  
Dinesh Neupane ◽  
Ashish Krishna ◽  
...  
Keyword(s):  
Public Health ◽  
Health System ◽  
Public Health System ◽  
Health Workers ◽  
Scale Up ◽  
System Reform ◽  
Task Sharing ◽  
Treatment Coverage ◽  
The Public ◽  
The Status

Background: Approaches to scale up hypertension (HTN) treatment are needed in India, where only ~10% of individuals with HTN have controlled blood pressure. Objective: Estimate the current HTN treatment capacity of the public health system in India and model the effects of selected health system reform options. Methods: Using constrained optimization models, we estimated the HTN treatment capacity and salary costs of HTN-treating staff within the public health system; and simulated the potential effects of 1) increased workforce, 2) greater task sharing, and/or 3) reduced visit frequency (quarterly) vs the common practice of monthly visits for prescription refills. Results: An estimated 8% of all adults with HTN could be treated in the status quo (current number of health workers, no further task sharing, and monthly visits) (Figure). Treating 70% of adults with HTN with monthly visits without greater task sharing could require an additional 1.6 million staff, with ~200 billion ₹ (≈US$2.7 billion)) in additional annual salaries. Greater task sharing was estimated to allow the current workforce to treat ~25% of individuals with HTN with monthly visits. Quarterly visits (i.e., longer prescription periods) together with greater task sharing could allow the current workforce to treat ~70% of patients with HTN in India. Conclusion: Expanding HTN treatment coverage through workforce expansion alone will require substantial human and financial resources. The combination of greater task sharing and quarterly visits could increase the coverage of HTN treatment to ~70% of adults with HTN in India, without any expansion of the current workforce of the public health system.

scholarly journals Who could be One Health Activist at the community level?: A case for India

2020 ◽  
Author(s):  
Sandul Yasobant ◽  
Walter Bruchhausen ◽  
Deepak Saxena ◽  
Farjana Zakir Memon ◽  
Timo Falkenberg
Keyword(s):  
Health System ◽  
Financial Incentives ◽  
One Health ◽  
Health Workers ◽  
Structured Interview ◽  
Communicable Diseases ◽  
Community Level ◽  
System Level ◽  
Cross Sectional

Abstract Background: Community Health Workers (CHWs) are the mainstay of the public health system, serving for decades in low resource countries. Their multi-dimensional work in diverse health care services, including the prevention of communicable diseases and health promotion for non-communicable diseases, are making CHWs the frontline workers in their respective communities in India. As India is heading towards the development of One Health (OH), this study attempted to provide an insight into potential OH activists (OHA) at the community level. Thus, this case study in one of the western cities of India, Ahmedabad, targeted to identify OHA by exploring the motivation to become an OHA in a local setting.Methods: This case study explores two major CHWs i.e. female (Accredited Social Health Activists-ASHA) and male (multipurpose male health worker) on their motivation for becoming an OHA. The data was collected between September 2018 and August 2019 through a mixed design i.e. quantitative data (cross-sectional structured questionnaire) and qualitative data (focus group discussion with a semi-structured interview guide). Results: The motivation of the CHWs for OHA was found to be low. Although most CHWs have received zoonoses training or contributed to zoonoses prevention campaigns, their awareness level was found to be different among male and female health workers. ASHAs were found to be willing to accept the additional new liaison role of OHAs if measures like financial incentives and improved recognition are provided. Conclusion: The high demotivation of CHWs that has been documented on the individual, community, and health system level needs to be urgently addressed in future policies.

scholarly journals Constraints, synergies and avenues for scaling up breastfeeding, antibiotics for pneumonia and IMCI interventions in the Cusco region, Peru

F1000Research ◽  
2012 ◽  
Vol 1 ◽  
pp. 60 ◽  
Author(s):  
Giselle Sarganas ◽  
Robert Scherpbier ◽  
Christian A Gericke
Keyword(s):  
Low Income ◽  
Exclusive Breastfeeding ◽  
Rural Areas ◽  
Health Workers ◽  
Local Level ◽  
Health Centre ◽  
Scale Up ◽  
Scaling Up ◽  
System Level

Objective: The purpose of this qualitative case study was to assess the feasibility of scaling up exclusive breastfeeding for 6 months, antibiotics for pneumonia and integrated management of childhood illness (IMCI) child interventions in three districts of the Cusco region, Peru.Methods: During field visits, constraints, synergies and solutions to the implementation of the selected interventions were collected through observational recording and interviews of mothers, health workers, and health managers/decision makers. Results are presented for each intervention according to the health system level where they occurred: mother/community, health worker, health centre, and political/managerial levels.Findings: This case study demonstrates that it is feasible to scale up exclusive breastfeeding, antibiotics for pneumonia and IMCI interventions in poverty-stricken rural areas of a low-income country. Factors that helped and hindered the implementation were identified for each intervention.Conclusions: The need for a coherent multi-sector approach that includes regulation, implementation and monitoring of health policies and education of all involved stakeholders was apparent. This study also demonstrates that global health interventions need to undergo local adaptation. Identifying local constraints and facilitating factors in a systematic way as proposed in this study is a useful step to increase their effectiveness and reach at the local level and to identify areas for improvement in the original intervention policies.

scholarly journals Individual capacities influencing uses of routine health data for decision making among health workersat Muhimbili National Hospital; Dar es Salaam – Tanzania: a quantitative study

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Salim Mpimbi ◽  
Mwangu Mughwira
Keyword(s):  
Decision Making ◽  
Emergency Medicine ◽  
Health System ◽  
Health Workers ◽  
Data Use ◽  
Routine Data ◽  
Health Data ◽  
Muhimbili National Hospital ◽  
National Hospital ◽  
Significant Difference

Background: The availability of health workers with the capacity to read and understand statistical data and then use them for work-related decision-making, therefore, supporting their institutions or the existing health system at large in developing countries is important. However, in some countries, Tanzania inclusive, this has remained critical. This requires the capacity-building of potential users. The study aimed to assess individual capacities influencing use of routine health data for decision-making among Emergency Medicine health workers at Muhimbili National Hospital (MNH). Methods: The study design used was a descriptive cross-sectional using a quantitative approach. Stratified random sampling was used to sample Nurses, Medical officers, Residents, and Emergency medicine specialists. A semi-structured questionnaire was used to collect data. The study involved 76 health workers working in the Emergency Medicine Department (EMD) at MNH. Results: Results showed 61.6% use of routine health data for decision making. Working experience, job title, and education level had a statistically significant association with information used for decision-making. There was a statistically significant difference in routine data use between those who had poor and good knowledge to collect, analyze, interpret, and use data. Also, results showed that there was a statistically significant difference in routine data use between those who had poor and good skills to collect, analyze, interpret, and use data. Specialists had a good level of knowledge and skills on data use compared to other health workers. Conclusion: The study demonstrates partial use of routine health data for decision-making with an interplay of individual capacities. A framework for statistical capacity building in Tanzania needs to be built, by training a cadre of health workers with core competencies and skills in measuring progress in the health system that could generate sustainable demand for data use within the health systems of the country.

scholarly journals Protocol for the mixed-methods process and context evaluation of theTB & Tobaccorandomised controlled trial in Bangladesh and Pakistan: a hybrid effectiveness–implementation study

BMJ Open ◽  
2018 ◽  
Vol 8 (3) ◽  
pp. e019878 ◽  
Author(s):  
Melanie Boeckmann ◽  
Iveta Nohavova ◽  
Omara Dogar ◽  
Eva Kralikova ◽  
Alexandra Pankova ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Medical Research ◽  
Process Evaluation ◽  
Tobacco Cessation ◽  
Qualitative Data ◽  
Research Council ◽  
Medical Research Council ◽  
Health Workers ◽  
Trial Data ◽  
Behavioural Support

IntroductionTuberculosis (TB) remains a significant public health problem in South Asia. Tobacco use increases the risks of TB infection and TB progression. TheTB& Tobaccoplacebo-controlled randomised trial aims to (1) assess the effectiveness of the tobacco cessation medication cytisine versus placebo when combined with behavioural support and (2) implement tobacco cessation medication and behavioural support as part of general TB care in Bangladesh and Pakistan. This paper summarises the process and context evaluation protocol embedded in the effectiveness–implementation hybrid design.Methods and analysisWe are conducting a mixed-methods process and context evaluation informed by an intervention logic model that draws on the UK Medical Research Council’s Process Evaluation Guidance. Our approach includes quantitative and qualitative data collection on context, recruitment, reach, dose delivered, dose received and fidelity. Quantitative data include patient characteristics, reach of recruitment among eligible patients, routine trial data on dose delivered and dose received, and a COM-B (‘capability’, ‘opportunity’, ‘motivation’ and ‘behaviour’) questionnaire filled in by participating health workers. Qualitative data include semistructured interviews with TB health workers and patients, and with policy-makers at district and central levels in each country. Interviews will be analysed using the framework approach. The behavioural intervention delivery is audio recorded and assessed using a predefined fidelity coding index based on behavioural change technique taxonomy.Ethics and disseminationThe study complies with the guidelines of the Declaration of Helsinki. Ethics approval for the study and process evaluation was granted by the University of Leeds (qualitative components), University of York (trial data and fidelity assessment), Bangladesh Medical Research Council and Bangladesh Drug Administration (trial data and qualitative components) and Pakistan Medical Research Council (trial data and qualitative components). Results of this research will be disseminated through reports to stakeholders and peer-reviewed publications and conference presentations.Trial registration numberISRCTN43811467; Pre-results.

scholarly journals A mixed-methods evaluation of the uptake of novel differentiated ART delivery models in a national sample of health facilities in Uganda

2021 ◽  
Author(s):  
Henry Zakumumpa ◽  
Kimani Makobu ◽  
Ntawiha Wilbrod ◽  
Everd Maniple
Keyword(s):  
Mixed Methods ◽  
Health System ◽  
Fast Track ◽  
Health Workers ◽  
Drug Distribution ◽  
Health Facilities ◽  
Hiv Care ◽  
Adult Males ◽  
Community Based ◽  
Art Delivery

Abstract INTRODUCTIONSince 2017, Uganda has been implementing differentiated antiretroviral therapy services (DARTS) to improve the quality of HIV care and health-system efficiencies. The Ministry of Health endorsed five models. The community-based models include Community Client-Led Drug Delivery (CCLAD) and Community Drug Distribution Points (CDDPs), with facility-based models being either Fast Track Drug Refill (FTDR), Facility Based Group (FBG) or Facility-Based Individual Management (FBIM). It is unclear what the uptake of DARTS is since roll-out in 2017. We set out to assess the extent of uptake of DARTS models and to describe barriers to uptake of either facility-based or community-based models.METHODSBetween August and December 2019, we conducted a mixed-methods study entailing a cross-sectional health facility survey (n=116) and in-depth interviews (n=18) with ART clinic managers in ten case-study facilities as well as six focus group discussions (56 participants) with patients enrolled in DARTS models. Facilities were selected based on the 10 geographic sub-regions of Uganda. Statistical analyses were performed in STATA (v13) while qualitative data were analyzed by thematic approach. The qualitative arm of our study was dominant.RESULTSMost facilities 63 (57%) commenced implementation of DARTS in 2018. The most implemented facility-based model was Fast Track Drug Refill (FTDR) implemented in 100 (86%) of health facilities. Community Client-Led ART Delivery (CCLAD) was the most popular community model implemented in more than a half of facilities (63/116 or 54%). Community Drug Distribution Points (CDDP) model had the lowest uptake and was implemented in only 33 (24.88%) facilities. Overall, there has been a higher uptake of facility-based models. Barriers to enrollment in community-based models include; HIV-related stigma and a fear of breach of confidentiality of HIV status, low enrollment of adult males in community models. Health-system constraints include insufficient training of health workers in DARTS and inadequate funding to facilities for implementing community-based models.CONCLUSIONTo the best of our knowledge this is the first study reporting national DARTS coverage in Uganda. There is need to devise stigma-reduction interventions to enhance uptake of community models and increased donor and government funding for community models to maximize DARTS potential for achieving health-system efficiencies.

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