Equally Able, But Unequally Accepted: Gender Differentials and Experiences of Community Health Volunteers Promoting Maternal, Newborn, and Child Health in Morogoro Region, Tanzania.

Despite emerging qualitative evidence of gendered community health worker (CHW) experience, few quantitative studies examine CHW gender differentials. The launch of a maternal, newborn, and child health (MNCH) CHW cadre in Morogoro Region, Tanzania enlisting both males and females as CHWs, provides an opportunity to examine potential gender differences in CHW knowledge, health promotion activities and client acceptability. All CHWs who received training from the Integrated MNCH Program between December 2012 and July 2013 in five districts were surveyed and information on health promotion activities undertaken drawn from their registers. CHW socio-demographic characteristics, knowledge, and health promotion activities were analyzed through bi- and multivariate analyses. Composite scores generated across ten knowledge domains were used in ordered logistic regression models to estimate relationships between knowledge scores and predictor variables. Thematic analysis was also undertaken on 60 purposively sampled semi-structured interviews with CHWs, their supervisors, community leaders, and health committee members in 12 villages from three districts. Of all CHWs trained, 97 % were interviewed (n = 228): 55 % male and 45 % female. No significant differences were observed in knowledge by gender after controlling for age, education, date of training, marital status, and assets. Differences in number of home visits and community health education meetings were also not significant by gender. With regards to acceptability, women were more likely to disclose pregnancies earlier to female CHWs, than male CHWs. Men were more comfortable discussing sexual and reproductive concerns with male, than female CHWs. In some cases, CHW home visits were viewed as potentially being for ulterior or adulterous motives, so trust by families had to be built. Respondents reported that working as female-male pairs helped to address some of these dynamics. Male and female CHWs in this study have largely similar knowledge and health promotion outputs, but challenges in acceptance of CHW counseling for reproductive health and home visits by unaccompanied CHWs varied by gender. Programs that pair male and female CHWs may potentially overcome gender issues in CHW acceptance, especially if they change gender norms rather than solely accommodate gender preferences

Key findings from a prospective trauma registry at a regional hospital in Southwest Cameroon

IntroductionTrauma is a leading cause of morbidity and mortality worldwide. Data characterizing the burden of trauma in Cameroon is limited. Regular, prospective injury surveillance can address the shortcomings of existing hospital administrative logs and medical records. This study aims to characterize trauma as seen at the emergency department (ED) of Limbe Regional Hospital (LRH) and assess the completeness of data obtained by a trauma registry.Methods and findingsFrom January 2008 to October 2013, we prospectively captured data on injured patients using a strategically designed, context-relevant trauma registry instrument. Indicators around patient demographics, injury characteristics, delays in accessing care, and treatment outcomes were recorded. Descriptive, bivariate, and multivariate statistical analyses were conducted. About 5,617 patients, aged from 0.5-95years (median age of 26 years), visited the LRH ED with an injury; 67% were male. Students (27%) were the most affected occupation category. Road traffic injuries (RTIs) (56%), assault (22%), and domestic injuries (13%) were the leading causes of injury. Two-thirds of RTIs were motorcycle-related. Working in transportation (AOR 4.42, p<0.001) and law enforcement (AOR 1.73, p = 0.004) were significant predictors of having a RTI. The trauma registry showed a significant improvement in completeness of all data (p<0.001) and it improved over time compared with previous administrative records. However, proportions of missing data still ranged from 0.5% to 8.2% and involved respiratory rate or Glasgow Coma scale.ConclusionsImplementation of a context-appropriate trauma registry in resource-constrained settings is feasible. Providing valuable, high-quality data, the trauma registry can inform trauma care quality improvement efforts and policy development. Study findings indicate the need for injury prevention interventions and policies that will prioritize high-risks groups, such as those aged 20-29 years, and those in occupations requiring frequent road travel. The high incidence of motorcycle-related injuries is concerning and calls for a proactive solution

Health system modelling research : towards a whole-health-system perspective for identifying good value for money investments in health system strengthening

Global health research has typically focused on single diseases, and most economic evaluation research to date has analysed technical health interventions to identify 'best buys'. New approaches in the conduct of economic evaluations are needed to help policymakers in choosing what may be good value (ie, greater health, distribution of health, or financial risk protection) for money (ie, per budget expenditure) investments for health system strengthening (HSS) that tend to be programmatic. We posit that these economic evaluations of HSS interventions will require developing new analytic models of health systems which recognise the dynamic connections between the different components of the health system, characterise the type and interlinks of the system's delivery platforms; and acknowledge the multiple constraints both within and outside the health sector which limit the system's capacity to efficiently attain its objectives. We describe priority health system modelling research areas to conduct economic evaluation of HSS interventions and ultimately identify good value for money investments in HSS

Profile, knowledge, and work patterns of a cadre of maternal, newborn, and child health CHWs focusing on preventive and promotive services in Morogoro Region, Tanzania

BACKGROUND: Despite impressive decreases in under-five mortality, progress in reducing maternal and neonatal mortality in Tanzania has been slow. We present an evaluation of a cadre of maternal, newborn, and child health community health worker (MNCH CHW) focused on preventive and promotive services during the antenatal and postpartum periods in Morogoro Region, Tanzania. Study findings review the effect of several critical design elements on knowledge, time allocation, service delivery, satisfaction, and motivation. METHODS: A quantitative survey on service delivery and knowledge was administered to 228 (of 238 trained) MNCH CHWs. Results are compared against surveys administered to (1) providers in nine health centers (n = 88) and (2) CHWs (n = 53) identified in the same districts prior to the program’s start. Service delivery outputs were measured by register data and through a time motion study conducted among a sub-sample of 33 randomly selected MNCH CHWs. RESULTS: Ninety-seven percent of MNCH CHWs (n = 228) were interviewed: 55% male, 58% married, and 52% with secondary school education or higher. MNCH CHWs when compared to earlier CHWs were more likely to be unmarried, younger, and more educated. Mean MNCH CHW knowledge scores were <50% for 8 of 10 MNCH domains assessed and comparable to those observed for health center providers but lower than those for earlier CHWs. MNCH CHWs reported covering a mean of 186 households and were observed to provide MNCH services for 5 h weekly. Attendance of monthly facility-based supervision meetings was nearly universal and focused largely on registers, yet data quality assessments highlighted inconsistencies. Despite program plans to provide financial incentives and bicycles for transport, only 56% of CHWs had received financial incentives and none received bicycles. CONCLUSIONS: Initial rollout of MNCH CHWs yields important insights into addressing program challenges. The social profile of CHWs was not significantly associated with knowledge or service delivery, suggesting a broader range of community members could be recruited as CHWs. MNCH CHW time spent on service delivery was limited but comparable to the financial incentives received. Service delivery registers need to be simplified to reduce inconsistencies and yet expanded to include indicators on the timing of antenatal and postpartum visits. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12960-015-0086-3) contains supplementary material, which is available to authorized users

Perceptions of science, science communication, and climate change attitudes in 68 countries – the TISP dataset

Science is integral to society because it can inform individual, government, corporate, and civil society decision-making on issues such as public health, new technologies or climate change. Yet, public distrust and populist sentiment challenge the relationship between science and society. To help researchers analyse the science-society nexus across different geographical and cultural contexts, we undertook a cross-sectional population survey resulting in a dataset of 71,922 participants in 68 countries. The data were collected between November 2022 and August 2023 as part of the global Many Labs study “Trust in Science and Science-Related Populism” (TISP). The questionnaire contained comprehensive measures for individuals’ trust in scientists, science-related populist attitudes, perceptions of the role of science in society, science media use and communication behaviour, attitudes to climate change and support for environmental policies, personality traits, political and religious views and demographic characteristics. Here, we describe the dataset, survey materials and psychometric properties of key variables. We encourage researchers to use this unique dataset for global comparative analyses on public perceptions of science and its role in society and policy-making

Trust in scientists and their role in society across 68 countries

Science is crucial for evidence-based decision-making. Public trust in scientists can help decision makers act on the basis of the best available evidence, especially during crises. However, in recent years the epistemic authority of science has been challenged, causing concerns about low public trust in scientists. We interrogated these concerns with a preregistered 68-country survey of 71,922 respondents and found that in most countries, most people trust scientists and agree that scientists should engage more in society and policymaking. We found variations between and within countries, which we explain with individual- and country-level variables, including political orientation. While there is no widespread lack of trust in scientists, we cannot discount the concern that lack of trust in scientists by even a small minority may affect considerations of scientific evidence in policymaking. These findings have implications for scientists and policymakers seeking to maintain and increase trust in scientists

Identifying Health System Priorities for Equitable Access to Health Services in Low- and Middle-Income Countries

In 2019, the World Health Organization announced that up to 5 billion people will be unable to access health care in 2030 if governments fail to sufficiently increase investments in health care. The three papers that comprise this dissertation explore themes of access to health care and priority setting to improve access via outreach and financial risk protection for the most vulnerable populations. They employ methods of economic evaluation and decision sciences to support decision-making towards these aims in resource-constrained settings. Immunization remains one of the most effective interventions to reduce child morbidity and mortality, but is an essential health service that still fails to reach every child in low- and middle-income countries. Using a structural equation model informed by the literature on 'decision space' in health systems, Paper 1 examines whether the decentralized management structure of India’s intensified immunization program and its capacity to reached previously unimmunized children were related. Study results highlighted that a greater capacity to make decisions at local operational levels was associated with fewer planned vaccination sessions being implemented under the program at the subdistrict level, but was not related to the number of children vaccinated per session. Greater reductions in morbidity and mortality due to vaccine-preventable diseases may be derived from greater attention to programmatic management and organization to improve immunization coverage and access to other essential health services. Achieving high levels of financial risk protection is another indication of adequate access to health care and continues to be an objective of health systems. Despite comprehensive social health protection schemes, some countries experience low claims of the entitlements provided through these schemes. Paper 2 investigates this phenomenon, examining the relationships between patients’ awareness of their benefits and their utilization of them in Cambodia. Study findings reveal that the majority of beneficiaries under the country's public health protection scheme were aware of their entitlements, but chose to seek care from private rather than public providers, where services would be free of user fees. Microsimulations of interventions aimed at increasing patients' awareness suggest that initiatives intervening on the decision of where to seek care (i.e., public vs. private facilities) may prove more fruitful towards increasing financial risk protection compared to interventions implemented within public facilities alone. Overall, interventions aimed at increasing awareness of entitlements were only associated with very small increases in user claims and suggest that beneficiary awareness may not be a major barrier to access in this context as initially hypothesized. With the increasing burden of expensive non-communicable diseases, health policies will need to establish efficient and equitable policies that reduce financial barriers to accessing routine health services for the poor. Paper 3 explores the potential economic costs, health gains, and financial risk protection benefits associated with provision of diabetes-related care in the context of Cambodia’s social health protection scheme, the Health Equity Funds. Using Markov modeling and cost-effectiveness analysis, the study points to how providing effective service and financial coverage for screening and treatment services for diabetes would lead to the substantial health and financial risk protection benefits for the Cambodian population. Examining the impact of health and financial benefits showed that such a policy would particularly benefit women and the poorest. These three papers tackle burgeoning challenges in access to health care for children, the poorest, and women in lower-middle income settings, pointing to potentially effective and cost-effective solutions to improve access to address communicable and non-communicable diseases. Paper 1 highlights how the design of organizational structures for decision making may relate to improved outreach to increase access to immunization for hard-to-reach children. Paper 2 evaluates hypotheses on how to improve access to health services through appropriate use of health coverage, and Paper 3 determines the cost-effectiveness of reducing barriers to accessing non-communicable disease services among the poor. Together, these studies contribute to decision making regarding health systems strengthening interventions aimed at reducing access barriers and addressing population health needs in the unique contexts of low- and middle-income country settings.Population Health Science