Suchergebnisse

Introduction: Estimates suggest that one in two deaths go unrecorded globally every year in terms of medical causes, with the majority occurring in low and middle-income countries (LMICs). This can be related to low investment in civil registration and vital statistics (CRVS) systems. Verbal autopsy (VA) is a method that enables identification of cause of death where no other routine systems are in place and where many people die at home. Considering the utility of VA as a pragmatic, interim solution to the lack of functional CRVS, this review aimed to examine the use of VA to inform health policy and systems improvements. Methods: A literature review was conducted including papers published between 2010 and 2017 according to a systematic search strategy. Inclusion of papers and data extraction were assessed by three reviewers. Thereafter, thematic analysis and narrative synthesis were conducted in which evidence was critically examined and key themes were identified. Results: Twenty-six papers applying VA to inform health policy and systems developments were selected, including studies in 15 LMICs in Africa, Asia, the Middle East and South America. The majority of studies applied VA in surveillance sites or programmes actively engaging with decision makers and governments in different ways and to different degrees. In the papers reviewed, the value of continuous collection of cause of death data, supplemented by social and community-based investigations and underpinned by electronic data innovations, to establish a robust and reliable evidence base for health policies and programmes was clearly recognised. Conclusion: VA has considerable potential to inform policy, planning and measurement of progress towards goals and targets. Working collaboratively at sub-national, national and international levels facilitates data collection, aggregation and dissemination linked to routine information systems. When used in partnerships between researchers and authorities, VA can help to close critical information gaps and guide policy development, implementation, evaluation and investment in health systems.

Introduction: Estimates suggest that one in two deaths go unrecorded globally every year in terms of medical causes, with the majority occurring in low and middle-income countries (LMICs). This can be related to low investment in civil registration and vital statistics (CRVS) systems. Verbal autopsy (VA) is a method that enables identification of cause of death where no other routine systems are in place and where many people die at home. Considering the utility of VA as a pragmatic, interim solution to the lack of functional CRVS, this review aimed to examine the use of VA to inform health policy and systems improvements. Methods: A literature review was conducted including papers published between 2010 and 2017 according to a systematic search strategy. Inclusion of papers and data extraction were assessed by three reviewers. Thereafter, thematic analysis and narrative synthesis were conducted in which evidence was critically examined and key themes were identified. Results: Twenty-six papers applying VA to inform health policy and systems developments were selected, including studies in 15 LMICs in Africa, Asia, the Middle East and South America. The majority of studies applied VA in surveillance sites or programmes actively engaging with decision makers and governments in different ways and to different degrees. In the papers reviewed, the value of continuous collection of cause of death data, supplemented by social and community-based investigations and underpinned by electronic data innovations, to establish a robust and reliable evidence base for health policies and programmes was clearly recognised. Conclusion: VA has considerable potential to inform policy, planning and measurement of progress towards goals and targets. Working collaboratively at sub-national, national and international levels facilitates data collection, aggregation and dissemination linked to routine information systems. When used in partnerships between researchers and authorities, VA can help to close critical information gaps and guide policy development, implementation, evaluation and investment in health systems.

SummaryMaternal mortality persists in low-income settings despite preventability with skilled birth attendance and emergency obstetric care. Poor access limits the effectiveness of life-saving interventions and is typical of maternal health care in low-income settings. This paper examines access to care in obstetric emergencies from the perspectives of service users, using established and contemporary theoretical frameworks of access and a routine health surveillance method. The implications for health planning are also considered. The final caregivers of 104 women who died during pregnancy or childbirth were interviewed in two rural districts in Indonesia using an adapted verbal autopsy. Qualitative analysis revealed social and economic barriers to access and barriers that arose from the health system itself. Health insurance for the poor was highly problematic. For providers, incomplete reimbursements, and low public pay, acted as disincentives to treat the poor. For users, the schemes were poorly socialized and understood, complicated to use and led to lower quality care. Services, staff, transport, equipment and supplies were also generally unavailable or unaffordable. The multiple barriers to access conferred a cumulative disadvantage that culminated in exclusion. This was reflected in expressions of powerlessness and fatalism regarding the deaths. The analysis suggests that conceiving of access as a structurally determined, complex and dynamic process, and as a reciprocally maintained phenomenon of disadvantaged groups, may provide useful explanatory concepts for health planning. Health planning from this perspective may help to avoid perpetuating exclusion on social and economic grounds, by health systems and services, and help foster a sense of control at the micro-level, among peoples' feelings and behaviours regarding their health. Verbal autopsy surveys provide an opportunity to routinely collect
information on the exclusory mechanisms of health systems, important information for equitable health planning.

INTRODUCTION: In the absence of unifying conceptual frameworks, there have been calls to identify and share practical experiences of community participation in health (CPH) to document the contexts and dynamics of participatory practice. OBJECTIVES: This article describes the process of a community-based review of care in obstetric emergencies from rural Indonesia. METHODS: Four village-based groups were convened to review a series of cases of maternal death and disability and to develop recommendations for health planning. Narrative analysis of the reviewers' discussions was employed to describe and explain whether and how participation occurred. RESULTS: Participation was complex, dynamic and evolved over the course of the study. Although blame and defensiveness characterised the early discussions, over time the reviewers became less condemning of individuals and more so of systems and services, situating individual behaviours within wider health and social systems. Participants also increasingly shared personal experiences, generating rich and explicit reviews of care. Eliciting this information was contingent on skilful facilitation, assuring anonymity and instilling a 'permission to criticise' among participants. Sufficient time was also required to convey the necessary principles and reassurances. Despite evidence of learning outcomes, implementation and evaluation of the recommendations were not possible so sustainability and empowerment were likely to be limited. CONCLUSIONS: Despite its potential and relevance, the adoption of meaningful CPH activities may be threatened by wider socio-economic and political conditions, as well as by prevailing evidence hierarchies. We recommend policy and research to establish a firmer foundation for this progressive, yet obscured, public health concept.

Background An integrated chronic disease management (ICDM) model was introduced by the National Department of Health in South Africa to tackle the dual burden of HIV/AIDS and non-communicable diseases. One of the aims of the ICDM model is to reduce HIV-related stigma. This paper describes the viewpoints of service users and providers on HIV stigma in an ICDM model in rural South Africa. Materials and methods A content analysis of HIV stigmatisation in seven primary health care (PHC) facilities and their catchment communities was conducted in 2013 in the rural Agincourt sub-district, South Africa. Eight Focus Group Discussions were used to obtain data from 61 purposively selected participants who were 18 years and above. Seven In-Depth Interviews were conducted with the nurses-in-charge of the facilities. The transcripts were inductively analysed using MAXQDA 2018 qualitative software. Results The emerging themes were HIV stigma, HIV testing and reproductive health-related concerns. Both service providers and users perceived implementation of the ICDM model may have led to reduced HIV stigma in the facilities. On the other hand, service users and providers thought HIV stigma increased in the communities because community members thought that home-based carers visited the homes of People living with HIV. Service users thought that routine HIV testing, intended for pregnant women, was linked with unwanted pregnancies among adolescents who wanted to use contraceptives but refused to take an HIV test as a precondition for receiving contraceptives. Conclusions Although the ICDM model was perceived to have contributed to reducing HIV stigma in the health facilities, it was linked with stigma in the communities. This has implications for practice in the community component of the ICDM model in the study setting and elsewhere in South Africa.

The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients >= 18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian's structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low-and middle-income countries.

Sophie Witter - orcid:0000-0002-7656-6188 orcid:0000-0002-7656-6188 ; Background In South Africa, community participation has been embraced through the development of progressive policies to address past inequities. However, limited information is available to understand community involvement in priority setting, planning and decision-making in the development and implementation of public services. ; Objective This narrative review aims to provide evidence on forms, extents, contexts and dynamics of community participation in primary health care (PHC) and water governance in South Africa and draw cross-cutting lessons. This paper focuses on health and water governance structures, such as health committees, Catchment Management Agencies (CMA), Water User Associations (WUAs), Irrigation Boards (IBs) and Community Management Forums (CMFs). ; Methods Articles were sourced from Medline (Ovid), EMBASE, Google Scholar, Web of Science, WHO Global Health Library, Global Health and Science Citation Index between 1994 and 2020 reporting on community participation in health and water governance in South Africa. Databases were searched using key terms to identify relevant research articles and grey literature. Twenty-one articles were included and analysed thematically. ; Results There is limited evidence on how health committees are functioning in all provinces in South Africa. Existing evidence shows that health committees are not functioning effectively due to lack of clarity on roles, autonomy, power, support, and capacity. There was slow progress in establishment of water governance structures, although these are autonomous and have mechanisms for democratic control, unlike health committees. Participation in CMAs/WUAs/IBs/CMFs is also not effective due to manipulation of spaces by elites, lack of capacity of previously disadvantaged individuals, inadequate incentives, and low commitment to the process by stakeholders. ; Conclusion Power and authority in decision-making, resources and accountability are key for ...

Background: In South Africa, community participation has been embraced through the development of progressive policies to address past inequities. However, limited information is available to understand community involvement in priority setting, planning and decision-making in the development and implementation of public services. Objective: This narrative review aims to provide evidence on forms, extents, contexts and dynamics of community participation in primary health care (PHC) and water governance in South Africa and draw cross-cutting lessons. This paper focuses on health and water governance structures, such as health committees, Catchment Management Agencies (CMA), Water User Associations (WUAs), Irrigation Boards (IBs) and Community Management Forums (CMFs). Methods: Articles were sourced from Medline (Ovid), EMBASE, Google Scholar, Web of Science, WHO Global Health Library, Global Health and Science Citation Index between 1994 and 2020 reporting on community participation in health and water governance in South Africa. Databases were searched using key terms to identify relevant research articles and grey literature. Twenty-one articles were included and analysed thematically. Results: There is limited evidence on how health committees are functioning in all provinces in South Africa. Existing evidence shows that health committees are not functioning effectively due to lack of clarity on roles, autonomy, power, support, and capacity. There was slow progress in establishment of water governance structures, although these are autonomous and have mechanisms for democratic control, unlike health committees. Participation in CMAs/WUAs/IBs/CMFs is also not effective due to manipulation of spaces by elites, lack of capacity of previously disadvantaged individuals, inadequate incentives, and low commitment to the process by stakeholders. Conclusion: Power and authority in decision-making, resources and accountability are key for effective community participation of marginalized people. Practical guidance is urgently required on how mandated participatory governance structures can be sustained and linked to wider governance systems to improve service delivery.

ABSTRACTSmoking is responsible for over 8 million deaths globally per annum. While socially disadvantaged communities are disproportionately affected, few interventions effectively reach these groups. We progressed a participatory action research (PAR) study on smoking‐related health inequalities in the context of the current UK cost‐of‐living crisis. We worked with people living in deprived neighbourhoods in rural northeast Scotland. The objective was to engage affected communities together with the health authority in cooperative action learning. Community‐based participants (n = 9) engaged in a series of workshops (n = 8) adopting roles as co‐researchers, collecting and arranging new data and evidence. We then connected with service providers in a series of additional workshops (n = 3) to analyse and interpret the data, appraise local action and reflect on the process. Community partners identified a convergence between increased stress owing to the crisis, and increased availability, affordability and acceptability of tobacco‐related products, namely e‐cigarettes. The situation was compounded by lack of awareness of available cessation services. A shared action agenda was developed prioritising: (a) the stress‐related root causes of smoking, (b) inclusive access to cessation support, (c) incentivised cessation with locally framed messaging and (d) deliberative dialogue between communities and service providers. There was a high level of engagement, openness and honesty and the strategic relevance of the process was acknowledged. The study provides holistic understandings of health and hardship and demonstrates that existing services can be enhanced with community intelligence. We provide practical methods to support policy commitments to community health emphasising mutual empowerment between service users and providers.

BACKGROUND: Frontline managers and health service providers are constrained in many contexts from responding to community priorities due to organizational cultures focused on centrally defined outputs and targets. This paper presents an evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme—a collaborative learning platform embedded in the local health system in Mpumalanga, South Africa—for strengthening of rural primary healthcare (PHC) systems. The programme aims to address exclusion from access to health services by generating and acting on research evidence of practical, local relevance. METHODS: Drawing on existing links in the provincial and national health systems and applying rapid, participatory evaluation techniques, we evaluated the first action-learning cycle of the VAPAR programme (2017–19). We collected data in three phases: (1) 10 individual interviews with programme stakeholders, including from government departments and parastatals, nongovernmental organizations and local communities; (2) an evaluative/exploratory workshop with provincial and district Department of Health managers; and (3) feedback and discussion of findings during an interactive workshop with national child health experts. RESULTS: Individual programme stakeholders described early outcomes relating to effective research and stakeholder engagement, and organization and delivery of services, with potential further contributions to the establishment of an evidence base for local policy and planning, and improved health outcomes. These outcomes were verified with provincial managers. Provincial and national stakeholders identified the potential for VAPAR to support engagement between communities and health authorities for collective planning and implementation of services. Provincial stakeholders proposed that this could be achieved through a two-way integration, with VAPAR stakeholders participating in routine health planning and review activities and frontline health officials being involved in the ...

From Crossref journal articles via Jisc Publications Router ; Sophie Witter - orcid:0000-0002-7656-6188 orcid:0000-0002-7656-6188 ; Background Despite legislative and policy commitments to participatory water governance in South Africa, and some remarkable achievements, there has been limited progress to improve the water infrastructure servicing in marginalized rural communities. Around five million South Africans still do not have access to safe water. ; Objective This paper seeks to understand and advance processes to engage multisectoral stakeholders to respond to lack of safe water as a community-nominated health priority in rural South Africa. ; Method We engaged representatives from Mpumalanga Department of Health (MDoH), rural communities, other government departments and non-governmental organisations (NGOs) to cooperatively generate, interpret and act on evidence addressing community-nominated priorities. A series of participatory workshops were conducted where stakeholders worked together as co-researchers to develop shared accounts of the problem, and recommendations to address it. Consensus on the problem, mapping existing planning and policy landscapes, and initiating constructive dialogue was facilitated through group discussions in a collective learning process. ; Results Community stakeholders nominated lack of safe water as a local priority public health issue and generated evidence on causes and contributors, and health and social impacts. Together with government and NGO stakeholders, this evidence was corroborated. Stakeholders developed a local action plan through consensus and feasibility appraisal. Actions committed to behavioural change and reorganization of existing services, were relevant to the needs of the local community and were developed with consideration of current policies and strategies. A positive, collective reflection was made on the process. The greatest gain reported was the development of dialogue in 'safe spaces' through which mutual understanding, insights into the ...

From Springer Nature via Jisc Publications Router ; Sophie Witter - orcid:0000-0002-7656-6188 orcid:0000-0002-7656-6188 ; Background: Frontline managers and health service providers are constrained in many contexts from responding to community priorities due to organizational cultures focused on centrally defined outputs and targets. This paper presents an evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme—a collaborative learning platform embedded in the local health system in Mpumalanga, South Africa—for strengthening of rural primary healthcare (PHC) systems. The programme aims to address exclusion from access to health services by generating and acting on research evidence of practical, local relevance. Methods: Drawing on existing links in the provincial and national health systems and applying rapid, participatory evaluation techniques, we evaluated the first action-learning cycle of the VAPAR programme (2017–19). We collected data in three phases: (1) 10 individual interviews with programme stakeholders, including from government departments and parastatals, nongovernmental organizations and local communities; (2) an evaluative/exploratory workshop with provincial and district Department of Health managers; and (3) feedback and discussion of findings during an interactive workshop with national child health experts. Results: Individual programme stakeholders described early outcomes relating to effective research and stakeholder engagement, and organization and delivery of services, with potential further contributions to the establishment of an evidence base for local policy and planning, and improved health outcomes. These outcomes were verified with provincial managers. Provincial and national stakeholders identified the potential for VAPAR to support engagement between communities and health authorities for collective planning and implementation of services. Provincial stakeholders proposed that this could be achieved through a two-way integration, with VAPAR ...

Background: Despite legislative and policy commitments to participatory water governance in South Africa, and some remarkable achievements, there has been limited progress to improve the water infrastructure servicing in marginalized rural communities. Around five million South Africans still do not have access to safe water. Objective: This paper seeks to understand and advance processes to engage multisectoral stakeholders to respond to lack of safe water as a community-nominated health priority in rural South Africa. Method: We engaged representatives from Mpumalanga Department of Health (MDoH), rural communities, other government departments and non-governmental organisations (NGOs) to cooperatively generate, interpret and act on evidence addressing community-nominated priorities. A series of participatory workshops were conducted where stakeholders worked together as co-researchers to develop shared accounts of the problem, and recommendations to address it. Consensus on the problem, mapping existing planning and policy landscapes, and initiating constructive dialogue was facilitated through group discussions in a collective learning process. Results: Community stakeholders nominated lack of safe water as a local priority public health issue and generated evidence on causes and contributors, and health and social impacts. Together with government and NGO stakeholders, this evidence was corroborated. Stakeholders developed a local action plan through consensus and feasibility appraisal. Actions committed to behavioural change and reorganization of existing services, were relevant to the needs of the local community and were developed with consideration of current policies and strategies. A positive, collective reflection was made on the process. The greatest gain reported was the development of dialogue in 'safe spaces' through which mutual understanding, insights into the functioning of other sectors and learning by doing were achieved. Conclusion: Our process reflected willingness and commitment among stakeholders to work together collectively addressing local water challenges. Location in an established public health observatory helped to create neutral, mediated spaces for participation.

Background: Alcohol and other drug (AOD) abuse is a major public health challenge disproportionately affecting marginalised communities. Involving communities in the development of responses can contribute to acceptable solutions. Objectives: To: (1) document forms, processes, and contexts of engaging communities to nominate health concerns and generate new knowledge for action; (2) further build participation in the local health system by reflecting on and adapting the process. Methods: PAR was progressed with 48 community stakeholders across three rural villages in the MRC/Wits Agincourt Health and Socio Demographic Surveillance System (HDSS) in Mpumalanga, South Africa. A series of workshops explored community-nominated topics, systematised lived experience into shared accounts and considered actions to address problems identified. Photovoice was also used to generate visual evidence. Narrative and visual data were thematically analysed, situated within practice frameworks, and learning and adaption elicited. Results: AOD abuse was identified as a topic of high priority. It was understood as an entrenched social problem with destructive effects. Biopsychosocial impacts were mapped and related to unemployment, poverty, stress, peer pressure, criminal activity, corruption, and a proliferating number of taverns. Integrated action agendas were developed focussed on demand, supply, and harm reduction underpinned by shared responsibility among community, state, and non-state actors. Community stakeholders appreciated systematising and sharing knowledge, taking active roles, developing new skills in planning and public speaking, and progressing shared accountability processes. Expectations required sensitive management, however. Conclusion: There is significant willingness and capacity among community stakeholders to work in partnership with authorities to address priority health concerns. As a process, participation can help to raise and frame issues, which may help to better inform action and encourage shared responsibility. Broader understandings of participation require reference to, and ultimately transfer of power towards, those most directly affected, developing community voice as continuous processes within social and political environments.