The Mixed Nature of Incentives for Community Health Workers: Lessons from a Qualitative Study in Two Districts in India

Incentives play an important role in motivating community health workers (CHWs). In India, accredited social health activists (ASHAs) are female CHWs who provide a range of services, including those specific to reproductive, maternal, neonatal, child, and adolescent health. 

Qualitative interviews were conducted with 49 ASHAs and one of their family members (husband, mother-in-law, sister-in-law, or son) from Gurdaspur and Mewat districts to explore the role of family, community, and health system in supporting ASHAs in their work. Thematic analysis revealed that incentives were both empowering and a source of distress for ASHAs and their families. Earning income and contributing to the household’s financial wellbeing inspired a sense of financial independence and self-confidence for ASHAs, especially with respect to relations with their husbands and parents-in-law. 

In spite of the empowering effects of the incentives, they were a cause of distress. Low incentive rates relative to the level of effort required to complete ASHA responsibilities, compounded by irregular and incomplete payment, put pressure on families. ASHAs dedicated much of their time and own resources to perform their duties, drawing them away from their household responsibilities. Communication around incentives from supervisors may have led ASHAs to prioritize and promote those services that yielded higher incentives, as opposed to focusing on the most appropriate services for the client. ASHAs and their families maintained hope that their positions would eventually bring in a regular salary, which contributed to retention of ASHAs. 

Incentives, therefore, are both motivating and inspiring as well as a cause dissatisfaction among ASHAs and their families. Recommendations include revising the incentive scheme to be responsive to the time and effort required to complete tasks and the out-of-pocket costs incurred while working as an ASHA; improve communication to ASHAs on incentives and responsibilities; and ensure timely and complete payment of incentives to ASHAs. 

The findings from this study contribute to the existing literature on incentivized CHW programs and help throw added light on the role incentives play in family dynamics which affects performance of CHW.

Full article at:   http://goo.gl/wyuobV

By:  Enisha Sarin,^1,* Sarah Smith Lunsford,² Ankur Sooden,¹ Sanjay Rai,¹ and Nigel Livesley¹

¹University Research Co., LLC, New Delhi, India

²EnCompass LLC, Bethesda, MD, USA

Edited by: Chikaikeo Ogbonna, University of Jos, Nigeria

Reviewed by: Luret Albert Lar, University of Jos, Nigeria; Emmanuel Nwabueze Aguwa, University of Nigeria Nsukka, Nigeria; Afolaranmi Olumide Tolulope, University of Jos, Nigeria

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Infant Deaths Due to Herpes Simplex Virus, Congenital Syphilis, and HIV in New York City

BACKGROUND:

Neonatal infection with herpes simplex virus (HSV) is not a nationally reportable disease; there have been few population-based measures of HSV-related infant mortality. We describe infant death rates due to neonatal HSV as compared with congenital syphilis (CS) and HIV, 2 reportable, perinatally transmitted diseases, in New York City from 1981 to 2013.

METHODS:

We identified neonatal HSV-, CS-, and HIV-related deaths using International Classification of Diseases (ICD) codes listed on certificates of death or stillbirth issued in New York City. Deaths were classified as HSV-related if certificates listed (1) any HSV ICD-9/ICD-10 codes for deaths ≤42 days of age, (2) any HSV ICD-9/ICD-10 codes and an ICD code for perinatal infection for deaths at 43 to 365 days of age, or (3) an ICD-10 code for congenital HSV. CS- and HIV-related deaths were those listing any ICD code for syphilis or HIV.

RESULTS:

There were 34 deaths due to neonatal HSV (0.82 deaths per 100 000 live births), 38 from CS (0.92 per 100 000), and 262 from HIV (6.33 per 100 000). There were no CS-related deaths after 1996, and only 1 HIV-related infant death after 2004. The neonatal HSV-related death rate during the most recent decade (2004-2013) was significantly higher than in previous years.

CONCLUSIONS:

The increasing neonatal HSV-related death rate may reflect increases in neonatal herpes incidence; an increasing number of pregnant women have never had HSV type 1 and are therefore at risk of acquiring infection during pregnancy and transmitting to their infant.

Purchase full article at:   http://goo.gl/u9qPwE

By:  Sampath A1, Maduro G2, Schillinger JA3.

• 1Bureaus of Public Health Training.
• 2Vital Statistics, and.
• 3Sexually Transmitted Disease Control, New York City Department of Health and Mental Hygiene, New York, New York; and Division of Sexually Transmitted Disease Prevention, National Center for HIV, Hepatitis, Sexually Transmitted Diseases, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia jschilli@health.nyc.gov.
• Pediatrics. 2016 Mar 1. pii: peds.2015-2387. 

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Effect of Facilitation of Local Stakeholder Groups on Equity in Neonatal Survival; Results from the NeoKIP Trial in Northern Vietnam

Background

To operationalize the post-MDG agenda, there is a need to evaluate the effects of health interventions on equity. The aim of this study is to evaluate the effect on equity in neonatal survival of the NeoKIP trial (ISRCTN44599712), a population-based, cluster-randomized intervention trial with facilitated local stakeholder groups for improved neonatal survival in Quang Ninh province in northern Vietnam.

Methods

Semi-structured interviews were conducted with all mothers experiencing neonatal mortality and a random sample of 6% of all mothers with a live birth in the study area during the study period (July 2008-June 2011). Multilevel regression analyses were performed, stratifying mothers according to household wealth, maternal education and mother’s ethnicity in order to assess impact on equity in neonatal survival.

Findings

In the last year of study the risk of neonatal death was reduced by 69% among poor mothers in the intervention area as compared to poor mothers in the control area (OR 0.31, 95% CI 0.15–0.66). This pattern was not evident among mothers from non-poor households. Mothers with higher education had a 50% lower risk of neonatal mortality if living in the intervention area during the same time period (OR 0.50, 95% CI 0.28–0.90), whereas no significant effect was detected among mothers with low education.

Interpretation

The NeoKIP intervention promoted equity in neonatal survival based on wealth but increased inequity based on maternal education.

Full article at:   http://goo.gl/Ivc09T

By:   

Mats Målqvist, Lars-Åke Persson, Katarina Ekholm Selling

International Maternal and Child Health, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden

Dinh Phuong Thi Hoa

Hanoi School of Public Health, Hanoi, Vietnam

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Thai Health Care Provider Knowledge of Neonatal Male Circumcision in Reducing Transmission of HIV & Other STIs

Background

Male circumcision (MC) reduces the risk of female-to-male transmission of HIV and other sexually transmitted infections (STIs). MC has not been practiced as a disease prevention measure in Thailand probably because of low recognition of its benefits among stakeholders. Neonatal male circumcision (NMC) is simpler, safer and cheaper than adult MC. This study aimed to assess Thai health care provider knowledge of benefits implementing NMC in Thailand.

Methods

Multi-stage sampling identified 16 government hospitals to represent various hospital sizes and regions of the country. Researchers administered a fixed choice questionnaire, developed by the research team based on a previous study, to physician administrators, practicing physicians, and nurses whose jobs involved NMC clinical procedures or oversight. The participants reviewed printed educational materials on the benefits of NMC during questionnaire completion. Data were analyzed using descriptive statistics, chi square tests, odds ratios, and logistic regression.

Results

One hundred thirty-three individuals participated in this quantitative study. Only 38 % of the participants agreed that NMC reduced the risk of sexual transmission of HIV while 65 % indicated that they knew that NMC prevented STIs. Most participants recognized the benefits of NMC on hygiene (96 %) as well as cancer prevention (74 %). Major concerns raised were potential trauma to the child, child rights and safety of NMC. After reviewing written information about the benefits of NMC, 59 % of the participants agreed that NMC should be offered in their hospital. Physicians and nurses who had previous experience with circumcising patients of all ages were more reluctant to have NMC performed in their hospital.

Conclusions

A clear policy advocating NMC, thorough preparation of health facilities, and staff training are needed before NMC could be used in Thailand as prevention strategy for HIV and other STIs.

Full article at:   http://goo.gl/PIvMcp

By: Kriengkrai Srithanaviboonchai^12*, Boonlure Pruenglampoo², Kanittha Thaikla², Namtip Srirak², Jiraporn Suwanteerangkul¹, Jiraporn Khorana¹, Richard M. Grimes³⁴, Deanna E. Grimes⁴⁵, Vipa Danthamrongkul⁶, Suchada Paileeklee⁷ and Uraiwan Pattanasutnyavong⁸

¹Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

²Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand

³Division of General Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA

⁴Baylor-UT Houston Center for AIDS Research, Houston, TX, USA

⁵School of Nursing, University of Texas Health Science Center at Houston, Houston, TX, USA

⁶College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand

⁷Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

⁸Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, Thailand

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Assessing the Performance of Maternity Care in Europe: A Critical Exploration of Tools & Indicators

This paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or “normal birth”. The work formed part of COST Actions IS0907: “Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care” (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care.

A structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions.

A total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or “good” or positive outcomes more generally.

The tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures.

Full article at: http://goo.gl/Jtno43

By: Ramón Escuriet,# Joanna White,# Katrien Beeckman, Lucy Frith, Fatima Leon-Larios, Christine Loytved, Ans Luyben,Marlene Sinclair, Edwin van Teijlingen, and and EU COST Action IS0907. ‘Childbirth Cultures, Concerns, and Consequences’

Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain

Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain

Centre for Research in Anthropology/Centro em Rede de Investigação em Antropologia (CRIA-IUL, Lisbon, Portugal

Department of Health and Social Sciences, University of the West of England, Bristol, UK

Nursing and Midwifery research unit, University hospital Brussels, Vrije universiteit Brussel, Brussel, Belgium

Department of Health Services Research, The University of Liverpool, Liverpool, UK

Departamento de Enfermería. Facultad de Enfermería, Fisioterapia y Podología, Universidad de Sevilla, Sevilla, Spain

Zurich University of Applied Sciences, School of Health Professions, Institute of Midwifery, Zurich, Switzerland

Women’s Clinic, Spital STS AG, Thun, Switzerland

Maternal Fetal and Infant Research Centre, University of Ulster, Coleraine, UK

Centre for Midwifery, Maternal & Perinatal Health Bournemouth University, Bournemouth, UK

Ramón Escuriet, Email: tac.tulastac@teirucser.

Contributor Information.

Corresponding author.

^#Contributed equally.

  

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