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  • 1. Ajeani, Judith
    et al.
    Ayiasi, Richard Mangwi
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Namazzi, Gertrude
    Kananura, Rornald Muhumuza
    Kiwanuka, Suzanne Namusoke
    Beyeza-Kashesya, Jolly
    A cascade model of mentorship for frontline health workers in rural health facilities in Eastern Uganda: processes, achievements and lessons2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1345497Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers.

    Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model.

    Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors.

    Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better.

    Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff.

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  • 2. Bennett, Sara
    et al.
    Mahmood, Shehrin Shaila
    Edward, Anbrasi
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda2017Inngår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, artikkel-id 108Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up.

    Methods: We draw upon three IR studies conducted by Future Health Systems (FHS) in Afghanistan, Bangladesh and Uganda. We reviewed project documents from the period 2011-2016 to identify information related, to the dimensions of scaling up. Further, for each country, we developed rich descriptions of how the research teams approached scaling up, and how IR contributed to scale-up. The rich descriptions were checked by FHS research teams. We identified common patterns and. differences across the three cases.

    Results: The three cases planned quite different innovations/interventions and had very different types of scale-up strategies. In all three cases, the research teams had extensive prior experience within the study communities, and. little explicit attention was paid, to contextual factors. All three cases involved complex interactions between the research teams and other stakeholders, among stakeholders, and between stakeholders and the intervention. The IR planned by the research teams focussed primarily on feasibility and effectiveness, but in practice, the research teams also had critical insights into other factors such as sustainability, acceptability, cost-effectiveness and appropriateness. Stakeholder analyses and other project management tools further complemented IR.

    Conclusions: IR can provide significant insights into how best to scale-up a particular intervention. To take advantage of insights from IR, scale-up strategies require flexibility and IR must also be sufficiently flexible to respond to new emerging questions. While commonly used conceptual frameworks for scale-up clearly delineate actors, such as implementers, target communities and the support team, in our experience, IR blurred the links between these groups.

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  • 3. Daniels, Karen
    et al.
    Loewenson, Rene
    George, Asha
    Howard, Natasha
    Koleva, Gergana
    Lewin, Simon
    Marchal, Bruno
    Nambiar, Devaki
    Paina, Ligia
    Sacks, Emma
    Sheikh, Kabir
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Makerere University School of Public Health, Makerere, Uganda.
    Theobald, Sally
    Topp, Stephanie M.
    Zwi, Anthony B.
    Fair publication of qualitative research in health systems: a call by health policy and systems researchers2016Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 15, artikkel-id 98Artikkel i tidsskrift (Annet vitenskapelig)
    Fulltekst (pdf)
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  • 4. Ekirapa-Kiracho, Elizabeth
    et al.
    Kananura, Rornald Muhumuza
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Namazzi, Gertrude
    Mutebi, Aloysius
    George, Asha
    Paina, Ligia
    Waiswa, Peter
    Bumba, Ahmed
    Mulekwa, Godfrey
    Nakiganda-Busiku, Dinah
    Lyagoba, Moses
    Naiga, Harriet
    Putan, Mary
    Kulwenza, Agatha
    Ajeani, Judith
    Kakaire-Kirunda, Ayub
    Makumbi, Fred
    Atuyambe, Lynn
    Okui, Olico
    Kiwanuka, Suzanne Namusoke
    Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1363506Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: The MANIFEST study in eastern Uganda employed a participatory multisectoral approach to reduce barriers to access to maternal and newborn care services.

    Objectives: This study analyses the effect of the intervention on the utilization of maternal and newborn services and care practices.

    Methods: The quasi-experimental pre- and post-comparison design had two main components: community mobilization and empowerment, and health provider capacity building. The primary outcomes were utilization of antenatal care (ANC), delivery and postnatal care, and newborn care practices. Baseline (n = 2237) and endline (n = 1946) data were collected from women of reproductive age. The data was analysed using difference in differences (DiD) analysis and logistic regression.

    Results: The DiD results revealed an 8% difference in early ANC attendance (p < 0.01) and facility delivery (p < 0.01). Facility delivery increased from 66% to 73% in the intervention area, but remained unchanged in the comparison area (64% vs 63%, p < 0.01). The DiD results also demonstrated a 20% difference in clean cord care (p < 0.001) and an 8% difference in delayed bathing (p < 0.001). The intervention elements that predicted facility delivery were attending ANC four times [adjusted odds ratio (aOR) 1.42, 95% confidence interval (CI) 1.171.74] and saving for maternal health (aOR 2.11, 95% CI 1.39-3.21). Facility delivery and village health team (VHT) home visits were key predictors for clean cord care and skin-to-skin care.

    Conclusions: The multisectoral approach had positive effects on early ANC attendance, facility deliveries and newborn care practices. Community resources such as VHTs and savings are crucial to maternal and newborn outcomes and should be supported. VHT-led health education should incorporate practical measures that enable families to save and access transport services to enhance adequate preparation for birth.

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  • 5. Ekirapa-Kiracho, Elizabeth
    et al.
    Namazzi, Gertrude
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda.
    Mutebi, Aloysius
    Waiswa, Peter
    Oo, Htet
    Peters, David H.
    George, Asha S.
    Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda2016Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, artikkel-id 638Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. Methods: A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. Results: Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women's access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. Conclusions: This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.

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  • 6. Ekirapa-Kiracho, Elizabeth
    et al.
    Paina, Ligia
    Kananura, Rornald Muhumuza
    Mutebi, Aloysius
    Jane, Pacuto
    Tumuhairwe, Juliet
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health, Department of Health Policy Planning and Management, Kampala, Uganda.
    Kiwanuka, Suzanne N.
    'Nurture the sprouting bud; do not uproot it'. Using saving groups to save for maternal and newborn health: lessons from rural Eastern Uganda2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1347311Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Saving groups are increasingly being used to save in many developing countries. However, there is limited literature about how they can be exploited to improve maternal and newborn health.

    Objectives: This paper describes saving practices, factors that encourage and constrain saving with saving groups, and lessons learnt while supporting communities to save through saving groups.

    Methods: This qualitative study was done in three districts in Eastern Uganda. Saving groups were identified and provided with support to enhance members' access to maternal and newborn health. Fifteen focus group discussions (FGDs) and 18 key informant interviews (KIIs) were conducted to elicit members' views about saving practices. Document review was undertaken to identify key lessons for supporting saving groups. Qualitative data are presented thematically.

    Results: Awareness of the importance of saving, safe custody of money saved, flexible saving arrangements and easy access to loans for personal needs including transport during obstetric emergencies increased willingness to save with saving groups. Saving groups therefore provided a safety net for the poor during emergencies. Poor management of saving groups and detrimental economic practices like gambling constrained saving. Efficient running of saving groups requires that they have a clear management structure, which is legally registered with relevant authorities and that it is governed by a constitution.

    Conclusions: Saving groups were considered a useful form of saving that enabled easy acess to cash for birth preparedness and transportation during emergencies. They are like 'a sprouting bud that needs to be nurtured rather than uprooted', as they appear to have the potential to act as a safety net for poor communities that have no health insurance. Local governments should therefore strengthen the management capacity of saving groups so as to ensure their efficient running through partnerships with non-governmental organizations that can provide support to such groups.

    Fulltekst (pdf)
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  • 7. Ekirapa-Kiracho, Elizabeth
    et al.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda.
    Bua, John
    Kananura, Rornald Muhumuza
    Waiswa, Peter
    Makumbi, Fred
    Atuyambe, Lynn
    Ajeani, Judith
    George, Asha
    Mutebi, Aloysuis
    Kakaire, Ayub
    Namazzi, Gertrude
    Paina, Ligia
    Kiwanuka, Suzanne Namusoke
    Maternal and neonatal implementation for equitable systems: a study design paper2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1346925Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Evidence on effective ways of improving maternal and neonatal health outcomes is widely available. The challenge that most low-income countries grapple with is implementation at scale and sustainability. Objectives: The study aimed at improving access to quality maternal and neonatal health services in a sustainable manner by using a participatory action research approach.

    Methods: The study consisted of a quasi-experimental design, with a participatory action research approach to implementation in three rural districts (Pallisa, Kibuku and Kamuli) in Eastern Uganda. The intervention had two main components; namely, community empowerment for comprehensive birth preparedness, and health provider and management capacity-building. We collected data using both quantitative and qualitative methods using household and facility-level structured surveys, record reviews, key informant interviews and focus group discussions. We purposively selected the participants for the qualitative data collection, while for the surveys we interviewed all eligible participants in the sampled households and health facilities. Descriptive statistics were used to describe the data, while the difference in difference analysis was used to measure the effect of the intervention. Qualitative data were analysed using thematic analysis.

    Conclusions: This study was implemented to generate evidence on how to increase access to quality maternal and newborn health services in a sustainable manner using a multisectoral participatory approach.

    Fulltekst (pdf)
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  • 8. George, Asha
    et al.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Makerere University, Kampala, Uganda.
    Pariyo, George W.
    Peterson, Stefan S.
    Maternal and newborn health implementation research: programme outcomes, pathways of change and partnerships for equitable health systems in Uganda2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1359924Artikkel i tidsskrift (Annet vitenskapelig)
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  • 9. Kananura, Rornald Muhumuza
    et al.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Bua, John
    Ekirapa-Kiracho, Elizabeth
    Mutebi, Aloysius
    Namazzi, Gertrude
    Kiwanuka, Suzanne Namusoke
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Waiswa, Peter
    Effect of a participatory multisectoral maternal and newborn intervention on birth preparedness and knowledge of maternal and newborn danger signs among women in Eastern Uganda: a quasi-experiment study2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1362826Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Knowledge of obstetric danger signs and adequate birth preparedness (BP) are critical for improving maternal services utilization.

    Objectives: This study assessed the effect of a participatory multi-sectoral maternal and newborn intervention on BP and knowledge of obstetric danger signs among women in Eastern Uganda.

    Methods: The Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study was implemented in three districts from 2013 to 2015 using a quasi-experimental pre-post comparison design. Data were collected from women who delivered in the last 12 months. Difference-in-differences (DiD) and generalized linear modelling analysis were used to assess the effect of the intervention on BP practices and knowledge of obstetric danger signs.

    Results: The overall BP practices increased after the intervention (DiD = 5, p < 0.05). The increase was significant in both intervention and comparison areas (7-39% vs. 7-36%, respectively), with a slightly higher increase in the intervention area. Individual savings, group savings, and identification of a transporter increased in both intervention and comparison area (7-69% vs. 10-64%, 0-11% vs. 0-5%, and 9-14% vs. 9-13%, respectively). The intervention significantly increased the knowledge of at least three obstetric danger signs (DiD = 31%) and knowledge of at least two newborn danger signs (DiD = 21%). Having knowledge of at least three BP components and attending community dialogue meetings increased the odds of BP practices and obstetric danger signs' knowledge, respectively. Village health teams' home visits, intervention area residence, and being in the 25+ age group increased the odds of both BP practices and obstetric danger signs' knowledge.

    Conclusions: The intervention resulted in a modest increase in BP practices and knowledge of obstetric danger signs. Multiple strategies targeting women, in particular the adolescent group, are needed to promote behavior change for improved BP and knowledge of obstetric danger signs.

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  • 10. Kananura, Rornald Muhumuza
    et al.
    Wamala, Robert
    Ekirapa-Kiracho, Elizabeth
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Makerere University College of Health Sciences, Kampala, Uganda.
    Kiwanuka, Suzanne N.
    Waiswa, Peter
    Atuhaire, Leonard K.
    A structural equation analysis on the relationship between maternal health services utilization and newborn health outcomes: a cross-sectional study in Eastern Uganda2017Inngår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, artikkel-id 98Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Neonatal and maternal health services have a bearing on neonatal mortality. Direct and indirect factors affecting neonatal health outcomes therefore require understanding to enable well-targeted interventions. This study, therefore, assessed the interrelationship between newborn health outcomes and maternal service utilization factors.

    Methods: We investigated maternal health utilization factors using health facility delivery and at least four Antenatal Care (ANC) visits; and newborn health outcomes using newborn death and low birth weight (LBW). We used data from a household cross-sectional survey that was conducted in 2015 in Kamuli, Pallisa and Kibuku districts. We interviewed 1946 women who had delivered in the last 12 months. The four interrelated (Endogenous) outcomes were ANC attendance, health facility delivery, newborn death, and LBW. We performed analysis using a structural equation modeling technique.

    Results: A history of newborn death (aOR = 12.64, 95% CI 5.31–30.10) and birth of a LBW baby (aOR = 3.51, 95% CI 1.48–8.37) were directly related to increased odds of newborn death. Factors that reduced the odds of LBW as a mediating factor for newborn death were ANC fourth time attendance (aOR = 0.62, 95% CI 0.45–0.85), having post-primary level education (aOR = 0.68, 95% CI 0.46–0.98) compared to none and being gravida three (aOR = 0.49, 95% CI 0.26–0.94) compared to being gravida one. Mother’s age group, 20–24 (aOR = 0.24, 95% CI 0.08–0.75) and 25–29 years (aOR = 0.20, 95% CI 0.05–0.86) compared to 15–19 years was also associated with reduced odds of LBW. Additionally, ANC visits during the first trimester (aOR = 2.04, 95% CI 1.79–2.34), and village health teams (VHTs) visits while pregnant (aOR = 1.14, 95% CI 1.01–1.30) were associated with increased odds of at least four ANC visits, which is a mediating factor for health facility delivery, LBW and newborn death. Surprisingly, newborn death was not significantly different between health facility and community deliveries.

    Conclusions: Attending ANC at least four times was a mediating factor for reduced newborn death and low birth weight. Interventions in maternal health and newborn health should focus on factors that increase ANC fourth time attendance and those that reduce LBW especially in resource-limited settings. Targeting women with high-risk pregnancies is also crucial for reducing newborn deaths.

    Fulltekst (pdf)
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  • 11. Kiwanuka, Suzanne Namusoke
    et al.
    Akulume, Martha
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda.
    Kananura, Rornald Muhumuza
    Bua, John
    Ekirapa-Kiracho, Elizabeth
    Balancing the cost of leaving with the cost of living: drivers of long-term retention of health workers: an explorative study in three rural districts in Eastern Uganda2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1345494Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Health worker retention in rural and underserved areas remains a persisting problem in many low and middle income countries, and this directly affects the quality of health services offered.

    Objective: This paper explores the drivers of long-term retention and describes health worker coping mechanisms in rural Uganda.

    Methods: A descriptive qualitative study explored the factors that motivated health workers to stay, in three rural districts of Uganda: Kamuli, Pallisa, and Kibuku. In-depth interviews conducted among health workers who have been retained for at least 10 years explored factors motivating the health workers to stay within the district, opportunities, and the benefits of staying.

    Results: Twenty-one health workers participated. Ten of them male and 11 female with the age range of 33-51 years. The mean duration of stay among the participants was 13, 15, and 26 years for Kamuli, Kibuku, and Pallisa respectively. Long-term retention was related to personal factors, such as having family ties, community ties, and opportunities to invest. The decentralization policy and pension benefits also kept workers in place. Opportunities for promotion or leadership motivated long stay only if they came with financial benefits. Workload reportedly increased over the years, but staffing and emoluments had not increased. Multiple job, family support, and community support helped health workers cope with the costs of living, and holding a secure pensionable government job was valued more highly than seeking uncertain job opportunities elsewhere.

    Conclusion: The interplay between the costs of leaving and the benefit of staying is demonstrated. Family proximity, community ties, job security, and pension enhance staying, while higher costs of living and an unpredictable employment market make leaving risky. Health workers should be able to access investment opportunities in order to cope with inadequate remuneration. Promotions and leadership opportunities only motivate if accompanied by financial benefits.

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  • 12. Morgan, Rosemary
    et al.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Kananura, Rornald Muhumuza
    Ekirapa-Kiracho, Elizabeth
    George, A. S.
    Gender dynamics affecting maternal health and health care access and use in Uganda2017Inngår i: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 32, s. V13-V21Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women's access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women's lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women's lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women's workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women's attitudes and behaviour during pregnancy, men's attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.

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  • 13. Mutebi, Aloysius
    et al.
    Kananura, Rornald Muhumuza
    Ekirapa-Kiracho, Elizabeth
    Bua, John
    Kiwanuka, Suzanne Namusoke
    Nammazi, Gertrude
    Paina, Ligia
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health, Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda.
    Characteristics of community savings groups in rural Eastern Uganda: opportunities for improving access to maternal health services2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1347363Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Rural populations in Uganda have limited access to formal financial Institutions, but a growing majority belong to saving groups. These saving groups could have the potential to improve household income and access to health services.

    Objective: To understand organizational characteristics, benefits and challenges, of savings groups in rural Uganda.

    Methods: This was a cross-sectional descriptive study that employed both quantitative and qualitative data collection techniques. Data on the characteristics of community-based savings groups (CBSGs) were collected from 247 CBSG leaders in the districts of Kamuli, Kibukuand Pallisa using self-administered open-ended questionnaires. To triangulate the findings, we conducted in-depth interviews with seven CBSG leaders. Descriptive quantitative and content analysis for qualitative data was undertaken respectively.

    Results: Almost a quarter of the savings groups had 5-14 members and slightly more than half of the saving groups had 15-30 members. Ninety-three percent of the CBSGs indicated electing their management committees democratically to select the group leaders and held meetings at least once a week. Eighty-nine percent of the CBSGs had used metallic boxes to keep their money, while 10% of the CBSGs kept their money using mobile money and banks, respectively. The main reasons for the formation of CBSGs were to increase household income, developing the community and saving for emergencies. The most common challenges associated with CBSG management included high illiteracy (35%) among the leaders, irregular attendance of meetings (22%), and lack of training on management and leadership (19%). The qualitative findings agreed with the quantitative findings and served to triangulate the main results.

    Conclusions: Saving groups in Uganda have the basic required structures; however, challenges exist in relation to training and management of the groups and their assets. The government and development partners should work together to provide technical support to the groups.

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  • 14. Namazzi, Gertrude
    et al.
    Okuga, Monica
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University, School of Public Health (MakSPH), Kampala, Uganda.
    Kananura, Rornald Muhumuza
    Kakaire, Ayub
    Namutamba, Sarah
    Mutebi, Aloysius
    Kiwanuka, Suzanne Namusoke
    Ekirapa-Kiracho, Elizabeth
    Waiswa, Peter
    Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1345495Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation.

    Objectives: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy.

    Methods: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences.

    Results: CHWs' knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (>= 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles.

    Conclusions: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.

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  • 15. Paina, Ligia
    et al.
    Namazzi, Gertrude
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Complex, Kampala, Uganda.
    Mayora, Chrispus
    Kananura, Rornald Muhumuza
    Kiwanuka, Suzanne N.
    Waiswa, Peter
    Mutebi, Aloysius
    Ekirapa-Kiracho, Elizabeth
    Applying the model of diffusion of innovations to understand facilitators for the implementation of maternal and neonatal health programmes in rural Uganda2019Inngår i: Globalization and Health, ISSN 1744-8603, E-ISSN 1744-8603, Vol. 15, artikkel-id 38Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    In Uganda, more than 336 out of every 100,000 women die annually during childbirth. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care - through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this short report, we used an adaptation of Greenhalgh's Model of Diffusion to reflect on these projects' approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs.

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  • 16. Paina, Ligia
    et al.
    Wilkinson, Annie
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Barman, Debjani
    Ahmed, Tanvir
    Mahmood, Shehrin Shaila
    Bloom, Gerry
    Knezovich, Jeff
    George, Asha
    Bennett, Sara
    Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda2017Inngår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, artikkel-id 109Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: The Theory of Change (ToC) is a management and evaluation too ! supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.

    Methods: This paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams' experiences along four potential uses of ToCs, namely planning, communication, learning and. accountability.

    Results: The three teams developed ToCs for planning and. evaluation purposes as required for their initial plans for FHS in 2011 and. revised, them half-way through the project, based on assumptions informed, by and adjusted, through the teams' experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and. revision fostered, channels for both internal and external communication, among research team members and. with key stakeholders, respectively. The process of revising the ToCs challenged the teams' initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes.

    Conclusions: The ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement.

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  • 17. Sayinzoga, Felix
    et al.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    van der Velden, Koos
    van Dillen, Jeroen
    Bijlmakers, Leon
    Understanding variation in health service coverage and maternal health outcomes among districts in Rwanda - A qualitative study of local health workers' perceptions2019Inngår i: PLoS ONE, E-ISSN 1932-6203, Vol. 14, nr 10, artikkel-id e0223357Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVE: To obtain the perspectives of health professionals and community health workers on factors that determine health service coverage and maternal health outcomes so as to understand variations between districts.

    METHODS: 16 Focus group discussions involving four different groups of participants were conducted in May 2015 in four purposively selected districts, complemented by three key informant interviews in one of the districts.

    RESULTS: The solidarity support for poor people and the interconnectedness between local leaders and heads of health facilities were identified as enablers of health service utilization. Geographical factors, in particular location close to borders with mobile populations and migrants, and large populations with sparsely distributed health infrastructure, exacerbated by hilly topography and muddy roads were identified as barriers. Shortages of skilled health providers at the level of district hospitals were cited as contributing to poor maternal health outcomes.

    CONCLUSION: There is a need to take into account disparities between districts when allocating staff and financial resources in order to achieve universal coverage for high-quality maternal health services and better outcomes. Local innovations such as the use of SMS and WhatsApp text messages by health workers and financial protection schemes for poor patients improve solidarity and are worth to be scaled up.

  • 18.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Participatory approaches to strengthening district health managers' capacity: Ugandan and global experiences2018Doktoravhandling, med artikler (Annet vitenskapelig)
    Abstract [en]

    Introduction:

    Residents of low in-come countries have persistently suffered poor health outcomes, modest progress made over time notwithstanding. Weak health systems are one of the key reasons for the less than optimum progress. These health systems are constrained by inadequately equipped managers who play a main role in curbing this progress. Strengthening the capacity of health managers capacity is one of the known ways to improve the performance of health systems. This study examined strategies for strengthening the capacity of health managers at the sub-national level, with a special focus on the Participatory Action Research (PAR) approach.

    Methods:

    I used an emergent qualitative design which included both primary data collection and a literature review. Primary data collection techniques included individual interviews, Focus Group Discussions (FGDs), participant observations, and a review of project documents and meeting minutes, while searching for peer-reviewed databases was used for the literature review. Several analytical tools were adopted to answer the objectives, including the grounded theory, content and thematic analysis approaches. The Critical Interpretive Synthesis (CIS) method was used to analyze the literature reviewed.

    Findings:

    Stakeholders’ perceived the approaches to strengthening health managers’ capacity as an overarching process comprised of three interconnected subprocesses namely: the professionalizing of health managers, the use of engaging approaches to learning, and the availability of a supportive work environment. PAR as an engaging approach to learning was experienced by stakeholders as a nuanced awakening approach. On the one hand, stakeholders felt engaged, valued, responsible, awakened and a sense of ownership. On the other hand, they felt conflicted, stressed and uncertain. The PAR approach enhanced health managers’ capacity to collaborate with others, be creative, attain goals, and review progress. Expanded spaces for interaction, the encouragement of flexibility, the empowerment of local managers and the promotion of reflection and accountability enabled this enhancement. Lastly, the literature reviewed revealed five interrelated elements for harnessing PAR to strengthen health managers capacity. These were: a shared purpose, skilled facilitation and social psychological safety, activity integration into organizational procedures, organizational support and supportive external monitoring.

    Conclusions:

    Health managers have a central role in strengthening health systems; hence the formalization of their role, especially within the public-sector, is needed. In addition, significant investments into developing and strengthening their capacity is required. Strengthening the capacity of health managers is an iterative process that draws synergies from different approaches. The process leans on formal trainings as well as more engaging means of learning, such as PAR. As an engaging approach to learning, PAR expands interaction spaces, provides inclusiveness and flexibility, promotes local ingenuity and shared responsibility, and allows for monitoring and learning. PAR had positive effects on the strengthening of the capacity of health managers while at the same time achieving other project outcomes. Participatory approaches are hence relevant for dealing with the complex challenges bedevilling health systems. The approach nonetheless should be applied with a more nuanced appreciation of the challenges when using it and the elements for harnessing it to strengthen health systems.

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  • 19.
    Tetui, Moses
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Makerere University, New Mulago Complex, Kampala, Uganda.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Bennett, Sara
    Kiwanuka, Suzanne N.
    George, Asha
    Kiracho, Elizabeth Ekirapa
    A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda2017Inngår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, artikkel-id 110Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Many approaches to improving health managers' capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers' capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers' capacity in Eastern Uganda.

    Methods: This was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers' capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus.

    Results: The findings indicate that the participatory action research approach enhanced health managers' capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness.

    Conclusions: Improved health manager capacity is essential if sustained improvements in health outcomes in low-income countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers' capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers' capacity.

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  • 20.
    Tetui, Moses
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Health Policy, Planning and Management, Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ekirapa-Kiracho, Elizabeth
    Kiwanuka, Suzanne N.
    Experiences of using a participatory action research approach to strengthen district local capacity in Eastern Uganda2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1346038Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: To achieve a sustained improvement in health outcomes, the way health interventions are designed and implemented is critical. A participatory action research approach is applauded for building local capacity such as health management. Thereby increasing the chances of sustaining health interventions.

    OBJECTIVE: This study explored stakeholder experiences of using PAR to implement an intervention meant to strengthen the local district capacity.

    METHODS: This was a qualitative study featuring 18 informant interviews and a focus group discussion. Respondents included politicians, administrators, health managers and external researchers in three rural districts of eastern Uganda where PAR was used. Qualitative content analysis was used to explore stakeholders' experiences.

    RESULTS: 'Being awakened' emerged as an overarching category capturing stakeholder experiences of using PAR. This was described in four interrelated and sequential categories, which included: stakeholder involvement, being invigorated, the risk of wide stakeholder engagement and balancing the risk of wide stakeholder engagement. In terms of involvement, the stakeholders felt engaged, a sense of ownership, felt valued and responsible during the implementation of the project. Being invigorated meant being awakened, inspired and supported. On the other hand, risks such as conflict, stress and uncertainty were reported, and finally these risks were balanced through tolerance, risk-awareness and collaboration.

    CONCLUSIONS: The PAR approach was desirable because it created opportunities for building local capacity and enhancing continuity of interventions. Stakeholders were awakened by the approach, as it made them more responsive to systems challenges and possible local solutions. Nonetheless, the use of PAR should be considered in full knowledge of the undesirable and complex experiences, such as uncertainty, conflict and stress. This will enable adequate preparation and management of stakeholder expectations to maximize the benefits of the approach.

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  • 21.
    Tetui, Moses
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Makerere University, New Mulago Complex, P.O. B0X 7072, Kampala, Uganda.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ekirpa-Kiracho, Elizabeth
    Kiwanuka, Suzanne N.
    Coe, Anna-Britt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Building a competent health manager at district level: a grounded theory study from Eastern Uganda2016Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, artikkel-id 665Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Health systems in low-income countries are often characterized by poor health outcomes. While many reasons have been advanced to explain the persistently poor outcomes, management of the system has been found to play a key role. According to a WHO framework, the management of health systems is central to its ability to deliver needed health services. In this study, we examined how district managers in a rural setting in Uganda perceived existing approaches to strengthening management so as to provide a pragmatic and synergistic model for improving management capacity building.

    Methods: Twenty-two interviews were conducted with district level administrative and political managers, district level health managers and health facility managers to understand their perceptions and definitions of management and capacity building. Kathy Charmaz's constructive approach to grounded theory informed the data analysis process.

    Results: An interative, dynamic and complex model with three sub-process of building a competent health manager was developed. A competent manager was understood as one who knew his/her roles, was well informed and was empowered to execute management functions. Professionalizing health managers which was viewed as the foundation, the use of engaging learning approaches as the inside contents and having a supportive work environment the frame of the model were the sub-processes involved in the model. The sub-processes were interconnected although the respondents agreed that having a supportive work environment was more time and effort intensive relative to the other two sub-processes.

    Conclusions: The model developed in our study makes four central contributions to enhance the WHO framework and the existing literature. First, it emphasizes management capacity building as an iterative, dynamic and complex process rather than a set of characteristics of competent managers. Second, our model suggests the need for professionalization of health managers at different levels of the health system. Third, our model underscores the benefits that could be accrued from the use of engaging learning approaches through prolonged and sustained processes that act in synergy. Lastly, our model postulates that different resource investments and a varied range of stakeholders could be required at each of the sub-processes.

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  • 22.
    Tetui, Moses
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Zulu, Joseph Mumba
    School of Public Health, University of Zambia, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ekirapa-Kiracho, Elizabeth
    Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Kiwanuka, Suzanne N.
    Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Elements for harnessing participatory action research to strengthen health managers’ capacity: a critical interpretative synthesis2018Inngår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 16, artikkel-id 33Artikkel, forskningsoversikt (Fagfellevurdert)
    Abstract [en]

    Background: Health managers play a key role in ensuring that health services are responsive to the needs of the population. Participatory action research (PAR) is one of the approaches that have been used to strengthen managers’ capacity. However, collated knowledge on elements for harnessing PAR to strengthen managers’ capacity is missing. This paper bridges this gap by reviewing existing literature on the subject matter.

    Methods: A critical interpretive synthesis method was used to interrogate eight selected articles. These articles reported the use of PAR to strengthen health managers’ capacity. The critical interpretive synthesis method’s approach to analysis guided the synthesis. Here, the authors interpretively made connections and linkages between different elements identified in the literature. Finally, the Atun et al. (Heal Pol Plann, 25:104–111, 2010) framework on integration was used to model the elements synthesised in the literature into five main domains.

    Results: Five elements with intricate bi-directional interactions were identified in the literature reviewed. These included a shared purpose, skilled facilitation and psychological safety, activity integration into organisational procedures, organisational support, and external supportive monitoring. A shared purpose of the managers’ capacity strengthening initiative created commitment and motivation to learn. This purpose was built upon a set of facilitation skills that included promoting participation, self-efficacy and reflection, thereby creating a safe psychological space within which the managers interacted and learnt from each other and their actions. Additionally, an integrated intervention strengthened local capacity and harnessed organisational support for learning. Finally, supportive monitoring from external partners, such as researchers, ensured quality, building of local capacity and professional safety networks essential for continued learning.

    Conclusions: The five elements identified in this synthesis provide a basis upon which the use of PAR can be harnessed, not only to strengthen health managers’ capacity, but also to foster other health systems strengthening initiatives involving implementation research. In addition, the findings demonstrated the intricate and complex relations between the elements, which further affirms the need for a systems thinking approach to tackling health systems challenges.

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  • 23. Wanduru, Phillip
    et al.
    Tetui, Moses
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Makerere University, Kampala, Uganda.
    Tuhebwe, Doreen
    Ediau, Michael
    Okuga, Monica
    Nalwadda, Christine
    Ekirapa-Kiracho, Elizabeth
    Waiswa, Peter
    Rutebemberwa, Elizeus
    The performance of community health workers in the management of multiple childhood infectious diseases in Lira, northern Uganda: a mixed methods cross-sectional study2016Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, artikkel-id 33194Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Community health workers (CHWs) have the potential to reduce child mortality by improving access to care, especially in remote areas. Uganda has one of the highest child mortality rates globally. Moreover, rural areas bear the highest proportion of this burden. The optimal performance of CHWs is critical. In this study, we assess the performance of CHWs in managing malaria, pneumonia, and diarrhea in the rural district of Lira, in northern Uganda.

    Designs: A cross-sectional mixed methods study was undertaken to investigate the performance of 393 eligible CHWs in the Lira district of Uganda. Case scenarios were conducted with a medical officer observing CHWs in their management of children suspected of having malaria, pneumonia, or diarrhea. Performance data were collected using a pretested questionnaire with a checklist used by the medical officer to score the CHWs. The primary outcome, CHW performance, is defined as the ability to diagnose and treat malaria, diarrhea, and pneumonia appropriately. Participants were described using a three group performance score (good vs. moderate vs. poor). A binary measure of performance (good vs. poor) was used in multivariable logistic regression to show an association between good performance and a range of independent variables. The qualitative component comprised seven key informant interviews with experts who had informed knowledge with regard to the functionality of CHWs in Lira district.

    Results: Overall, 347 CHWs (88.3%) had poor scores in managing malaria, diarrhea, and pneumonia, 26 (6.6%) had moderate scores, and 20 (5.1%) had good scores. The factors that were positively associated with performance were secondary-level education (adjusted odds ratio [AOR] 2.72; 95% confidence interval [CI] 1.50-4.92) and meeting with supervisors in the previous month (AOR 2.52; 95% CI 1.12-5.70). Those factors negatively associated with CHW performance included: serving 100-200 households (AOR 0.24; 95% CI 0.12-0.50), serving more than 200 households (AOR 0.22; 95% CI 0.10-0.48), and an initial training duration lasting 2-3 days (AOR 0.13; 95% CI 0.04-0.41). The qualitative findings reinforced the quantitative results by indicating that refresher training, workload, and in-kind incentives were important determinants of performance.

    Conclusions: The performance of CHWs in Lira was inadequate. There is a need to consider pre-qualification testing before CHWs are appointed. Providing ongoing support and supervision, and ensuring that CHWs have at least secondary education can be helpful in improving their performance. Health system managers also need to ensure that the CHWs' workload is moderated as work overload will reduce performance. Finally, although short training programs are beneficial to some degree, they are not sufficient and should be followed up with regular refresher training.

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