TY - JOUR
T1 - Piloting a participatory, community-based health information system for strengthening communitybased health services
T2 - Findings of a cluster-randomized controlled trial in the slums of Freetown, Sierra Leone
AU - O'Connor, Emily Cummings
AU - Hutain, Jennifer
AU - Christensen, Megan
AU - Kamara, Musa Sahid
AU - Conteh, Abu
AU - Sarriot, Eric
AU - Samba, Thomas T.
AU - Perry, Henry B.
N1 - Funding Information:
David Pyle contributed to the design of this child survival project and operations research study, and Jennifer Weiss supported the initial stage of implementation of both. The authors acknowledge the support and cooperation of the community members, the community leaders, the CHWs and Peer Supervisors, and the HMCs and WDCs who were part of this study and the child survival project. They generously and tirelessly gave their time and unrelenting efforts, despite enormous adversity, to improve health within their communities. We also acknowledge the efforts of Laura Hastings and Khadijatu Bakarr, Program Managers of the child survival project, as well as the full child survival project team. We thank Lawrence Moulton and Hossein Zare for statistical assistance. Finally, we thank the Ministry of Health and Sanitation and the District Health Management Team for its full support. This study was generously supported by the American and Irish people through the United States Agency for International Development (USAID), Irish Aid and Concern Worldwide. The contents of this report do not necessarily reflect the views of USAID, Irish Aid or the United States Government and Irish Government.
Funding Information:
Each PHU is supported by a Health Management Committee (HMC). The HMC serves as a liaison between the PHU and the community and supports community mobilization and outreach activities from the PHU. Each of the 39 wards within the Freetown municipal area has an elected Ward Development Committee (WDC), responsible for engaging community members on general development activities. The WDC chair sits as a Councilor on the FCC. Each community in the study area covers 1-2 wards. In cases where the community covers more than one ward, both WDCs participated in the study. Roles and methods for HMCs and WDCs to act as the liaison to the community have not been well-developed. While the Government of Sierra Leone highlights the need for community engagement in recently developed policy documents, such as the Basic Package of Essential Health Services (BPEHS) 2015-2020, it focuses on CHWs to fulfil this role. The BPEHS recognizes HMCs and WDCs as community actors but does not outline roles or the ways in which they should fit into the health system [12].
Publisher Copyright:
© 2019 The Author(s).
PY - 2019
Y1 - 2019
N2 - Background Although community engagement has been promoted as a strategy for health systems strengthening, there is need for more evidence for effectiveness of this approach. We describe an operations research (OR) Study and assessment of one form of community engagement, the development and implementation of a participatory community-based health information system (PCBHIS), in slum communities in Freetown, Sierra Leone. Methods A child survival project was implemented in 10 slum communities, which were then randomly allocated to intervention (PCBHIS) and comparison areas. In the 5 PCBHIS communities, the findings from monthly reports submitted by community health workers (CHWs) and verbal autopsy findings for deaths of children who died before reaching 5 years of age, were processed and shared at bimonthly meetings in each community. These meetings, called Community Health Data Review (CHDR) meetings, were attended by community leaders, including members of the Ward Development Committee (WDC) and Health Management Committee (HMC), by the CHW Peer Supervisors, and by representatives of the Peripheral Health Unit. Following a review of the information, attendees proposed actions to strengthen community- based health services in their community. These meetings were held over a period of 20 months from July 2015 to March 2017. At baseline and endline, knowledge, practice and coverage (KPC) surveys measured household health-related behaviors and care-seeking behaviors. The capacity of HMCs and WDCs to engage with the local health system was also measured at baseline and endline. Reports of CHW household contact and assessments of CHW quality were obtained in the endline KPC household survey, and household contacts measured in monthly submitted reports were also tabulated. Results The self-assessment scores of WDCs' capacity to fulfil their roles improved more in the intervention than in the comparison area for all six components, but for only 1 of the 6 was the improvement statistically significant (monthly and quarterly meetings in which Peer Supervisor and/or CHW supervision was an agenda item). The scores for the HMCs improved less in the intervention area than in the comparison area for all six components, but none of these differences were statistically significant. Topics of discussion in CHDRs focused primarily on CHW functionality. All three indicators of CHW functioning (as measured by reports submitted from CHWs) improved more in the intervention area relative to the comparison area, with 2 out of 3 measures of improvement reaching statistical significance. Five of 7 household behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 2 out of the 5 were statistically significant (feeding colostrum and appropriate infant and young child feeding). Four of the 6 care-seeking behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 1 was statistically significant (treatment of diarrhea with ORS and zinc). None of the findings that favored the comparison area were statistically significant. Conclusions This study was implemented in challenging circumstances. The OR Study intervention was delayed because of interruptions in finalizing the national CHW policy, two separate cholera epidemics, and the Ebola epidemic lasting more than 2 years. Weaknesses in the CHW intervention severely limited the extent to which the PCBHIS could be used to observe trends in mortality and morbidity. Nonetheless, the positive results achieved in the area of functionality of the CHW intervention and community structure capacity are encouraging. Results suggest there is value in further methodologically rigorous investigations into improving community- based health system functioning through a similar approach to community engagement.
AB - Background Although community engagement has been promoted as a strategy for health systems strengthening, there is need for more evidence for effectiveness of this approach. We describe an operations research (OR) Study and assessment of one form of community engagement, the development and implementation of a participatory community-based health information system (PCBHIS), in slum communities in Freetown, Sierra Leone. Methods A child survival project was implemented in 10 slum communities, which were then randomly allocated to intervention (PCBHIS) and comparison areas. In the 5 PCBHIS communities, the findings from monthly reports submitted by community health workers (CHWs) and verbal autopsy findings for deaths of children who died before reaching 5 years of age, were processed and shared at bimonthly meetings in each community. These meetings, called Community Health Data Review (CHDR) meetings, were attended by community leaders, including members of the Ward Development Committee (WDC) and Health Management Committee (HMC), by the CHW Peer Supervisors, and by representatives of the Peripheral Health Unit. Following a review of the information, attendees proposed actions to strengthen community- based health services in their community. These meetings were held over a period of 20 months from July 2015 to March 2017. At baseline and endline, knowledge, practice and coverage (KPC) surveys measured household health-related behaviors and care-seeking behaviors. The capacity of HMCs and WDCs to engage with the local health system was also measured at baseline and endline. Reports of CHW household contact and assessments of CHW quality were obtained in the endline KPC household survey, and household contacts measured in monthly submitted reports were also tabulated. Results The self-assessment scores of WDCs' capacity to fulfil their roles improved more in the intervention than in the comparison area for all six components, but for only 1 of the 6 was the improvement statistically significant (monthly and quarterly meetings in which Peer Supervisor and/or CHW supervision was an agenda item). The scores for the HMCs improved less in the intervention area than in the comparison area for all six components, but none of these differences were statistically significant. Topics of discussion in CHDRs focused primarily on CHW functionality. All three indicators of CHW functioning (as measured by reports submitted from CHWs) improved more in the intervention area relative to the comparison area, with 2 out of 3 measures of improvement reaching statistical significance. Five of 7 household behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 2 out of the 5 were statistically significant (feeding colostrum and appropriate infant and young child feeding). Four of the 6 care-seeking behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 1 was statistically significant (treatment of diarrhea with ORS and zinc). None of the findings that favored the comparison area were statistically significant. Conclusions This study was implemented in challenging circumstances. The OR Study intervention was delayed because of interruptions in finalizing the national CHW policy, two separate cholera epidemics, and the Ebola epidemic lasting more than 2 years. Weaknesses in the CHW intervention severely limited the extent to which the PCBHIS could be used to observe trends in mortality and morbidity. Nonetheless, the positive results achieved in the area of functionality of the CHW intervention and community structure capacity are encouraging. Results suggest there is value in further methodologically rigorous investigations into improving community- based health system functioning through a similar approach to community engagement.
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U2 - 10.7189/jogh.09.010418
DO - 10.7189/jogh.09.010418
M3 - Article
C2 - 30842881
AN - SCOPUS:85062753375
SN - 2047-2978
VL - 9
JO - Journal of global health
JF - Journal of global health
IS - 1
M1 - 010418
ER -