Ethics of Neighborly Intimacy among Community Health Activists in Delhi.

What makes community health activism an ethical undertaking? I examine how, among Accredited Social Health Activists (ASHAs) in an urban poor neighborhood in Delhi, health work is underscored by relational sensibilities. By primarily situating the inquiry into the everyday lives of ASHAs, and beyond the formal trajectories of their work, I show how their care work and relational commitments exceed the forms of care foregrounded in public health program protocols. ASHAs operate through an ethics of neighborly intimacy - relational knowledge and acts, guided by ethical obligations toward their neighbors, and underscored by existing dependencies and care, and the detachments and differentiations of relationships.

Does volunteer community health work empower women? Evidence from Ethiopia's Women's Development Army.

Of the millions of Community Health Workers (CHWs) serving their communities across the world, there are approximately twice as many female CHWs as there are male. Hiring women has in many cases become an ethical expectation, in part because working as a CHW is often seen as empowering the CHW herself to enact positive change in her community. This article draws on interviews, participant observation, document review and a survey carried out in rural Amhara, Ethiopia from 2013 to 2016 to explore discourses and experiences of empowerment among unpaid female CHWs in Ethiopia's Women's Development Army (WDA). This programme was designed to encourage women to leave the house and gain decision-making power vis-à-vis their husbands-and to use this power to achieve specific, state-mandated, domestically centred goals. Some women discovered new opportunities for mobility and self-actualization through this work, and some made positive contributions to the health system. At the same time, by design, women in the WDA had limited ability to exercise political power or gain authority within the structures that employed them, and they were taken away from tending to their individual work demands without compensation. The official rhetoric of the WDA-that women's empowerment can happen by rearranging village-level social relations, without offering poor women opportunities like paid employment, job advancement or the ability to shape government policy-allowed the Ethiopian government and its donors to pursue 'empowerment' without investments in pay for lower-level health workers, or fundamental freedoms introduced into state-society relations.

Revelando a dimensão da ética no cotidiano dos agentes comunitários de saúde de um município da região norte do estado do Paraná / Revealing the extent of ethics in the daily life of community health workers in a city in the northof the state of Paraná

Os Agentes Comunitários de Saúde (ACS) revelam-se atores intrigantes no diálogo entre saberes e práticas populares com o conhecimento científico. Não possuem Código de Ética Profissional que os respaldem ou são capacitados para solucionar questões éticas cotidianas. O objetivo deste trabalho foi revelar a percepção dos aspectos éticos inerentes ao trabalho dos ACS que atuam na Estratégia de Saúde da Família (ESF) em Rolândia (Paraná). Trata-se de estudo quantitativo e qualitativo, de ética descritiva. Participaram 52 mulheres, que atuam nas 12 equipes da ESF. Obteve-se perfil sociodemográfico, seguido de entrevista, onde as ACS foram expostas a três situações comuns em sua vivência. Utilizou-se "análise de conteúdo" para avaliação dos discursos. As participantes responderam satisfatoriamente considerando preceitos morais e declararam fundamental a existência de legislação deontológica específica. As entrevistas revelaram dilemas éticos profundos, fruto deste relacionamento próximo com a comunidade. Processo de intervenção educativa contextualizado foi proposto e aplicado às ACS.(AU)

The Community Health Workers (ACS) prove to be intriguing actors in what concerns the dialogue between the common knowledge and practice and the scientific knowledge. They do not have a Code of Professional Ethics to endorse them, nor are they trained to solve ethical problems related to their daily life. The goal of this study was to reveal the perception of the inherently ethical aspects of ACSs who work in the Family Health Teams (ESF) in the city of Rolândia, Paraná, Brazil. The study was both quantitative and qualitative, and of descriptive ethics. The subjects were 52 female ACSs who work in the twelve teams of ESF. A social and demographic profile was obtained, followed by an interview, in which all ACSs were exposed to three situations that are common in their daily practice. The interviews were analyzed by the "content analysis" method. The participants' answers are, most of the time, correct and guided by their own moral principles. They all declared that the existence of specific deontological legislation is crucial. The interviews revealed deep ethical dilemmas that stem from this close relation to the community. A contextualized process of educational intervention was proposed and applied to the ACSs. (AU)

Ethics of task shifting in the health workforce: exploring the role of community health workers in HIV service delivery in low- and middle-income countries.

BACKGROUND: Task shifting is increasingly used to address human resource shortages impacting HIV service delivery in low- and middle-income countries. By shifting basic tasks from higher- to lower-trained cadres, such as Community Health Workers (CHWs), task shifting can reduce overhead costs, improve community outreach, and provide efficient scale-up of essential treatments like antiretroviral therapies. Although there is rich evidence outlining positive outcomes that CHWs bring into HIV programs, important questions remain over their place in service delivery. These challenges often reflect concerns over whether CHWs can mitigate HIV through a means that does not overlook the ethical and practical constraints that undergird their work. Ethical and practical guidance thus needs to become the cornerstone of CHW deployment. This paper analyzes such challenges through the lens of Ethical Principlism. METHODS: We examined papers identifying substantive and ethical challenges impacting CHWs as they provide HIV services in low- and middle-income contexts. To do this, we analyzed papers written in English and published from year 2000 or later. These articles were identified using MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar databases. In total, 465 articles were identified, 78 of which met our inclusion criteria. Article reference lists and grey literature were also examined. RESULTS: CHWs experience specific challenges while carrying out their duties, such as conducting emotionally- and physically-demanding tasks with often inadequate training, supervision and compensation. CHWs have also been poorly integrated into health systems, which not only impacts quality of care, but can hinder their prospects for promotion and lead to CHW disempowerment. As we argue, these challenges can be addressed if a set of ethical principles is prioritized, which specifically entail the principles of respect for persons, justice, beneficence, proportionality and cultural humility. CONCLUSIONS: CHWs play a crucial role in HIV service delivery, yet the ethical challenges that can accompany their work cannot be overlooked. By prioritizing ethical principles, policymakers and program implementers can better ensure that CHWs are combatting HIV through a means that does not exploit or take their critical role within service delivery for granted.

O reconhecer e o lidar dos agentes comunitários de saúde diante da bioética: entre a ética do cuidado e os poderes disciplinares / The recognition and dealing of community health agents in light of bioethics: between care ethics and disciplinary powers

Resumo Este artigo discute o trabalho do agente comunitário de saúde (ACS) com foco nos problemas éticos enfrentados no cotidiano do trabalho e cuidado, espaço de cuidado e as diretrizes disciplinares sobre sua atividade. A metodologia é de origem qualitativa com utilização da cartografia associada a instrumentos da etnografia (observação participante, caderno de campo e entrevista semiestruturada). O ACS tem sido considerado um trabalhador diferenciado por pertencer à comunidade e à instituição de saúde. Tal característica pode trazer um potencial para a produção de projetos terapêuticos singulares e apontam também para a existência de conflitos na relação trabalhador-usuário e para o exercício de poder e de novas formas de controle. Trabalho e espaços de convivência comunitária não encontram limites precisos. As narrativas dos ACS mostram sua visão a respeito dos usuários, o sentido de vínculo, demonstrando sentimento de solidariedade e compaixão, o que corrobora a proposta da ética do cuidar baseada na responsabilidade pela conexão humana. Há fragilidades na formação do ACS para lidar com as questões de cuidado em saúde. Ser da comunidade interfere na sua própria privacidade e na intervenção excessiva na vida das pessoas, reproduzindo atitude de controle dos corpos.

Abstract This article discusses the work of community health agents (ACS) focusing on the ethical problems in their daily work and care, the space of care and the disciplinary guidelines in their activities. In the scenario of changing care model, ACS have increasingly been considered differentiated workers as they belong to the community and to the health institution. These characteristics can bring a differential and potential for the production of unique therapeutic projects at the same time, which point to the existence of conflicts in the worker-user relationship and to the exercise of power and new forms of control in the primary care setting. Work and community spaces do not find precise limits. The ACS narratives show their viewpoint about users, the weaknesses in their formation, still based on actions that make them the sanitary police. There is professional hierarchy in the health team, the interviewees' statements showed the idea they have about the bond with users, which shows the feeling of solidarity and compassion, corroborating with the proposal of the ethics of caring based on responsibility for the human connection. Being from the community interferes with one's privacy and excessive intervention in people's lives, reproducing biopower attitudes in the control of bodies.

Measuring work engagement among community health workers in Sierra Leone: validating the Utrecht Work Engagement Scale / La medición del compromiso con el trabajo en trabajadores sanitarios comunitarios de Sierra Leona: validación de la Escala Utrecht de Engagement

This study examines the concept of volunteer work engagement in a sample of 334 community health workers in Bonthe District, Sierra Leone. Structural equation modelling was used to validate both the 9-item and the 17-item Utrecht Work Engagement Scale (UWES-9 and UWES-17, respectively). Results assessing the UWES-17 invalidated the three-factor structure within this cohort of community health workers, as high correlations were found between latent factors. Findings for the validity of the UWES-9 were largely consistent with those of the UWES-17. Model fit for the UWES-9 were generally equivalent for the one-factor, three-factor, and bifactor solutions, however the three-factor model was once again rejected due to high factor correlations. Based on these results, the current sample provides evidence that work engagement is best represented as a unidimensional construct in this context. Findings are considered alongside previous research to offer support for the utilization of the shortened UWES-9 in this context, as it appears to provide a good representation of work engagement and possess a parsimonious unidimensional scoring scheme (AU)

Este estudio analiza el concepto de compromiso en el trabajo voluntario de una muestra de 224 trabajadores sanitarios comunitarios del distrito de Bonthe, Sierra Leona. Se utilizó el modelado de ecuaciones estructurales para validar la Escala Utrecht de Engagement, tanto la de 9 (UWES-9) como la de 17 (UWES-17) elementos. Los resultados de la evaluación de la UWES-17 invalidaron la estructura de tres factores en esta muestra de trabajadores sanitarios comunitarios, ya que se hallaron correlaciones elevadas entre los factores latentes. Los resultados de la validez de la UWES-9 mostraban gran congruencia con los de la UWES-17. El ajuste de modelo para la UWES-9 era en general equivalente para las soluciones de uno, tres y dos factores, aunque el modelo de tres factores fue una vez más rechazado por las elevadas correlaciones entre factores. A la vista de los resultados, esta muestra prueba que el compromiso con el trabajo se representa mejor como constructo unidimensional en este contexto. En la línea de la investigación precedente, se considera que estos resultados respaldan la utilización de la forma abreviada, UWES-9, en este contexto, dado que parece representar mejor el compromiso con el trabajo y dispone de un método unidimensional de puntuación parsimonioso (AU)

Inuit interpreters engaged in end-of-life care in Nunavik, Northern Quebec.

BACKGROUND: Inuit interpreters are key players in end-of-life (EOL) care for Nunavik patients and families. This emotionally intensive work requires expertise in French, English and Inuit dialects to negotiate linguistic and cultural challenges. Cultural differences among medical institutions and Inuit communities can lead to value conflicts and moral dilemmas as interpreters navigate how best to transmit messages of care at EOL. OBJECTIVES: Our goal was to understand the experience of Inuit interpreters in the context of EOL care in Nunavik in order to identify training needs. DESIGN: In the context of a larger ethnographic project on EOL care in Nunavik, we met with 24 current and former interpreters from local health centres and Montreal tertiary care contexts. Data included informal and formal interviews focusing on linguistic resources, experiences concerning EOL care, and suggestions for the development of interpretation training. RESULTS: Inuit working as interpreters in Nunavik are hired to provide multiple services of which interpretation plays only a part. Many have no formal training and have few resources (e.g. visual aids, dictionaries) to draw upon during medical consultations. Given the small size of communities, many interpreters personally know their clients and often feel overwhelmed by moral dilemmas when translating EOL information for patients and families. The concept of moral distress is a helpful lens to make sense of their experience, including personal and professional repercussions. CONCLUSIONS: Inuit interpreters in Nunavik are working with little training yet in context with multiple linguistic and cultural challenges. Linguistic and cultural resources and focused training on moral dilemmas unique to circumpolar contexts could contribute to improved work conditions and ultimately to patient care.​​​​.

Exposició a tuberculosi pulmonar en una unitat neonatal: decisions diagnòstiques i terapèutiques / Exposición a tuberculosis pulmonar en una unidad neonatal: decisiones diagnósticas y terapéuticas / Exposure to pulmonary tuberculosis in a neonatal unit: diagnostic and therapeutic decisions

Fonament: els nounats tenen un risc incrementat de patir malaltia tuberculosa greu a causa de la seva condició d'immunosupressió. Objectiu: avaluar la incidència d'infecció tuberculosa o malaltia latent en una cohort de nounats exposats a un treballador sanitari d'una unitat neonatal diagnosticat de malaltia tuberculosa pulmonar, així com descriure les estratègies per al seu diagnòstic i tractament. Mètode: per al cribratge inicial es va fer una prova de tuberculina (PT) i una radiografia (Rx) toràcica. En cas de dubte, es practicaria una tomografia axial computada (TC) i un QuantiFERON(R)-TB Gold test. Descartada la infecció, es va iniciar tractament amb isoniazida fins als 6 mesos. A aquesta edat, es va fer una segona PT. Resultats: seixanta nounats van estar exposats al cas índex. La PT va ser negativa tant a l'inici com als 6 mesos. Un nadó presentava una imatge dubtosa en la radiografia toràcica, però la TC i el QuantiFERON(R)-TB Gold test van ser normals. El 88,6% dels nounats van iniciar profilaxi, es va contraindicar en el 3% i hi va haver negativa dels pares en el 8%. Tan sols un pacient va presentar efectes secundaris per isoniazida. El 78% dels casos va completar la profilaxi. Als 12 mesos no es va detectar cap cas de tuberculosi. Conclusions: la incidència d'infecció tuberculosa en nounats hospitalitzats exposats és baixa, però, a causa de la gravetat potencial, la profilaxi amb isoniazida fins als 6 mesos i un cribratge precoç amb una PT i una Rx toràcica poden ser una estratègia vàlida per minimitzar el risc

Fundamento. Los neonatos tienen un riesgo incrementado de sufrir enfermedad tuberculosa grave dada su condición de inmunosupresión. Objetivo. Evaluar la incidencia de infección tuberculosa o enfermedad latente en una cohorte de neonatos expuestos a un trabajador sanitario de una unidad neonatal diagnosticado de enfermedad tuberculosa pulmonar, así como describir las estrategias para su diagnóstico y tratamiento. Método. Para el cribado inicial se realizó una prueba de tuberculina (PT) yuna radiografía (Rx) torácica. En caso de duda, se practicaría tomografía axial computerizada (TC) y prueba del QuantiFERON®-TB Gold test. Descartada la infección, se inició tratamiento con isoniazida hasta los 6 meses. A esta edad se practicó una segunda PT. Resultados. Sesenta neonatos fueron expuestos. La PT fue negativa tanto al inicio como a los 6 meses. Un neonato presentaba una imagen dudosa en la radiografía torácica, pero la TC y el QuantiFERON®-TB Gold test fueron normales. El 88,6% de los neonatos iniciaron profilaxis, se contraindicó en el 3% y hubo negativa de los padres en el 8%. Tan sólo un paciente presentó efectos secundarios por isoniazida. El 78% de los casos completó la profilaxis. A los 12 meses no se detectó ningún caso de tuberculosis. Conclusiones. La incidencia de infección tuberculosa en neonatos hospitalizados expuestos es baja, pero, debido a la potencial gravedad, la profilaxis con isoniazida hasta los 6 meses y un cribado precoz con una PT y una Rx torácica pueden ser una estrategia válida para minimizar el riesgo (AU)

Background. Neonates have an increased risk to suffer severe tuber culosis due to their immunosuppressed condition. Objective. To assess the incidence of tuberculosis infection or latent disease in a cohort of newborns exposed to a healthcare worker of the neonatal unit, diagnosed with pulmonary tuberculosis disease, as well as describe diagnostic and treatment strategies. Method. Tuberculin skin test (TST) and chest X-rays were performed at the initial screening. Chest computed tomography (CT) and QuantiFERON®-TB Gold test were performed on cases where chest X-ray was not clear. Once all diagnostic tests were negative, infants were treated with isoniazid up to 6 months of age. At this age, a second TST was performed. Results. 60 newborns were exposed. TST were negative at baseline and at 6 months. One infant had an abnormal chest X-ray, with normal findings on CT and QuantiFERON®-TB Gold test. 88.6% neonates started with prophylaxis, it was contraindicated in 3% and was refused by the parents in 8%. Isoniazid was withdrawn due to side effects in only 1 infant. Prophylaxis was completed by 78% of patients. At 12 months, no cases of tuberculosis were reported. Conclusions. The tuberculous infection incidence in hospitalized neonates exposed is low but, due to the potential severity, prophylaxis with isoniazid until 6 months and an early screening with TST and chest X-ray is a valid strategy to minimized risks (AU)

Concepções dos agentes comunitários de saúde sobre suas práticas assistenciais / Conceptions of community health agents about their health care practices

O presente estudo objetivou identificar as representações elaboradas por agentes comunitários de saúde (ACS) acerca de suas práticas assistenciais. Utilizamos a metodologia qualitativa de pesquisa, adotando, como instrumento de coleta de dados, a entrevista semiestruturada e, para a interpretação dos dados, recorremos à Análise Temática. Foram ouvidos 12 ACS das Equipes do Programa de Agentes Comunitários de Saúde (PACS) de um município do interior paulista. O material obtido permitiu verificar como temas: o vínculo como instrumento de trabalho e a prática pautada na promoção da saúde e na prevenção das doenças. Os relatos demonstram a importância do vínculo na prática diária, enfatizam os princípios humanitários que embasam as ações de solidariedade, destacam o sentimento de gratificação quando o trabalho executado é reconhecido pelas famílias e revelam que os sujeitos ouvidos têm dificuldades para discernir o alcance de seus limites. Embora estes profissionais apresentem um bom suporte técnico para o cumprimento de suas ações, também demonstram carência na instrumentalização para o exercício profissional. Concluímos que as diretrizes e normas estabelecidas para o PACS funcionam como norteadoras do processo de assistência, mas ainda não respondem a questões mais subjetivas encontradas na assistência ao indivíduo-famíliacomunidade. Além disso, os ACS parecem estar vulneráveis às flutuações de gestão dos municípios, estados e Governo Federal, apresentam inconsistência na ideologia do desempenho do próprio papel e não conseguem inverter o modelo assistencial pautado na doença e na intervenção médica individual.

This study aimed to identify the representations developed by community health agents (CHA) about their care practices. We used the qualitative research methodology, taking semistructured interviews for collecting data; for data interpretation, we adopted the thematic analysis. Twelve CHA of the Community Agents Program (PACS) from a hinterland town in São Paulo State. The material obtained presented two themes: the bond as working tool and practice based on health promotion and disease prevention. The reports show the importance of the bond in daily practice, emphasizing the humanitarian principles that underlie the actions of solidarity, highlight the feeling of gratification when the work performed is recognized by families and reveal that the interviewed ones have trouble in discerning the scope of its limits. Although these professionals have a good technical support for the fulfillment of their actions, they also show the need for professional instrumentation. We conclude that the guidelines and standards set for the PACS function as guidelines for the health care process, but do not respond to more subjective issues found in the care of individual-family-community. Moreover, the CHA seem to be vulnerable to fluctuations in the municipal, state and federal administration, have inconsistent ideology in playing their own role and cannot reverse the health care model guided by disease and individual medical intervention.

An ethical framework for community health workers and related institutions.

The aim of this article is to provide practical ethical guidance and to foster further critical reflection on ethical issues in the work, education, and training of community health workers. The analysis includes implications for associated institutions. We first summarize the roles of community health workers and some evaluations of their work. After next highlighting ethical elements from the literature, we then give a justification for the ethical framework that follows. The article then provides a detailed discussion of a set of basic ethical principles for the field of community health work. Among the principles, we argue that the following 3 should have a foundational role: equal and substantial respect, justice, and care. Among these, respect is most fundamental.

Assessment of the technical competence and ethical behaviour of Community-based Animal Health Workers in Mwingi District, Kenya.

This paper describes an assessment of the technical competence and ethical behaviour of Community-based Animal Health Workers (CAHWs) in Mwingi District, Kenya. From 99 trained CAHWs, 40 participated in the study. Using a pre-tested semi-structured questionnaire, direct observation of the relevant veterinary drug kits and participatory discussions, the study team found that the CAHWs knowledge of clinical signs of local livestock diseases and notifiable and zoonotic diseases and their ability to use veterinary drugs correctly and safely were adequate. Marks were awarded to the candidates according to an agreed marking scheme between the CAHWs' trainers and study team members. The results showed that, overall, 36 out of 40 (90%) of the sampled CAHWs passed the tests. The existence of a referral system for CAHWs and refresher trainings helped to ensure that CAHW competence and ethical behaviour were maintained. However, it was also found that some areas of the current curriculum required more detailed input based on field experience. The CAHW system could serve as an alternative animal health care system in areas lacking veterinary services.

[Community health agents and patients' privacy]. / O agente comunitário de saúde e a privacidade das informações dos usuários.

This is an exploratory study on views of various social players in the Brazilian Family Health Program, concerning the right to privacy in the relationship between users of the program and community health agents (CHA). The following healthcare professionals were interviewed: heads of basic healthcare units, physicians, nurses and community health agents, working at health units in the city of Sao Paulo, Brazil, in 2002. Healthcare professionals and managers agreed that limits should be placed on access by CHAs to certain user information, including diagnosis. The study showed that frequent contact between users and CHAs results in users' disclosure of their health conditions to CHAs prior to consulting other professionals in the healthcare team. This generates the following ethical issue: Is there any specific scope of confidentiality between the CHA and users over information that should not be disclosed to other team members?