Post-intervention perceptions on the antiretroviral therapy community group model in Trans Nzoia County, Kenya.

Introduction: the increasing number of people receiving antiretroviral therapy (ART) in sub-Saharan Africa has stressed already overburdened health systems. A care model utilizing community-based peer-groups (ART Co-ops) facilitated by community health workers (CHW) was implemented (2016-2018) to address these challenges. In 2018, a post-intervention study assessed perceptions of the intervention. Methods: forty participants were engaged in focus group discussions consisting of ART Co-op clients, study staff, and health care providers from Kitale HIV clinic. Data were analyzed thematically for content on the intervention, challenges, and recommendations for improvement. Results: all participants liked the intervention. However, some reported traveling long distances to attend ART Co-op meetings and experiencing stigma with ART Co-ops participation. The ART Co-op inclusion criteria were considered appropriate; however, additional outreach to deliberately include spouses living with HIV, the disabled, the poor, and HIV pregnant women was recommended. Participants liked CHW-directed quarterly group meetings which included ART distribution, adherence review, and illness identification. The inability of the CHW to provide full clinical care, inconvenient meeting venues, poor timekeeping, and non-attendance behaviors were noted as issues. Participants indicated that program continuation, regular CHW training, rotating meetings at group members´ homes, training ART Co-ops leaders to assume CHW tasks, use of pill diaries to check adherence, nutritional support, and economically empowering members through income generation projects would be beneficial. Conclusion: the intervention was viewed positively by both clinic staff and clients. They identified specific challenges and generated actionable key considerations to improve access and acceptability of the community-based model of care.

"And then the person sort of just drops off the radar ": barriers in the transition from hospital to community-based care among survivors of intimate partner violence in Metropolitan Atlanta.

Introduction: Hospitals and community-based organizations (CBOs) provide the service-base for survivors of intimate partner violence (IPV), particularly those in acute crisis. Both settings face discrete challenges in meeting survivors' needs. In hospitals these challenges include the pressures of a fast-paced work setting, and a lack of trauma-informed and survivor-centered care. Connections to community care are often unmeasured, with relatively little known about best practices. Often IPV survivors who receive hospital care fail to connect with community-based services after discharge. Despite the critical role of CBOs in supporting IPV survivors, there is limited research examining the perspectives and insights of CBO staff on the challenges and opportunities for improving care coordination with hospitals. The purpose of this study was to address this knowledge gap by characterizing CBO staff perceptions of IPV care coordination between hospital and community-based organizations in Metropolitan Atlanta. Methods: We used a qualitative study design to conduct a cross-sectional examination of the perceptions and experiences of staff working at CBOs serving IPV survivors in Metropolitan Atlanta, Georgia. The adapted in-depth interview (IDI) guide was used to explore: (1) IPV survivor experiences; (2) Survivors' needs when transitioning from hospital to community-based care; (3) Barriers and facilitators to IPV care coordination; and (4) Ideas on how to improve care coordination. Data analysis consisted of a thematic analysis using MAXQDA Analytics Pro 2022. Results: Participants (N = 14) included 13 women and one man who were staff of CBOs serving IPV survivors in Metropolitan Atlanta. CBO staff perceived that: (1) IPV survivors face individual-, organizational-, and systems-level barriers during help seeking and service provision; (2) Care coordination between hospitals and CBOs is limited due to siloed care provision; and (3) Care coordination can be improved through increased bidirectional efforts. Conclusion: Our findings highlight the multi-level barriers IPV survivors face in accessing community-based care following medical care, the limitations of existing hospital-CBO coordination, and opportunities for improvement from the perspectives of CBO staff. Participants identified silos and inconsistent communication/relationships between hospital and CBOs as major barriers to care connections. They also suggested warm handoffs and a Family Justice Center to support care connection.

Understanding the perspective of community co-educators on community-based service learning: a qualitative analysis.

Background: Community-based service learning (CBSL) is a core component of the Canadian medical education system. However, the unique role of community partner organizations (CPOs) in supporting CBSL remains unclear. This qualitative study evaluates the perspective of CPOs as co-educators in the undergraduate medical curriculum. Methods: We conducted eight semi-structured, one-on-one interviews with CPOs at a medical school in Toronto, Ontario between 2020-2021. Interviews were conducted following a pre-determined interview guide and then recorded, de-identified, and transcribed. Three reviewers independently performed an inductive thematic analysis of codes followed by a group review of discrepancies. Results: Five main findings were identified: 1) CPOs share a common interest in serving as co-educators; 2) considerable heterogeneity in the understanding of co-education exists; 3) there is an opportunity for increased partnerships between CPOs and faculty; 4) the role of co-educators is limited by curriculum structure; and 5) co-educators facilitate unique teachings of social determinants of health otherwise not available through traditional didactic teaching. Conclusions: There is an emerging, unique role for community co-educators in the undergraduate medical curriculum, supported by interest from CPOs. Its emphasis may contribute to future cohorts of medical students capable of understanding and addressing the needs of the populations they serve.

Contexte: L'apprentissage par le service communautaire (APSC) est une composante essentielle du système d'éducation médicale canadien. Cependant, le rôle unique des organismes communautaires partenaires (OCP) dans le soutien de l'APSC n'est toujours pas clair. Cette étude qualitative évalue le point de vue des OCP en tant que co-éducateurs dans le programme d'études médicales de premier cycle. Méthodes: Nous avons mené huit entrevues individuelles semi-structurées avec des OCP d'une faculté de médecine de Toronto, en Ontario, entre 2020 et 2021. Les entrevues ont été menées en suivant un guide d'entrevue prédéterminé, puis enregistrées, dépersonnalisées et transcrites. Trois examinateurs ont effectué indépendamment une analyse thématique inductive des codes, suivie d'un examen collectif des divergences. Résultats: Cinq conclusions principales ont été identifiées : 1) les OCP ont un intérêt commun à agir en tant que co-éducateurs; 2) il existe une grande hétérogénéité dans la compréhension de la co-éducation; 3) il est possible d'accroître les partenariats entre les OCP et le corps professoral; 4) le rôle des co-éducateurs est limité par la structure du curriculum médical et 5) les co-éducateurs facilitent des opportunités d'apprentissage uniques sur les déterminants sociaux de la santé qui ne sont pas disponibles dans le cadre de l'enseignement didactique traditionnel. Conclusions: Les co-éducateurs communautaires jouent un rôle novateur et unique dans le programme d'études médicales de premier cycle, soutenu par l'intérêt des OCP. L'accent mis sur ce rôle peut contribuer à former de futures cohortes d'étudiants en médecine capables de comprendre et de répondre aux besoins des populations qu'ils servent.

The Community As A Full Partner: A New Model For Public Health.

The COVID-19 pandemic demonstrated a need to strengthen the US public health system by shifting toward much greater community engagement and leadership. In November and December 2023, we conducted separate online surveys of community-based organizations and large metropolitan health departments to identify barriers and opportunities for building a public health system with strong community partnerships. Identified barriers included mistrust, siloed health departments with structural challenges in funding community-based organizations, and insufficient shared decision making. The surveys helped inform our six policy recommendations: establish state and local community councils to formalize the roles of community-based organizations in public health decision making; dedicate funding to these organizations; offer funding that is not limited to a specific disease or condition; simplify procurement and reporting processes directed to community-based organizations; create a training and technical assistance program for these organizations; and increase public health worker diversity, including sustainable funding for community health workers.

Burnout among community service doctors in South Africa.

BACKGROUND:  Burnout in doctors is an important issue with far-reaching consequences. Community service doctors may be particularly vulnerable because of their specific roles (rural settings, junior positions and reduced supervision). AIM:  This study aimed to determine the prevalence of burnout among community service doctors in South Africa (SA), the potential contributory and protective factors and the consequences thereof. SETTING:  This was a national study of community service doctors in SA. METHODS:  A quantitative, descriptive cross-sectional study was performed. The Maslach Burnout Inventory was used to measure burnout. The online questionnaire also included demographic data, workplace and individual characteristics. RESULTS:  Of the 208 community service doctors analysed, 89% and 94% had high emotional exhaustion and depersonalisation, respectively, while 97% had a low personal accomplishment. Mental illness, financial difficulties, unmanageable volume of patients and female gender were found to be potential contributory factors. Having manageable patient volumes, satisfaction with their decision to study medicine, talking to colleagues and feeling supported by healthcare facility management were among the significant potential protective factors. Significant potential consequences of burnout included: leaving the government sector, ever being diagnosed with a mental illness, using alcohol as a coping mechanism and possible current major depression. CONCLUSION:  Burnout among community service doctors in SA is highly prevalent with significant potential consequences. There are a number of modifiable possible contributory and protective factors identified that may be targets for mental health interventions.Contribution: Healthcare burnout research is lacking in the African and specifically SA context. This void includes community service doctors.

Community-based management of arterial hypertension and cardiovascular risk factors by lay village health workers for people with controlled and uncontrolled blood pressure in rural Lesotho: joint protocol for two cluster-randomized trials within the ComBaCaL cohort study (ComBaCaL aHT Twic 1 and ComBaCaL aHT TwiC 2).

BACKGROUND: Arterial hypertension (aHT) is a major cause for premature morbidity and mortality. Control rates remain poor, especially in low- and middle-income countries. Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems may help to overcome the current aHT care cascade gaps. However, evidence on the effectiveness of comprehensive VHW-led aHT care models, in which VHWs provide antihypertensive drug treatment and manage cardiovascular risk factors is scarce. METHODS: Using the trials within the cohort (TwiCs) design, we are assessing the effectiveness of VHW-led aHT and cardiovascular risk management in two 1:1 cluster-randomized trials nested within the Community-Based chronic disease Care Lesotho (ComBaCaL) cohort study (NCT05596773). The ComBaCaL cohort study is maintained by trained VHWs and includes the consenting inhabitants of 103 randomly selected villages in rural Lesotho. After community-based aHT screening, adult, non-pregnant ComBaCaL cohort participants with uncontrolled aHT (blood pressure (BP) ≥ 140/90 mmHg) are enrolled in the aHT TwiC 1 and those with controlled aHT (BP < 140/90 mmHg) in the aHT TwiC 2. In intervention villages, VHWs offer lifestyle counseling, basic guideline-directed antihypertensive, lipid-lowering, and antiplatelet treatment supported by a tablet-based decision support application to eligible participants. In control villages, participants are referred to a health facility for therapeutic management. The primary endpoint for both TwiCs is the proportion of participants with controlled BP levels (< 140/90 mmHg) 12 months after enrolment. We hypothesize that the intervention is superior regarding BP control rates in participants with uncontrolled BP (aHT TwiC 1) and non-inferior in participants with controlled BP at baseline (aHT TwiC 2). DISCUSSION: The TwiCs were launched on September 08, 2023. On May 20, 2024, 697 and 750 participants were enrolled in TwiC 1 and TwiC 2. To our knowledge, these TwiCs are the first trials to assess task-shifting of aHT care to VHWs at the community level, including the prescription of basic antihypertensive, lipid-lowering, and antiplatelet medication in Africa. The ComBaCaL cohort and nested TwiCs are operating within the routine VHW program and countries with similar community health worker programs may benefit from the findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05684055. Registered on January 04, 2023.

Expanding community case management of malaria to all ages can improve universal access to malaria diagnosis and treatment: results from a cluster randomized trial in Madagascar.

BACKGROUND: Global progress on malaria control has stalled recently, partly due to challenges in universal access to malaria diagnosis and treatment. Community health workers (CHWs) can play a key role in improving access to malaria care for children under 5 years (CU5), but national policies rarely permit them to treat older individuals. We conducted a two-arm cluster randomized trial in rural Madagascar to assess the impact of expanding malaria community case management (mCCM) to all ages on health care access and use. METHODS: Thirty health centers and their associated CHWs in Farafangana District were randomized 1:1 to mCCM for all ages (intervention) or mCCM for CU5 only (control). Both arms were supported with CHW trainings on malaria case management, community sensitization on free malaria care, monthly supervision of CHWs, and reinforcement of the malaria supply chain. Cross-sectional household surveys in approximately 1600 households were conducted at baseline (Nov-Dec 2019) and endline (Nov-Dec 2021). Monthly data were collected from health center and CHW registers for 36 months (2019-2021). Intervention impact was assessed via difference-in-differences analyses for survey data and interrupted time-series analyses for health system data. RESULTS: Rates of care-seeking for fever and malaria diagnosis nearly tripled in both arms (from less than 25% to over 60%), driven mostly by increases in CHW care. Age-expanded mCCM yielded additional improvements for individuals over 5 years in the intervention arm (rate ratio for RDTs done in 6-13-year-olds, RRRDT6-13 years = 1.65; 95% CIs 1.45-1.87), but increases were significant only in health system data analyses. Age-expanded mCCM was associated with larger increases for populations living further from health centers (RRRDT6-13 years = 1.21 per km; 95% CIs 1.19-1.23). CONCLUSIONS: Expanding mCCM to all ages can improve universal access to malaria diagnosis and treatment. In addition, strengthening supply chain systems can achieve significant improvements even in the absence of age-expanded mCCM. TRIAL REGISTRATION: The trial was registered at the Pan-African Clinical Trials Registry (#PACTR202001907367187).

Preventing tuberculosis with community-based care in an HIV-endemic setting: a modelling analysis.

INTRODUCTION: Antiretroviral therapy (ART) and tuberculosis preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community-based care, can increase the uptake of ART and TPT to prevent TB in settings with a high burden of HIV-associated TB, particularly among men. METHODS: We developed a gender-stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15-59 in KwaZulu-Natal, South Africa. We drew model parameters from a community-based ART initiation and resupply trial in sub-Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community-based ART and TPT care programmes during 2018-2027, assuming that community-based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e. ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for 10 years. We projected the number of TB cases, deaths and disability-adjusted life years (DALYs) averted relative to standard, clinic-based care. We calculated programme costs and incremental cost-effectiveness ratios from the provider perspective. RESULTS: If community-based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3%-34.1%) and TB mortality by 34.6% (range 24.8%-42.2%) after 10 years. Increasing both ART and TPT uptake through community-based ART with TPT care could reduce TB incidence by 29.7% (range 23.9%-36.0%) and TB mortality by 36.0% (range 26.9%-43.8%). Community-based ART with TPT care reduced gender disparities in TB mortality rates, with a projected 54 more deaths annually among men than women (range 11-103) after 10 years of community-based care versus 109 (range 41-182) in standard care. Over 10 years, the mean cost per DALY averted by community-based ART with TPT care was $846 USD (range $709-$1012). CONCLUSIONS: By substantially increasing coverage of ART and TPT, community-based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV-associated TB and reduce TB gender disparities.

Access to primary health care: perspectives of primary care physicians and community stakeholders.

BACKGROUND: Action on the social determinants of health is important to strengthen primary health care and promote access among underserved populations. We report on findings from stakeholder consultations undertaken at one of the Canadian sites of the Innovative Models Promoting Access-to-Care Transformation (IMPACT) program, as part of the development of a best practice intervention to improve access to primary health care. The overarching objective of this qualitative study was to understand the processes, barriers, and facilitators to connect patients to health enabling community resources (HERs) to inform a patient navigation model situated in primary care. METHODS: Focus groups and interviews were conducted with primary care physicians, and community health and social service providers to understand their experiences in supporting patients in reaching HERs. Current gaps in access to primary health care and the potential of patient navigation were also explored. We applied Levesque et al., (2013) access framework to code the data and four themes emerged: (1) Approachability and Ability to Perceive, (2) Acceptability and Ability to Seek, (3) Availability and Accommodation, and Ability to Reach, and (4) Appropriateness. RESULTS: Determinants of access included patient and provider awareness of HERs, the nature of the patient-provider relationship, funding of HERs, integration of primary and community care services, and continuity of information. Participants' perspectives about the potential scope and role of a patient navigator provided valuable insight for the development of the Access to Resources in the Community (ARC) navigation model and how it could be embedded in a primary care setting. CONCLUSION: Additional consultation with key stakeholders in the health region is needed to gain a broader understanding of the challenges in caring for primary care patients with social barriers and how to support them in accessing community-based primary health care to inform the design of the ARC intervention.

Community-oriented primary care footprinting: An undergraduate programme experience.

The Nelson Mandela Fidel Castro (NMFC) programme, a government initiative to address healthcare inequities in South Africa, focuses on the training of indigenous students to become competent healthcare practitioners. A collaboration combining training in a Cuban primary care, preventative system with integration in a South African institution within a quadruple disease burdened healthcare system. This article reflects on integration experience at the University of Witwatersrand, a programme pedagogically positioned within a workplace-based, situated learning framework. Since 2022, community-oriented primary care (COPC) projects became part of the integrated primary care and family medicine learning objectives. This article summarises the experience of the 2021-2022 cohort and calls for the strengthening of undergraduate medical education curricula with learning objectives reflective of social accountability.Contribution: This article spotlights work in the undergraduate space around teaching and experiential learning of community-oriented primary care in line with the journal's scope.

Community-based postnatal care model: Catalyst for management of mothers and neonates.

BACKGROUND:  Early postnatal discharge is perceived as a factor that contributes to the possibilities of the maternal, neonatal complications and deaths. The implementation of the community-based postnatal care model is crucial to mitigate the morbidity and mortality of postnatal women and neonates during the first weeks of delivery. A community-based postnatal care model was developed for the management of neonates during the postnatal care period in the community. OBJECTIVES:  The study aims to share the developed community-based postnatal care model that could assist postnatal women in the management of neonates. METHOD:  Empirical findings from the main study formed the basis for model development. The model development in this study was informed by the work of Walker and Avant; Chinn and Kramer Dickoff, James and Wiedenbach; and Chinn and Jacobs. RESULTS:  The results indicated that there was no community-based postnatal care model developed to manage neonates. The model is described using the practice theory of Dickoff, James and Wiedenbach elements of agents, recipients, context, process, dynamics and outcomes within the community context of the postnatal care period. The model was further described by Chinn and Krammer following the assumptions of the model, concept definition, relation statement and nature of structure. CONCLUSION:  The utilisation of the model is critical and facilitates the provision of an enabling and supportive community-based context by primary caregivers for the effective management of neonates.Contribution: This study provides a reference guide in the provision of community-based postnatal care by postnatal women after discharge from healthcare facilities.

Effectiveness and cost-effectiveness of community-based directly observed treatment (DOT) versus health facility-based DOT of tuberculosis in Africa: protocol for a systematic review and meta-analysis.

BACKGROUND: Tuberculosis (TB) remains a significant global health challenge, especially prevalent in the WHO African region. The WHO's End TB Strategy emphasises effective treatment approaches such as directly observed therapy (DOT), yet the optimal implementation of DOT, whether through health facility-based (HF DOT) or community-based (CB DOT) approaches, remains uncertain. OBJECTIVE: To conduct a systematic comparison of the effectiveness and cost-effectiveness of Community-Based Directly Observed Treatment (CB DOT) versus Health Facility-Based Directly Observed Treatment (HF DOT) for tuberculosis (TB) treatment in African settings. METHODS: We will conduct a systematic review and meta-analysis following Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will search PubMed, Embase, Web of Science, Scopus and the Cochrane Library for articles published up to 30 March 2023, without date restrictions. Eligible studies must be full economic evaluations conducted in African countries, comparing CB DOT to HF DOT regarding treatment outcomes and costs. Exclusion criteria include non-English, non-peer-reviewed or studies lacking caregiver involvement in CB DOT, health facility-based DOT comparison, direct comparability between CB DOT and HF DOT, significant selection bias or non-economic evaluations. Data extraction will be performed independently by reviewers, and meta-analyses will use STATA software. To pool the data, a random-effect model will be applied, and quality assessment of the studies will be conducted. ETHICS AND DISSEMINATION: Ethical approval is not required as the study will use previously published articles available publicly. Findings will be presented at international and national conferences and published in open-access, peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42023443260.

Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design.

BACKGROUND: Integrated Community Case Management (ICCM) of common childhood illness is one of the global initiatives to reduce mortality among under-five children by two-thirds. It is also implemented in Ethiopia to improve community access and coverage of health services. However, as per our best knowledge the implementation status of integrated community case management in the study area is not well evaluated. Therefore, this study aimed to evaluate the implementation status of the integrated community case management program in Gondar City, Northwest Ethiopia. METHODS: A single case study design with mixed methods was employed to evaluate the process of integrated community case management for common childhood illness in Gondar town from March 17 to April 17, 2022. The availability, compliance, and acceptability dimensions of the program implementation were evaluated using 49 indicators. In this evaluation, 484 mothers or caregivers participated in exit interviews; 230 records were reviewed, 21 key informants were interviewed; and 42 observations were included. To identify the predictor variables associated with acceptability, we used a multivariable logistic regression analysis. Statistically significant variables were identified based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value. The qualitative data was recorded, transcribed, and translated into English, and thematic analysis was carried out. RESULTS: The overall implementation of integrated community case management was 81.5%, of which availability (84.2%), compliance (83.1%), and acceptability (75.3%) contributed. Some drugs and medical equipment, like Cotrimoxazole, vitamin K, a timer, and a resuscitation bag, were stocked out. Health care providers complained that lack of refreshment training and continuous supportive supervision was the common challenges that led to a skill gap for effective program delivery. Educational status (primary AOR = 0.27, 95% CI:0.11-0.52), secondary AOR = 0.16, 95% CI:0.07-0.39), and college and above AOR = 0.08, 95% CI:0.07-0.39), prescribed drug availability (AOR = 2.17, 95% CI:1.14-4.10), travel time to the to the ICCM site (AOR = 3.8, 95% CI:1.99-7.35), and waiting time (AOR = 2.80, 95% CI:1.16-6.79) were factors associated with the acceptability of the program by caregivers. CONCLUSION AND RECOMMENDATION: The overall implementation status of the integrated community case management program was judged as good. However, there were gaps observed in the assessment, classification, and treatment of diseases. Educational status, availability of the prescribed drugs, waiting time and travel time to integrated community case management sites were factors associated with the program acceptability. Continuous supportive supervision for health facilities, refreshment training for HEW's to maximize compliance, construction clean water sources for HPs, and conducting longitudinal studies for the future are the forwarded recommendation.

Barriers and benefits of mHealth for community health workers in integrated community case management of childhood diseases in Banda Parish, Kampala, Uganda: a cross-sectional study.

BACKGROUND: Low-quality data presents a significant challenge for community health workers (CHWs) in low and middle-income countries (LMICs). Mobile health (mHealth) applications offer a solution by enabling CHWs to record and submit data electronically. However, the barriers and benefits of mHealth usage among CHWs in informal urban settlements remain poorly understood. This study sought to determine the barriers and benefits of mHealth among CHWs in Banda parish, Kampala. METHODS: This qualitative study involved 12 key informant interviews (KIIs) among focal persons from Kampala City Council Authority (KCCA) and NGOs involved in data collected by CHWs, and officials from the Ministry of Health (MOH) and two mixed-sex Focused Group Discussions (FGDs) of CHWs from Banda parish, Kampala district. Data analysis utilised Atlas Ti Version 7.5.7. Thematic analysis was conducted, and themes were aligned with the social-ecological model. RESULTS: Three themes of institutional and policy, community and interpersonal, and individual aligning to the Social ecological model highlighted the factors contributing to barriers and the benefits of mHealth among CHWs for iCCM. The key barriers to usability, acceptability and sustainability included high training costs, CHW demotivation, infrastructure limitations, data security concerns, community awareness deficits, and skill deficiencies. Conversely, mHealth offers benefits such as timely data submission, enhanced data quality, geo-mapping capabilities, improved CHW performance monitoring, community health surveillance, cost-effective reporting, and CHW empowering with technology. CONCLUSION: Despite limited mHealth experience, CHWs expressed enthusiasm for its potential. Implementation was viewed as a solution to multiple challenges, facilitating access to health information, efficient data reporting, and administrative processes, particularly in resource-constrained settings. Successful mHealth implementation requires addressing CHWs' demotivation, ensuring reliable power and network connectivity, and enhancing capacity for digital data ethics and management. By overcoming these barriers, mHealth can significantly enhance healthcare delivery at the community level, leveraging technology to optimize resource utilization and improve health outcomes. mHealth holds promise for transforming CHW practices, yet its effective integration necessitates targeted interventions to address systemic challenges and ensure sustainable implementation in LMIC contexts.

A qualitative exploration of professionals' perspectives on the implementation of reablement intervention programs in community care.

Reablement is considered a complex intervention due to its multicomponent, person-centered, holistic approach promoting older adults' active participation in daily activities. It is important to consider the unique context in which complex interventions are implemented, as contextual factors may interact and influence implementation outcomes. As part of the European TRANS-SENIOR project, this qualitative study aimed to gain insight into professionals' experiences with reablement implementation in Dutch community care. Using the Consolidated Framework for Implementation Research, four focus groups were conducted comprising 32 professionals. Two groups were formed: one at operational level, including therapists, nursing staff, social workers, and domestic support; and one at organizational/strategic level, including project leaders, managers, directors, municipality representatives and health insurers. Participating care organizations had at least 6 months of experience with deploying and implementing reablement. Findings reflected three themes: (1) strength of interdisciplinary collaboration; highlighting significance of sharing goals and beliefs, (2) integrating the reablement philosophy into the organization; underscoring managements role in fostering support across all organizational layers, and (3) achieving a culture change in the healthcare system; emphasizing current funding models impeding value-based care tailored to the individual's goals and needs. The results offer valuable insights for implementation of complex interventions, like reablement.

Environmental Modifications for People With Intellectual and Developmental Disabilities: A Policy Analysis of Medicaid Home- and Community-Based Services.

IMPORTANCE: Environmental modifications are targets for occupational therapy intervention because they support activities of daily living, self-efficacy, personal control, independence, and community living for people with intellectual and developmental disabilities (IDDs). OBJECTIVE: To examine how environmental modifications were provided to people with IDDs through Medicaid home- and community-based services (HCBS) waivers across the United States in fiscal year (FY) 2021. DESIGN: Using a mixed-methods policy analysis, we examined FY 2021 Medicaid HCBS 1915(c) waivers from across the United States to examine whether, and how, states provided environmental modifications to people with IDDs. RESULTS: In FY 2021, 35 states projected spending $68.8 million on environmental modifications for 12,671 people with IDDs. The purpose of environmental modifications was most often to promote the health, welfare, and safety of people with IDDs (82.68%), and to promote their independence (69.29%). The most common examples of environmental modifications included ramps and/or lifts (70.08%), widening doorways and/or hallways (61.42%), bathroom modifications (58.27%), specialized electrical and/or plumbing for medical equipment (54.33%), and grab bars and/or handrails (53.54%). CONCLUSIONS AND RELEVANCE: HCBS waiver data on environmental modifications for people with IDDs enhances an understanding of this funding source and provides a foundation of advocacy for occupational therapy practitioners to support people with IDDs with living, as well as aging, in the community rather than in institutions. An expansion of environmental modifications in HCBS for people with IDDs aligns with the aim of Medicaid HCBS waivers to promote community integration, self-determination, and independence, which are all benefits of environmental modifications. Plain-Language Summary: This study can help occupational therapy practitioners determine what funding sources are available in their state to help their clients with intellectual and developmental disabilities access environmental modifications. The findings can also help guide advocacy and lobbying efforts to expand access to environmental modifications.

Community medical service construction: identifying factors that influence medical choice for patients with non-communicable chronic diseases in the Southwest China.

BACKGROUND: Community medical institutions play a vital role in China's healthcare system. While the number of these institutions has increased in recent years, their construction contents remain insufficient. The potential of community medical institutions in preventing, screening, diagnosing, and treating non-communicable chronic diseases (NCDs) has not been fully utilized. This study aims to assess the status of construction contents in community medical institutions in Southwest China and examine how these contents influence the medical choices of NCD patients. METHODS: Descriptive statistics were used to evaluate the construction content of community medical institutions. Multiple-sets of multinomial logistic regression were employed to analyze the associations and marginal impacts between construction content and medical choices. Shapley value analysis was applied to determine the contribution and ranking of these impacts. RESULTS: Descriptive statistics revealed satisfactory construction contents in community medical institutions. Notably, factors such as service attitude, nursing services, expert consultations, charging standards, medical equipment, medical examinations, privacy protection, and referrals significantly influenced medical choices. Among these, service attitude, charging standards, and privacy protection had the most significant marginal improvement effects on NCD patients' choices, with improvements of 12.7%, 10.2%, and 5.9%, respectively. The combined contribution of privacy protection, medical examinations, service attitude, charging standards, and nursing services to medical choices exceeded 80%. CONCLUSION: Optimizing the service contents of community institutions can encourage NCD patients to seek medical care at grassroots hospitals. This study addresses crucial gaps in existing literature and offers practical insights for implementing new medical reform policies, particularly in underdeveloped regions of Southwest China focusing on hierarchical diagnosis and treatment.

Sustainable Participation in Community Health Programs to Promote a Healthy Lifestyle and Prevent and Protect against Dementia among Rural Taiwanese Middle-Aged and Older Adults.

BACKGROUND: Resource and economic constraints limit access to health care in rural populations, and consequently, rates of chronic illnesses are higher in this population. Further, little is known about how rural populations adopt active and healthy lifestyle behavior for dementia prevention. OBJECTIVES: This study aimed to explore the impact of modification in lifestyle behaviors on changes in cognitive function among middle-aged and older adults living in a rural area of Taiwan. DESIGN: In this prospective longitudinal study, changes in lifestyle and cognitive function were compared between the experimental and control groups. SETTING: Six rural community care stations were randomly cluster sampled in southern Taiwan. PARTICIPANTS: A total of 155 participants were enrolled and classified into two groups according to their community activity participation rate (CAPR). The control group (n=68) had a CAPR < 1x/month, and the experimental group (n=87) had a CAPR ≥ 1x/month. MEASUREMENTS: Cognitive function of the participants was measured using the MMSE scale. Lifestyle behaviors were measured using a self-designed questionnaire based on the Transtheoretical Model. RESULTS: From 2018-2020, the experimental group successfully maintained a healthy lifestyle. The MMSE score in the experimental group was significantly higher in the 3rd year than that in the control group (25.37 vs 22.56, p < 0.001). CONCLUSIONS: Sustainable community participation and adopting a healthy lifestyle could effectively maintain the cognitive function of the study participants. However, more needs to be done to support rural older adults to maintain a healthy diet and control their weight.

A community based intervention to modify preventive behaviors of cutaneous leishmaniasis in children: a randomized controlled trial based on PRECEDE PROCEED model.

OBJECTIVES: Iran ranks among the top six countries globally with a significant incidence of Cutaneous Leishmaniasis (CL). Using planning models is one community-based intervention to promote preventive behaviors. The purpose of our study was to evaluate the effectiveness of the PRECEDE-PROCEED model (PPM) in modifying preventive behaviors related to CL in children through mother training in a community intervention. METHODS: A randomized controlled trial based on the PPM model was conducted on 168 mothers (intervention (n = 84) and control group (n = 84) with 10 years old children in the rural areas of Iran. Mothers from 7 village areas were randomly allocated to the intervention (2 village) and control groups (5 village). The intervention group received a program comprising eight 90-minute training sessions and environmental interventions. In this study, we utilized the PPM as a framework to design the questionnaires on Leishmaniosis prevention behavior. Participants in both groups completed the questionnaires at baseline (before the intervention), immediately after the intervention, and at the 2-month follow-up. Analysis of the data was conducted utilizing SPSS20, with statistical significance set at p < 0.05. RESULTS: Compared to the control group, the intervention group showed significant increases in knowledge, enabling factors, reinforcing factors, attitude, and preventive behaviors related to Cutaneous Leishmaniasis over time from baseline to follow-up (P < 0.001). No significant differences (P > 0.05) were observed in the alterations of the PPM construct, knowledge, and preventive behaviors within the control group from pre-intervention to follow-up. CONCLUSIONS: Community (education and environmental) intervention based on PPM is feasible and acceptable to modify preventive behaviors of Cutaneous Leishmaniasis in children by increasing a mother's knowledge and attitude as well as changing enabling and reinforcing factors. TRIAL REGISTRATION: IRCT20160619028529N8.

"We might not have been in hospital, but we were frontline workers in the community": a qualitative study exploring unmet need and local community-based responses for marginalised groups in Greater Manchester during the COVID-19 pandemic.

BACKGROUND: The response to the COVID-19 pandemic saw a significant increase in demand for the voluntary, community, faith and social enterprise (VCFSE) sector to provide support to local communities. In Greater Manchester (GM), the VCFSE sector and informal networks provided health and wellbeing support in multiple ways, culminating in its crucial supportive role in the provision of the COVID-19 vaccination rollout across the GM city region. However, the support provided by the VCFSE sector during the pandemic remains under-recognised. The aims of the study were to: understand the views and experiences of marginalised communities in GM during the COVID-19 pandemic; explore how community engagement initiatives played a role during the pandemic and vaccine rollout; assess what can be learnt from the work of key stakeholders (community members, VCFSEs, health-system stakeholders) for future health research and service delivery. METHODS: The co-designed study utilised a participatory approach throughout and was co-produced with a Community Research Advisory Group (CRAG). Focus groups and semi-structured interviews were conducted remotely between September-November 2021, with 35 participants from local marginalised communities, health and care system stakeholders and VCFSE representatives. Thematic framework analysis was used to analyse the data. RESULTS: Local communities in GM were not supported sufficiently by mainstream services during the course of the COVID-19 pandemic, resulting in increased pressure onto the VCFSE sector to respond to local communities' need. Community-based approaches were deemed crucial to the success of the vaccination drive and in providing support to local communities more generally during the pandemic, whereby such approaches were in a unique position to reach members of diverse communities to boost uptake of the vaccine. Despite this, the support delivered by the VCFSE sector remains under-recognised and under-valued by the health system and decision-makers. CONCLUSIONS: A number of challenges associated with collaborative working were experienced by the VSCE sector and health system in delivering the vaccination programme in partnership with the VCFSE sector. There is a need to create a broader, more inclusive health system which allows and promotes inter-sectoral working. Flexibility and adaptability in ongoing and future service delivery should be championed for greater cross-sector working.