Adapting a health video library for use in Afghanistan: provider-level acceptability and lessons for strengthening operational feasibility

Lara Lorenzetti,Catherine S Todd,Lisa S Dulli,Amy Weissman,Sayed Haroon Rastagar,Sharif A H Ahmadzai,Shafiqullah Hemat,Subarna Pradhan,Jenae Tharaldson

doi:10.1186/s12960-020-00477-9

Abstract

BackgroundCommunity health workers (CHWs) in Afghanistan are a critical care extender for primary health services, including reproductive, maternal, neonatal, and child health (RMNCH) care. However, volunteer CHWs face challenges including an ever-expanding number of tasks and insufficient time to conduct them. We piloted a health video library (HVL) intervention, a tablet-based tool to improve health promotion and counseling by CHWs. We qualitatively assessed provider-level acceptability and operational feasibility.MethodsCHWs implemented the HVL pilot in three rural districts of Balkh, Herat, and Kandahar provinces. We employed qualitative methods, conducting 47 in-depth interviews (IDIs) with male and female CHWs and six IDIs with community health supervisors. We used semi-structured interview guides to explore provider perceptions of program implementation processes and solicit feedback on how to improve the HVL intervention to inform scale-up. We conducted a thematic analysis.ResultsCHWs reported that the HVL increased time efficiencies, reduced work burden, and enhanced professional credibility within their communities. CHWs felt video content and format were accessible for low literacy clients, but also identified challenges to operational feasibility. Although tablets were considered easy-to-use, certain technical issues required continued support from supervisors and family. Charging tablets was difficult due to inconsistent electricity access. Although some CHWs reported reaching most households in their catchment area for visits with the HVL, others were unable to visit all households due to sizeable populations and gender-related barriers, including women’s limited mobility.ConclusionsThe HVL was acceptable and feasible for integration into existing CHW duties, indicating it may improve RMNCH counseling, contributing to increased care-seeking behaviors in Afghanistan. Short-term challenges with technology and hardware can be addressed through continued training and provision of solar chargers. Longer-term challenges, including tablet costs, community coverage, and gender issues, require further consideration with an emphasis on equitable distribution.

Highlights

With a predominantly rural population, Afghanistan struggles with a low health workforce density [1, 2]
To enhance Community health worker (CHW)-led community-based RMNCH counseling and service demand creation efforts, we developed and pilot-tested the tablet-based health video library (HVL) intervention, which was implemented by CHWs in three rural districts of Afghanistan
When batteries depleted during meetings, CHWs reported counseling without tablets or ending meetings prematurely

Summary

Introduction

With a predominantly rural population, Afghanistan struggles with a low health workforce density [1, 2]. Geographic imbalances in formal health worker distribution, for female providers, are pronounced in areas facing insecurity or socio-cultural barriers limiting coverage [2]. This presents a major challenge for delivering health services in Afghanistan, which has the highest maternal and infant mortality ratios in Asia, despite a decline over the past 15 years [3]. Community health workers (CHWs) are fundamental to health service provision in Afghanistan, especially for women and children [4] These volunteers provide health promotion, basic care, and referrals to more than 70% of the population [5].

Methods

Results

Discussion

Conclusion