Training Primary Health Workers Research Articles

Compliance for Community-Based Cervical Cancer Screening Program among Women of Age 30-65 Years Residing in Low Socioeconomic Settings of Mumbai, India.

Low participation in screening and poor follow-up are major challenges in implementing population based screening in developing countries. Determinants of participation in a community-based organized cervical cancer screening program are discussed here. The objectives were to study factors determining compliance of women for cervical cancer screening in an urban low socioeconomic setting. Community-based service program was conducted for screening uterine cervix cancers with a visual inspection of the cervix on the application of 5% acetic acid by trained primary health workers. The process involved the selection of clusters, household surveys, health education, and screening of eligible women for uterine cervix cancer. Logistic regression analysis was conducted to identify determinants of participation in cervical cancer screening. A total of 138,383 population were surveyed, of which 21,422 eligible women were contacted and 16,424 (82.50%) complied for screening. According to the results of univariate and multivariate analysis, women belonging to the age group of 30-39 (80.69%), literate women with school level or education up to Senior College (78.97% and 80.86%) (odds ratio [OR], 1.323; P ≤ 0.001) and (OR, 1.402; P ≤ 0.001), belonging to Hindu religion (77.20%), speaking Marathi (77.07%), and with a family history of cancer (81.93%) had higher participation for screening, while women belonging to the Muslim community (73.95%) (OR, 0.743; P ≤ 0.001), speaking other than Marathi and Hindi language (73%) (OR, 0.872; P = 0.017), illiterate women (70.71%), and graduate women (70.78%) had lower participation. High compliance can be achieved by providing good-quality health education and setting up of screening clinics in vicinity of participating women.

Determinants of Compliance for Breast and Cervical Cancers Screening among Female Police Personnel of Mumbai, India—A Cross-Sectional Study

Abstract Introduction Women working in police force have unique and vital role to play in law enforcement. Although these women have established a secured place for themselves in the police force, they are exposed to several behavioral and health risks apart from job stress. All these can have potentially serious consequences on their well-being. Objectives To determine the compliance to breast and uterine cervical cancers screening and identify predictors of participation in breast and cervical cancers screening among women police personnel. Materials and Methods This is a cross-sectional study conducted among the Mumbai police personnel during the period 2019 to 2021. All women working for Mumbai police work force in 12 zones were invited to participate in the study. Temporary clinics for screening were set up in different police stations and eligible participants were enrolled after obtaining written informed consent. This was followed by sociodemographic and risk factor assessment, health education program, screening for common cancers conducted by trained primary health workers (breast by clinical breast examination and uterine cervix by visual inspection with 5% acetic acid). Screen positives were referred according to predefined referral criteria for further investigations and management. Results A total of 3,017 police women were contacted, among them, 2,629 (87.14%) were eligible for screening, 2,609 (99.24%) participated in health education, and 1,839 (69.95%) complied for breast or cervical cancer screening. Further, compliance for screening of breast and uterine cervix were 1,837 (91.67%) and 1,297 (64.72%). A total of 256 (13.94%) and 217 (11.81%) police women were screen positives for breast and cervical cancers. According to multivariate logistic regression analysis, women younger than 50 years, those who were not married or were widowed or separated, postmenopausal women, and those who did not have shift duties had higher compliance for breast and cervix cancers screening. Conclusion Good participation for breast and cervical cancers screening was seen among the women police personnel. This study has demonstrated that awareness and screening by simple low-cost methods for breast and cervical cancers screening is easily implementable and can be replicated among the women police force in different states of India.

Acceptability and Potential Effectiveness of eHealth Tools for Training Primary Health Workers From Nigeria at Scale: Mixed Methods, Uncontrolled Before-and-After Study

BackgroundThe in-service training of frontline health workers (FHWs) in primary health care facilities plays an important role in improving the standard of health care delivery. However, it is often expensive and requires FHWs to leave their posts in rural areas to attend courses in urban centers. This study reports the implementation of a digital health tool for providing video training (VTR) on maternal, newborn, and child health (MNCH) care to provide in-service training at scale without interrupting health services. The VTR intervention was supported by satellite communications technology and existing 3G mobile networks.ObjectiveThis study aims to determine the feasibility and acceptability of these digital health tools and their potential effectiveness in improving clinical knowledge, attitudes, and practices related to MNCH care.MethodsA mixed methods design, including an uncontrolled pre- and postquantitative evaluation, was adopted. From October 2017 to May 2018, a VTR mobile intervention was delivered to FHWs in 3 states of Nigeria. We examined changes in workers’ knowledge and confidence in delivering MNCH services through a pre- and posttest survey. Stakeholders’ experiences with the intervention were explored through semistructured interviews that drew on the technology acceptance model to frame contextual factors that shaped the intervention’s acceptability and usability in the work environment.ResultsIn total, 328 FHWs completed both pre- and posttests. FHWs achieved a mean pretest score of 51% (95% CI 48%-54%) and mean posttest score of 69% (95% CI 66%-72%), reflecting, after adjusting for key covariates, a mean increase between the pre- and posttest of 17 percentage points (95% CI 15-19; P<.001). Variation was identified in pre- and posttest scores by the sex and location of participants alongside topic-specific areas where scores were lowest. Stakeholder interviews suggested a wide acceptance of VTR Mobile (delivered via digital technology) as an important tool for enhancing the quality of training, reinforcing knowledge, and improving health outcomes.ConclusionsThis study found that VTR supported through a digital technology approach is a feasible and acceptable approach for supporting improvements in clinical knowledge, attitudes, and reported practices in MNCH. The determinants of technology acceptance included ease of use, perceived usefulness, access to technology and training contents, and the cost-effectiveness of VTR, whereas barriers to the adoption of VTR were poor electricity supply, poor internet connection, and FHWs’ workload. The evaluation also identified the mechanisms of the impact of delivering VTR Mobile at scale on the micro (individual), meso (organizational), and macro (policy) levels of the health system. Future research is required to explore the translation of this digital health approach for the VTR of FHWs and its impact across low-resource settings to ameliorate the financial and time costs of training and support high-quality MNCH care delivery.Trial RegistrationISRCTN Registry 32105372; https://www.isrctn.com/ISRCTN32105372

Determinants of Compliance to Population-Based Oral Cancer Screening Program among low Socioeconomic Women in Mumbai, India.

Background:The use of tobacco, especially smokeless variety, is common and culturally accepted among Indian women. Hence, oral cavity cancers rank as the fourth most common cancers among Indian women.Objectives:The objectives of this study were to study factors determining compliance of women for oral cancer screening in a population-based program in Mumbai and to create awareness among women regarding ill effects of tobacco and importance of oral cancer screening.Materials and Methods:This is a community-based organized service program for awareness and screening of oral cavity cancers among women residing in low socioeconomic areas of Mumbai, India. Screening was conducted by oral visual inspection by trained primary health workers (PHWs). Univariate and multivariate logistic regression analyses were conducted to identify predictors of participation in oral cancer screening.Results:138,383 population was surveyed, out of which 13,492 eligible women were enlisted for oral cancer screening. Among these, 12,495 were contacted and 11,895 (95.12%) women participated in a cancer awareness program and 11,768 (94.18%) participated in oral cancer screening. According to results of multivariate logistic regression analysis, women belonging to Hindu religion 94.57%, with mother tongue Marathi 94.76%, and with family history of cancer 95.84% complied significantly higher to oral cancer screening as compared to other women.Conclusion:This program has assisted in identifying predictors of compliance to oral cavity screening. Furthermore, it demonstrates that good compliance can be achieved through multiple household visits, personal invitation during camps, organizing well-planned Health Education Program, and the use of simple, low-cost visual inspection test performed by trained PHWs.

Determinants of Compliance to Breast Cancer Screening and Referral in Low Socio-Economic Regions of Urban India.

Background:Breast cancer (BC) is the most common cancer among women globally and also in India. Early detection by screening is likely to reduce mortality and improve survival. To study the determinants of compliance to BC screening and referral by women in a community based BC screening programme in urban India.Methods:A community-based one-time cancer screening programme, implemented in the urban slums of Mumbai, India. The programme involves screening for breast cancer by Clinical Breast Examination (CBE) performed by trained primary health workers (PHWs), referral of screen-positive women to the nodal hospital for further investigations, confirmation of diagnosis and treatment. Univariate and multivariate logistic regression analysis in SPSS version 16 was used.Results:The compliance to screening, referral and treatment were 90.58%, 74.22% and 100% respectively. The results of multivariate logistic regression analysis demonstrate literate women, having family history of cancer, with tobacco habit, being treated for breast abnormalities, being ever pregnant and having history of contraceptive use were positive predictors while, women belonging to Muslim religion or speaking mother-tongue other than Marathi or Hindi were negative predictors of participation to screening. Educational status was the only significant predictor of compliance to referral. Screen-positive women with education of secondary school level or more were more likely to comply with referral.Conclusions:The programme ensured good compliance with screening, referral and treatment indicating feasibility and acceptability of CBE based BC screening programme by the community.

Effectiveness of non-medical health worker-led counselling on psychological distress: a randomized controlled trial in rural Nepal.

An essential strategy to increase coverage of psychosocial treatments globally is task shifting to non-medical counsellors, but evidence on its effectiveness is still scarce. This study evaluates the effectiveness of lay psychosocial counselling among persons with psychological distress in a primary health care setting in rural Nepal. A parallel randomized controlled trial in Dang, rural Nepal (NCT03544450). Persons aged 16 and older attending primary care and with a General Health Questionnaire (GHQ-12) score of 6 or more were randomized (1:1) to receive either non-medical psychosocial counselling (PSY) or enhanced usual care (EUC). PSY was provided by lay persons with a 6-month training and consisted of 5-weekly counselling sessions of 35-60 min with a culturally adapted solution-focused approach. EUC was provided by trained primary health workers. Participants were followed up at 1 (T1) and 6 months (T2). The primary outcome, response to treatment, was the reduction of minimum 50% in the Beck Depression Inventory (BDI) score. A total of 141 participants, predominantly socially disadvantaged women, were randomized to receive PSY and 146 to EUC. In the PSY, 123 participants and 134 in the EUC were analysed. In PSY, 101 participants (81.4%) had a response compared with 57 participants (42.5%) in EUC [percentage difference 39.4% (95% CI 28.4-50.4)]. The difference in BDI scores at T2 between PSY and EUC was -7.43 (95% CI -9.71 to -5.14). Non-medical (lay) psychosocial counselling appears effective in reducing depressive symptoms, and its inclusion in mental health care should be considered in low-resource settings.

Cervical Cancer Screening in Low Resource Settings: Cytology versus HPV Triage for VIA Positive Women.

Background:The objective of the study is to comparatively evaluate performance of human papillomavirus (HPV) hybrid capture 2 (HC2) and cytology as triage tests among visual inspection after application of 3–5% acetic acid (VIA) screen positive women, thus aiming to reduce the referral burden.Methods:The community-based cross sectional cervical cancer screening with VIA was conducted among women aged between 30 and 65, residing in selected low socio-economic areas of Mumbai, India, during October 2010–March 2017. After obtaining informed consent, delivering health education and collecting socio-demographic data, participants were offered VIA screening by trained primary health workers. The VIA screen positive women underwent cytology, HPV HC2 and diagnostic colposcopy at nodal hospital. Women with positive colposcopy underwent cervical biopsies.Results:231 VIA positive women underwent cytology and HPV HC2 test, followed by colposcopy. Cervical biopsies were obtained in 83 cases. The sensitivity and specificity in detecting ≥ CIN 2 were 77.8 and 92.3 for HC2 and 66.7 and 98.2 for cytology. The false positivity and negativity rates were 7.7 and 22.2 for HC2 and 1.8 and 33.3 for cytology.Conclusions:HPV HC2 reduces referrals to larger extent and misses fewer cases compared to cytology, thus appearing a better triage test among VIA positive women.

Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts

BackgroundVisual impairment is a public health problem in sub-Saharan Africa, affecting nearly 5% of the population. Efforts to combat avoidable causes have been hampered by weak health systems and little evidence exists to suggest what interventions may be effective to improve the situation. Despite this, there are calls to promote some specific interventions, one of which being the closer integration of eye health services into health systems, often focusing on training primary health workers to deliver basic eye health services. This study seeks to understand how eye health services are delivered by primary health workers who have received training and what constraints remain to effective service provision.MethodsThis was a qualitative investigation into the experiences of 20 primary health workers trained in primary eye care and eight key informants working within specialist eye health services or regional and district health management positions in two districts in Tanzania.ResultsDespite feeling confident in their own eye care skills, most primary health workers felt constrained in the services they could provide to their communities by insufficient resources needed for diagnosis and treatment, and by lack of systematic supportive supervision to their work. Specialist ophthalmic staff were aware of this issue, although for the most part they felt it was not within their capacity to remedy and that it fell within the remit of general health managers. Many participants discussed the low support to eye health from the national government, evidenced through the lack of dedicated funding to the area and traditional reliance on outside funds including international charities.ConclusionsAlthough training of primary health workers is useful, it is recognised that is not sufficient to address the burden of eye health disease present in rural communities in Tanzania. It is likely that broader engagement with the general health system, and most likely with the private sector, will be necessary to improve the coverage of eye health care to remote and poor communities such as those in Morogoro. Further investment is needed to develop innovative approaches to delivering eye health services, including preventative, curative and rehabilitative services.

Mixed methods evaluation of a primary eye care training programme for primary health workers in Morogoro Tanzania.

BackgroundThere are 285 million people with visual impairment (VI) worldwide including 39 million who are blind; 15 % of those with VI live in Africa, and around 80 % of VI is preventable or treatable with the right equipment, information and skills. The scarcity of human resources for eye health, particularly in Sub-Saharan Africa, is a key challenge towards achieving this goal. Therefore training primary health workers (PHW) in providing eye-care services has been seen by some authors as a way to improve access to eye-care services in remote communities. However, the package of interventions which could be effectively delivered for eye-care at the primary-care level or the set of skills and competencies that PHWs need has not yet been delineated. The aim of the study was to evaluate the effectiveness of a four day training programme of PHWs in primary eye-care conducted in Morogoro, Tanzania in 2010/2011.MethodsA mixed methods study using pre- and immediate post-training knowledge assessment of 60 trainees, and in-depth face to face interviews with 20 PHWs and 8 service managers 2 to 3 years after the training.ResultsPre-and immediate post-training assessments indicated improvement in health worker knowledge about eye-care in the short term. Qualitative investigations 2 to 3 years after the training showed that although staff could make the correct management decisions when presented with eye-health problems, they often could not make a correct diagnosis. PHWs and managers reported satisfaction with the content of the training but some of the less well qualified staff found it overwhelming. Theoretical teaching was appreciated by most participants but almost all suggested increasing the time spent on acquiring skills. The training manual was accepted by many and some improvements were recommended. All interviewed PHWs were keen to improve their skills and knowledge. Acquired skills and knowledge were used for identification, referral of patients and for eye-health promotion.ConclusionThe training program in Morogoro was considered by PHWs as broadly successful and satisfying in terms of content, methods and duration of training. However, any future programme needs to be considered within the context of strengthening wider health systems.

Perceptions and experiences of perinatal mental disorders in rural, predominantly ethnic minority communities in northern Vietnam.

BackgroundPreliminary research has suggested that perinatal mental disorders (PMDs), including post-partum depression, are prevalent in Vietnam. However the extent to which these disorders are recognized at the community level remains largely undocumented in the literature. PMDs have also never been investigated within Vietnam’s significant ethnic minority populations, who are known to bear a greater burden of maternal and infant health challenges than the ethnic majority.ObjectiveTo investigate knowledge and perceptions of PMDs and their treatments at the community level in a rural, predominantly ethnic minority region of northern Vietnam.MethodsQualitative semi-structured interviews were conducted on the topic of common PMDs. Participant groups were primary health workers (PHWs) working at local community health centers, and pregnant or postpartum women enrolled in a program for maternal and infant health that was not mental health related. Interviews included vignette scenarios that asked respondents to interpret cases of women experiencing PMDs, as well as open-ended questions about mental disorders and their treatments.ResultsTwelve PHWs and 14 perinatal women completed the study. Major themes that emerged from the interviews included (1) Family relationships impact psychological well-being, (2) Nutrition contributes to perinatal mental health, (3) Both traditional and western medicine play roles in perinatal health, (4) There was a lack of personal experience with women experiencing PMDs, (5) Descriptions of mental health symptoms focused on behaviours, and (6) Community care is the primary mental health support.ConclusionsPHWs reported having almost never treated a woman with a PMD. However, anecdotal evidence from the women interviewed suggests that there are incidents of mental disorders during the perinatal period that go largely unaddressed. Willingness to present to primary care appears to be high, and presents an opportunity to address this need by training PHWs in effective screening, treatment, and referral. Such training should account for culturally specific presentations of mental disorders as well as the importance of the patient’s social context. To the best of the author’s knowledge, this research presents the first evidence of a PMD burden within Vietnam’s ethnic minority communities.

A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening

Cervix and Breast cancers are the most common cancers among women worldwide and extract a large toll in developing countries. In May 1998, supported by a grant from the NCI (US), the Tata Memorial Hospital, Mumbai, India, started a cluster-randomized, controlled, screening-trial for cervix and breast cancer using trained primary health workers to provide health-education, visual-inspection of cervix (with 4% acetic acid-VIA) and clinical breast examination (CBE) in the screening arm, and only health education in the control arm. Four rounds of screening at 2-year intervals will be followed by 8 years of monitoring for incidence and mortality from cervix and breast cancers. The methodology and interim results after three rounds of screening are presented here. Good randomization was achieved between the screening (n = 75360) and control arms (n = 76178). In the screening arm we see: High screening participation rates; Low attrition; Good compliance to diagnostic confirmation; Significant downstaging; Excellent treatment completion rate; Improving case fatality ratios. The ever-screened and never-screened participants in the screening arm show significant differences with reference to the variables religion, language, age, education, occupation, income and health-seeking behavior for gynecological and breast-related complaints. During the same period, in the control arm we see excellent participation rate for health education; Low attrition and a good number of symptomatic referrals for both cervix and breast.

Fluoride Levels of Major Sources of Drinking Water in Edo State of Nigeria

Fluorides are minerals found naturally in many foods and in most sources of drinking water, though in widely varying amounts. Fluoride is important in Dentistry because of its ability to inhibit cariogenic bacteria to produce acids and also strengthens the enamel thereby making the teeth generally more resistant to dental caries. The incidence of dental caries has increased in Nigeria today due to dietary changes and so it becomes important that means of enhancing resistance to tooth decay are put in place to check this down ward trend in oral health. This study was carried out on the major sources of drinking water in the Fourteen Local Government Areas [L.G.A] of Edo State. The calorimetric method of fluoride level determination in water was used. The fluoride level in all the water sample analyses ranged between 0.0ppm to 0.8ppm, which is below the upper limit of 1.5ppm to avoid unsightly fluorosis, [WHO 1984]. Therefore fluorosis is not likely to be a feature in the inhabitants of Edo State. The higher fluoride contents were predominantly associated with rocky or hilly areas, while the low fluoride content areas were mainly of the clay soil type. The fluoride level in most pasts of Edo State is below optimum level for caries prevention, which is estimated to be about 0.6ppm in the tropics. The use of fluoride tooth paste for all, the application of topical fluoride in the form of gel or rinse by Dentist or trained primary health workers is highly indicated in the rural areas in patients who are prone to dental caries. Water fluoridation is not feasible now in the rural areas, because of the present poor economic position of the country. NQJHM Vol. 14 (1) 2004: pp. 17-20

Experiential Training of Primary Health Workers in Nigeria

A training program which encourages trained primary health workers in Nigeria to develop and integrate theoretical and community-relevant skills, is described. Prior to field work (field posting), students received lectures on health concepts related to their prospective field assignments. They were then tested on these concepts at the end of the lectures. Practice modules, as an operational approach in the community were developed. There was evidence to suggest enhanced knowledge base, better understanding of the principles of primary health care, and an appreciation of the role and desirability of community-oriented training. The applicability of these findings to the training of other cadres of health workers, including medical students, is suggested. Their implications for the development and practice of primary health care are discussed.