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Impact of contextual factors on the effect of interventions to improve health worker performance in sub-Saharan Africa: review of randomised clinical trials

Impact of contextual factors on the effect of interventions to improve health worker performance in sub-Saharan Africa: review of randomised clinical trials
Impact of contextual factors on the effect of interventions to improve health worker performance in sub-Saharan Africa: review of randomised clinical trials
Background: Africa bears 24% of the global burden of disease but has only 3% of the world’s health workers. Substantial variation in health worker performance adds to the negative impact of this significant shortfall. We therefore sought to identify interventions implemented in sub-Saharan African aiming to improve health worker performance and the contextual factors likely to influence local effectiveness.

Methods and Findings: A systematic search for randomised controlled trials of interventions to improve health worker performance undertaken in sub-Saharan Africa identified 41 eligible trials. Data were extracted to define the interventions’ components, calculate the absolute improvement in performance achieved, and document the likelihood of bias. Within-study variability in effect was extracted where reported. Statements about contextual factors likely to have modified effect were subjected to thematic analysis. Interventions to improve health worker performance can be very effective. Two of the three trials assessing mortality impact showed significant reductions in death rates (age<5 case fatality 5% versus 10%, p<0.01; maternal in-hospital mortality 6.8/1000 versus 10.3/1000; p<0.05). Eight of twelve trials focusing on prescribing had a statistically significant positive effect, achieving an absolute improvement varying from 9% to 48%. However, reported range of improvement between centres within trials varied substantially, in many cases exceeding the mean effect. Nine contextual themes were identified as modifiers of intervention effect across studies; most frequently cited were supply-line failures, inadequate supervision or management, and failure to follow-up training interventions with ongoing support, in addition to staff turnover.

Conclusions: Interventions to improve performance of existing staff and service quality have the potential to improve patient care in underserved settings. But in order to implement interventions effectively, policy makers need to understand and address the contextual factors which can contribute to differences in local effect. Researchers therefore must recognise the importance of reporting how context may modify effect size.
1932-6203
e0145206
Faragher, Eric Brian
31b3f049-0d18-44c1-bc99-77dfa56a0c23
Blacklock, Claire
c2d550f3-22dd-4936-8692-82d8b21b8301
Gonçalves Bradley, Daniela C.
c7b6e6c6-35df-4cbd-97bc-094a767bdc9b
Mickan, Sharon
592e6dd0-caf2-4636-b3ed-472d5bdecfb8
Willcox, Merlin
dad5b622-9ac2-417d-9b2e-aad41b64ffea
Roberts, Nia
1e596d6d-2c57-421d-b04f-0d835aa22978
Bergström, Anna
b7b8b4f8-15a5-4a0a-82db-28bfe3e6abc2
Mant, David
d2e30212-70ec-48c9-b80a-a45cf4bcc46e
Faragher, Eric Brian
31b3f049-0d18-44c1-bc99-77dfa56a0c23
Blacklock, Claire
c2d550f3-22dd-4936-8692-82d8b21b8301
Gonçalves Bradley, Daniela C.
c7b6e6c6-35df-4cbd-97bc-094a767bdc9b
Mickan, Sharon
592e6dd0-caf2-4636-b3ed-472d5bdecfb8
Willcox, Merlin
dad5b622-9ac2-417d-9b2e-aad41b64ffea
Roberts, Nia
1e596d6d-2c57-421d-b04f-0d835aa22978
Bergström, Anna
b7b8b4f8-15a5-4a0a-82db-28bfe3e6abc2
Mant, David
d2e30212-70ec-48c9-b80a-a45cf4bcc46e

Faragher, Eric Brian, Blacklock, Claire, Gonçalves Bradley, Daniela C., Mickan, Sharon, Willcox, Merlin, Roberts, Nia, Bergström, Anna and Mant, David (2016) Impact of contextual factors on the effect of interventions to improve health worker performance in sub-Saharan Africa: review of randomised clinical trials. PLoS ONE, 11 (1), e0145206. (doi:10.1371/journal.pone.0145206).

Record type: Article

Abstract

Background: Africa bears 24% of the global burden of disease but has only 3% of the world’s health workers. Substantial variation in health worker performance adds to the negative impact of this significant shortfall. We therefore sought to identify interventions implemented in sub-Saharan African aiming to improve health worker performance and the contextual factors likely to influence local effectiveness.

Methods and Findings: A systematic search for randomised controlled trials of interventions to improve health worker performance undertaken in sub-Saharan Africa identified 41 eligible trials. Data were extracted to define the interventions’ components, calculate the absolute improvement in performance achieved, and document the likelihood of bias. Within-study variability in effect was extracted where reported. Statements about contextual factors likely to have modified effect were subjected to thematic analysis. Interventions to improve health worker performance can be very effective. Two of the three trials assessing mortality impact showed significant reductions in death rates (age<5 case fatality 5% versus 10%, p<0.01; maternal in-hospital mortality 6.8/1000 versus 10.3/1000; p<0.05). Eight of twelve trials focusing on prescribing had a statistically significant positive effect, achieving an absolute improvement varying from 9% to 48%. However, reported range of improvement between centres within trials varied substantially, in many cases exceeding the mean effect. Nine contextual themes were identified as modifiers of intervention effect across studies; most frequently cited were supply-line failures, inadequate supervision or management, and failure to follow-up training interventions with ongoing support, in addition to staff turnover.

Conclusions: Interventions to improve performance of existing staff and service quality have the potential to improve patient care in underserved settings. But in order to implement interventions effectively, policy makers need to understand and address the contextual factors which can contribute to differences in local effect. Researchers therefore must recognise the importance of reporting how context may modify effect size.

Full text not available from this repository.

More information

Accepted/In Press date: 30 November 2015
Published date: 5 January 2016
Organisations: Primary Care & Population Sciences

Identifiers

Local EPrints ID: 403722
URI: https://eprints.soton.ac.uk/id/eprint/403722
ISSN: 1932-6203
PURE UUID: fbdee7db-e281-417d-ae63-9a6045ebedc4
ORCID for Merlin Willcox: ORCID iD orcid.org/0000-0002-5227-3444

Catalogue record

Date deposited: 09 Dec 2016 11:32
Last modified: 20 Jul 2019 00:27

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