Advancing the Health of Rural Communities in Uganda Through Strong Community Health Programs

Study Overview
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Brief Summary
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The overarching goal of this study is to improve the health of women and children in rural areas of Uganda through strengthening of the community health workforce, which provides critical health services to the rural poor.

Detailed Description
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Uganda, like several countries in Sub-Saharan Africa, faces a shortage of skilled healthcare workers, and a disproportionate concentration of workers in urban areas. This disparity has dire consequences for rural populations, who have higher fertility rates, lower utilization of maternal and child health services, lower levels of access to safe drinking water and sanitation services, and poorer vaccination coverage. Women and children in rural and remote communities bear the disproportionate brunt of poor access to and poor quality of health care. Village Health Teams (VHTs), Uganda's community health workers (CHW), were introduced to address some of these inequities by providing basic health services to the rural poor. However, like many CHW programs globally, the VHT program has high levels of attrition, owing to inadequate systems and financial support. The objectives of this study are to understand: What structure and group of incentives is best suited to motivate VHTs, improve their performance in the delivery of services, and increase their retention in the health workforce? What is the behavioral mechanisms through which new incentives may work or fail to work? How do the changes in the national VHT program impact utilization of maternal and child health services, sanitary practices, and perception of quality of health services at the community-level? What is the impact of COVID-19 on VHT practices on community health? This study will evaluate a 1-year incentives intervention provided to VHTs in Uganda's Masindi District. It is a two-armed clinical trial, where parishes will be randomized to the incentives intervention (i.e., an incentives package will be provided to VHTs practicing in the intervention parishes; control parishes VHTs will not receive an incentives package). The primary outcomes include assessing VHT performance, VHT motivation, VHT retention, trends in utilization of maternal and child health services, and trends in the adoption of sanitary practices. Outcomes for VHT performance, VHT retention, trends in utilization of maternal and child health services, and trends in adoption of sanitary practices will be measured monthly. Outcomes for VHT motivation will be measured twice, at baseline (Month 1) and endline (Month 12).

Official Title
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Advancing the Health of Rural Communities in Uganda Through Strong Community Health Programs

Conditions
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Incentives, Health Behavior, Health Care Utilization

Intervention / Treatment
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* Behavioral: CHW Incentives Intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Must be an active VHT in Uganda's Masindi district. Exclusion Criteria: Anyone who fails to meet the inclusion criteria specified above will be excluded.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Parishes will be randomized to intervention or control. VHTs in the intervention parishes will receive the incentives package as part of the intervention.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention-Randomized Parishes<br>Parishes will be randomized in Masindi District to receive the intervention (i.e., an incentives package). VHTs who are active in that parish will thereby receive the incentives intervention. | Behavioral: CHW Incentives Intervention<br>* The intervention comprises of an incentives package provided to VHTs who are active in the intervention-randomized parishes. It will comprise of items that will motivate them and support their work as VHTs in the community.<br>|
| No Intervention: Control-Randomized Parishes<br>Non-intervention randomized parishes will be the control parishes. Active VHTs in the control parishes will not receive the incentives intervention. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in VHT Performance | Measure change in average number of VHT visits made over the course of the 1-year intervention. Types of VHT visits include: average number of home visits, antenatal care visits, postnatal care visits, visits to support immunization of children, visits to talk about safe drinking water, visits to examine latrines and observe handwashing, and number of referrals made to the health facility over the last month. | Measured monthly for 12 months | 
| Change in VHT Motivation | Measure the percentage of VHTs who have improved motivation during the course of the 1-year intervention through use of the Close-To-Community (CTC) Provider Motivational Indicator Scale, which measures satisfaction, organizational commitment, community commitment, and work conscientiousness. | Baseline (Month 1) and Endline (Month 12) | 
| Change in VHT Retention | Measure the percentage of VHTs who report to the health facility over the course of the 1-year intervention. | Measured monthly for 12 months | 
| Change in Maternal and Child Health Services Utilization | Measure change in maternal and child health services utilization, which includes proportion of antenatal care coverage, proportion of immunization coverage, and proportion of children under 5 who have been visited by a VHT, over the course of the 1-year intervention. | Measured monthly for 12 months | 
| Change in Adoption of Sanitary Practices | Measure changes in the adoption of sanitary practices, which includes assessing the average number of households with latrines, improved latrines, handwashing facilities, safe drinking water, and are open defecation free over the course of the 1-year intervention. | Measured monthly for 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Community Health Workers, Incentives, Uganda, Motivation, Retention, Performance