The role and effectiveness of traditional birth attendants in Somalia

In Somalia, many organisations have supported Traditional Birth Attendant (TBA) training as a strategy to reduce maternal mortality and morbidity. An evaluation was undertaken to assess the effectiveness of this intervention and its potential as a component of a national strategy for safe motherhood in Somalia. The study examined the TBAs actual influence in improving a womans chances of surviving life-threatening complications of pregnancy and delivery. The results of the study showed that despite a high standard in TBA training, when dealing with complications such as prolonged labour, haemorrhage or infection, families prefer traditional practices. Families are unlikely to value the opinion of the TBA in making a decision to refer a woman for emergency obstetric care. The report concludes that TBA programmes which exist in isolation of other interventions are unlikely to have any significant effect on maternal mortality although clean deliveries and ante-natal care pectised by trained TBAs may reduce maternal morbidity and perinatal mortality and morbidity.     

Socio-economic and other variables affecting maternal mortality in Sierra Leone

This study identifies socioeconomic and health care variables affecting maternal mortality in 12 villages in Gbendembu Ngowahun Chiefdom in Sierra Leone. Data were obtained from Bombali district in the Northern Province. The villages include about 245,000 people. Analysis is based on interviews, participant observation, and health records from primary health care (PHC) centers and peripheral health units (PHUs). Interviews were conducted among 400 households and among 31 traditional birth attendants (TBAs) and PHC staff during November 1989 to February 1990. Findings indicate that high parity was related to early marriage. Over 40% of women were married by the age of 15 years. About 85% of women aged 45-49 years had 6 or more children. 55.1% had 9 or more children. Localized areas within the Chiefdom had even higher fertility. Fertility was somewhat lower among women living beyond a 3-mile radius of the PHUs. Most of the women had never had any formal primary education, particularly older women. More people were Christians than Muslims. About 80-90% of the population was composed of very poor subsistence farmers. During the rainy season people went hungry. Few could afford health care. About 69.5% of deliveries in the prior 24 months occurred at home, 21.5% were performed at a health center, and about 9% occurred in the hospital. The health units were located in Gbendembu and Kalangba. One aide per unit was assigned to maternal and child health services. The program aim--to reduce maternal mortality by 30% by the year 2000--is unattainable. Many factors are constraints to quality health care. Facilities were inadequate, prices were high, and nurses were unfriendly. Over 70% of deliveries within 3 miles of PHUs and over 90% of outside deliveries were performed by TBAs. Over 60% of TBAs were untrained and did not use sterile supplies.     

The Implementation of Mental Health Evidence Based Practices from the Educator,Clinician and Researcher Perspective

Within the different arenas of social work practice, community based mental health is among the most advanced in terms of defining a set of evidence based practices (EBPs). Social workers play a major role in the delivery of community based mental health and are at the forefront of efforts to implement these practices through state and federal initiatives. One such initiative is The New York Office of Mental Health Evidence Based Project, which is designed to increase the knowledge and skills related to evidence-based practice among New York’s mental health human services workforce. The project had a social work component, which trained students in implementing EBP’s through specially designed curricula and field placements. The students participating in the project encountered numerous challenges in the field including lack of agency “buy-in” and infrastructure support; inadequate training and resources; poor supervision; and provider resistance. From the multilevel perspectives of educator, clinician and researcher, this paper addresses these challenges and makes recommendations to facilitate the implementation of EBPs.     

Prevention of child sexual abuse: implications of programme evaluation research

Thirty child abuse prevention programme evaluation studies were selected according to a set of methodological criteria following an extensive manual and computer literature search. Targets for intervention in 17 studies were children; in three parents; in four teachers; and in six studies multisystemic programmes were evaluated where some combination of children, parents and teachers was targeted for intervention. From a review of the 30 studies, it was concluded that child abuse prevention programmes can lead to significant gains in children's, parents' and teachers' safety knowledge and skills. Best practice guidelines arising from the review include the use of multisystemic programmes; child‐focused curricula which cover a wide range of safety skills and concepts; and the use of didactic instruction and discussion, video modelling and active behavioural skills training techniques in programme delivery. The curricula for parents' and teachers' programmes should cover child protection issues and local child protection procedures along with an overview of the children's programme lesson plans. Longer programmes conducted by trained staff are preferable and such staff may include teachers, parents, mental health professionals and law enforcement officers. Copyright © 2000 John Wiley & Sons, Ltd.     

A gender-informed model to train community health workers in maternal mental health

The New Haven Mental Health Outreach for MotherS (MOMS) Partnership is a community-academic partnership that works to develop public health approaches to ensure that pregnant and parenting women living in the City of New Haven achieve the highest possible level of mental health. The MOMS Partnership developed a training model for community health workers specializing in maternal mental health. Six community health workers (termed Community Mental Health Ambassadors or CMHAs) were trained on key topics in this gender-informed maternal mental health curriculum. Pre- and post-test questionnaires assessed changes in attitudes, perceived self-efficacy and control using standardized scales. The results indicated preliminary acceptability of the training curriculum in transforming knowledge and attitudes about maternal mental health among community health workers.     

A learning collaborative approach to training school-based health providers in evidence-based mental health treatment

Collaborative care models among pediatric primary care and child and adolescent mental health providers are increasingly emphasized to improve quality of and access to mental health services. The current case example of a multi-site clinical training opportunity in school-based collaborative care settings illustrates the success of a learning collaborative approach to improve children's mental health care in schools. Quality improvement data from participating sites indicated an increase in use of evidence-based practices (i.e., “core skills”) and an improvement in quality service delivery indicators for children's mental health (i.e., screening, risk assessment, diagnostic processes, associated diagnostic coding, use of core skills, associated procedural coding, and follow-up assessment and referral) over time. Clinician self-report and chart review data are supplemented by qualitative data from site leader interviews conducted following completion of the project. Implications for mental health workforce development to improve the quality of care to children and adolescents in schools and other community mental health settings are discussed.     

Willing but unable? Extending theory to investigate community capacity to participate in Ghana’s community-based health planning and service implementation

While primary health care programmes based on community participation are widely implemented in low- and middle- income settings, empirical evidence on whether and to what extent local people have the capacity to participate, support and drive such programmes scale up is scant in these countries. This paper assessed the level of community capacity to participate in one such programme – the Community-Based Health Planning and Service (CHPS) in Ghana. The capacity assessments were drawn from Chaskin’s (2001) theorised indicators of community capacity with modifications to include: sense of community; community members commitment; community leadership commitment; problem solving mechanisms; and access to resources. These capacity measures guided the design of an interview guide used to collect data from community informants, frontline health providers (FLP) and district health managers. Key qualitative themes were built into a questionnaire administered to households selected through systematic sampling approach. Findings showed that growing individualism, low trust in neighbours and apathetic behaviours undermined the capacity of mutual support for CHPS. The capacity to support CHPS was high for local leadership and community social mobilisation groups who often dedicated time to working with FLP to promote maternal and reproductive health service use, and in advocating broader support for CHPS. Within the wider community, commitment to voluntarism was low as members perceived CHPS to be owned by, and run on government funds and resources. Poor voluntarism was compounded by poverty that crippled the capacity to provide needed resource support for CHPS. Findings have great implications for building strong capable communities for participation in community oriented health programmes.     

Using an action research approach to involving service users in the assessment of professional competence

This paper reports on a piece of action research that has involved people who use mental health services in systematically providing feedback from a user perspective on participants’ assessed work completed for one module of a masters’ training programme in mental health. In an attempt to improve professional practice and include people who were accessing mental health services in so doing, it outlines how users were trained to provide feedback and the training methods employed. The findings summarise the kind of issues users raised in their feedback to participants about the evidence professionals provided to demonstrate their learning from the training programme. A focus group interview with professionals provides a contrasting insight into the participants’ experience of having their work commented upon from a user perspective. The paper draws on the experience of a five-year external evaluation of an interdisciplinary programme in community mental health at Birmingham University in the UK which has highlighted the involvement of people who use mental health services as a particular innovation in the design, delivery and evaluation of the curriculum.     

Evaluating the Impact of Post‐Qualifying Social Work Education

Post‐qualifying awards in social work are well established within the continuing professional development agenda for qualified social workers in the UK. The evaluation of education and training should be an integral part of this agenda because it is important to ensure that programmes continue to meet standards of delivery, are successful in meeting their aims and objectives and are making an impact on practice. However, there is a limited amount of published work on the evaluation of post‐qualifying social work education, with studies often focusing on programme delivery rather than on their impact on practice.

This paper explores evaluative work within the current post‐qualifying social work framework and discusses the results of an evaluation of the Vulnerable Adults and Community Care Practice programme, a specialist post‐qualifying social work education programme run by a UK university, as an example of an evaluation of the impact on practice. The results indicate positive evidence of impact on practice and demonstrate examples of how the programme has had a direct effect on individuals, teams, organisations and on people who use services.     

Looking beneath the surface of a preceptor-training programme through a realist evaluation

South Africa’s department of health devoted themselves to the clinical nursing education and training model, which indorses preceptors as essential stakeholders to promote competence in students. A preceptor-training programme was developed that build on this model and implemented through an intervention. The initial programme theory hypothesised that trained preceptors would promote support and develop competence in students in comparison to untrained preceptors. Results showed a poor outcome because few preceptors participated and a high student attrition rates. The authors then posed the question “Why did the preceptorship training programme not work?” This article offers insight into the context, mechanism, and outcome of the preceptor-training programme through a realist evaluation. Reflective field notes, gathered during the intervention, were used and gave insight regarding how, for whom, and under which circumstances the programme could work and offered a refined programme theory for preceptorship. The main conclusion drawn showed that a preceptor-training programme alone is not the sole determining factor to ensure preceptors’ motivation to transfer their learning; a systems approach, ensuring the effectiveness of the programme, should be followed. Reflection on findings indicated the implementation context as a major determining factor of the training programme.     

Training Strategies for Elder Abuse/Inadequate Care

A key component in the efforts to deal with elder abuse/inadequate care is the development of educational programmes for both the public and responsible staff. This article explores the development of training programmes that address the needs of adult learners in the caring professions. Central to the success of the training was the programme design that entailed three methods of teaching in response to the three ways adults learn. Participants acquired a knowledge base that will enable them to work in an environment with few legal directives.     

An effective programme is not enough: a review of factors associated with poor attendance and engagement with parenting support programmes

The provision of parenting support is a key feature of wealthier nations’ health and social care services. However, attendance and engagement by the neediest parents remains poor. Barriers experienced by parents include personal life factors (beliefs, lifestyles and limited resources) and programme‐specific factors (delivery, content and support arrangements). Here we give consideration to these issues, drawing on published reviews of parenting programme effectiveness identified through a comprehensive search of electronic databases. We suggest ways of improving attendance and engagement, by providing programmes as part of a comprehensive framework of family support.     

How was a national moving and handling people guideline intended to work? The underlying programme theory

In healthcare, moving and handling people (MHP) often cause musculoskeletal disorders. To prevent musculoskeletal disorders due to MHP, many national evidence-based guidelines have been developed. However, little is known about how these guidelines were intended to work, i.e. their ‘programme theory’, how implementation by intended users is influenced by contextual factors and mechanisms to produce outcomes. This paper identifies the programme theory of a national MHP guideline (MHPG) using thematic analysis of the MHPG document, three organisational planning documents, and interviews with MHPG developers. The analysis identified the intended users of the MHPG as health and safety managers and MHP coordinators. The programme theory comprised contextual factors, potentially hindering (e.g. budget constraints) or facilitating (e.g. changing demographics) implementation, being influenced by mechanisms mainly based on ethical (quality of care, evidence-based practices), and economic reasoning (reducing cost of MHP, return on investment) to reduce injuries caused by MHP – the intended outcome.     

Utilizing grassroots workers in family planning programs in India: prospects and problems

In order to rapidly expand the network of delivery systems and speed up the process of acceptance of family planning messages and methods, a shift took place in the Indian family planning program from the bureaucratic "clinical" approach to the people oriented "extension" approach. As a result, there is an increasing emphasis on moving the family planning efforts closer to the grassroots level. A key methodological issue centers on the proper selection, cultural acceptability, and the effectiveness of the grassroots workers who are to be trained and through whom family planning motivational messages and methods are to be introduced. The Indian government, from time to time, has trained and utilized different groups of grassroots workers in its family planning promotional efforts. Anthropological field studies were conducted in two different regions in India to examine the potential and actual roles of two groups of grassroots workers--opinion leaders and traditional birth attendants--in the delivery of family planning services in the rural areas. These studies revealed that while the traditional birth attendants can be trained and utilized to a limited extent in promoting family planning efforts, especially to the eligible female clients, the role of the opinion leaders in such efforts is at best questionable. Based on these field studies, cultural and technical (including bureaucratic) problems in training and utilizing opinion leaders and traditional birth attendants are explored in detail. Modifications in the training program strategies are suggested to improve and expand the family planning delivery system in rural India.     

Recruiting ethnic minority groups to evidence-based parent training. Who will come and how?

Recruiting ethnic minority groups into research is an international priority and could lead to increased knowledge of evidence-based interventions. Three different strategies for recruiting ethnic minority mothers to participate in research on the effects of parent training were compared. The strategies were recruitment via: 1) professionals from regular public services, 2) community information meetings, and 3) staff from the recruitment team. During the four-month recruitment period, 96 mothers with Somali or Pakistani origin signed up for the study. The results show that the information meetings were the most cost-effective strategy and that the highest proportion of the sample was recruited via these meetings. The three recruitment strategies were all suitable to recruit eligible families with regard to the levels of maternal parenting practices and child conduct problems required. While ethnic minority families are generally difficult to recruit for research, it seems that proactive strategies can pay off.     

A multi-level examination of how the organizational context relates to readiness to implement prevention and evidence-based programming in community settings

Prior theoretical and empirical research suggests that multiple aspects of an organization's context are likely related to a number of factors, from their interest and ability to adopt new programming, to client outcomes. A limited amount of the prior research has taken a more community-wide perspective by examining factors that associate with community readiness for change, leaving how these findings generalize to community organizations that conduct prevention or positive youth development programs unknown.Thus for the current study, we examined how the organizational context of the Cooperative Extension System (CES) associates with current attitudes and practices regarding prevention and evidence-based programming. Attitudes and practices have been found in the empirical literature to be key indicators of an organization's readiness to adopt prevention and evidence-based programming. Based on multi-level mixed models, results indicate that organizational management practices distinct from program delivery may affect an organization's readiness to adopt and implement new prevention and evidence-based youth programs, thereby limiting the potential public health impact of evidence-based programs. Openness to change, openness of leadership, and communication were the strongest predictors identified within this study. An organization's morale was also found to be a strong predictor of an organization's readiness. The findings of the current study are discussed in terms of implications for prevention and intervention.     

Maternal and child health and family planning services in the Sudan

Given the high rates of infant and maternal mortalty, the prevalence of infectious diseases, poor nutritional status among women and children, and numerous endemic diseases such as malaria and bilharzia, maternal-child health serivces have been given a high priority in the Sudan. In reality, however, this area has not received adequate attention within the primary health care system in terms of management, service provision, and training. Major obstacles to effective maternal-child health services include: 1) the lack of involvement of community health workers, the main providers of other primary health care services in the Sudan, in the area; 2) the clinical orientation of physicians, which mitigates against attention to the promotive and preventive components of health care; 3) a lack of standardization of medical records or data collection routines, which hinders program monitoring; and 4) the failure to integrate related national programs such as immunization into a comprehensive maternal-child health program. In addition, there are administrative and organizational obstacles, such as the lack of institutionalization of maternal-child health services within the Ministry of Health, inadequate managerial capabilities, an absence of guidelines for service delivery at the regional and provincial levels, delays in the procurement of equipment and supplies, a widely dispersed population, and transportation difficulties. Family planning, too, is supposed to be the responsibility of all primary health care workers in the Sudan. However, current training programs for physicians, nurses, village midwives, and community health workers do not prepare them to fulfill this role. Development of an official population policy in the Sudan is recommended to ameliorate some of these problems.     

Peer connections as an intervention with children of families where a parent has a mental illness: Moving towards an understanding of the processes of change

Prevention and early intervention programmes have been found to impede the transmission of mental illness from parents to children. However, the extant processes of change in such programmes are less clear. This study focuses on the impact of a peer support programme developed for children and adolescents who have a parent with a mental illness and examines the processes of change which might promote positive outcomes for youth. A mixed methods research approach was employed with participants aged between 8 and 12 years old; 69 completed pre- and post-questionnaires and 18 of these same participants engaged in telephone interviews post programme. Results demonstrate improved mental health knowledge and children reported that they were more likely to use an anonymous telephone helpline after attending the programme. Children indicated that the programme provided a place of respite from caring for their parent with a mental illness, an opportunity to connect with peers, and a positive change in perception of their parent's mental illness. The reported findings are moving towards an understanding of the process of change in programmes.     

Changing health culture in rural Appalachia: Implications for serving the elderly

This article explores the dual themes of place and time as influences on health care service delivery to the rural elderly, through a case study of rural Appalachia. Traditional patterns of indigenous health care practice and values are contrasted with more “professional” formal models of health care service delivery that have entered the region. The result has been a clash of health care cultures. The continuing validity of this perspective is appraised in relation to apparent generational differences between the old-old and the young-old in the degree to which contemporary health care practices and values are adopted. It is concluded that traditional and contemporary health care cultures can be reconciled through an expanded vision of health care service delivery premised on: understanding health care within a total community context; redefining the role of the health practitioner; improving education of both the rural elderly and service providers; and enhancing communication in the rural health care environment.