Advanced thematic framework: code book

Stage 3 of the iterative process adopted in data synthesis led to the development of a new “code book” which includes a greater range of categories and sub-categories that were used for indexing all data retrieved from included studies. If compared to the preliminary thematic framework (Table 5), this advanced version was wider, more comprehensive and fitted for the organization of the evidence available. The final “code book” was used to structure the evidence synthesis and contributed to the development of the logic thematic model as described in Stage 5.

The code book was organized around general categories furthered structured by intra- class and inter-class hierarchies and logic connections (or causal pathways) of influence on CHWs’ performance.

The two major categories defined within the advanced framework were “systemic inputs” and “mediators of effects”.

The category “systemic inputs” redefined and expanded the a priori classification of “system” and “components” within the preliminary framework (Table5) and includes all factors that are considered “inputs” for CHWs’ performance and belong to one of the two main systems, the formal health system and the community system. When factors were found to belong to the same category of “systemic inputs”, they were organized hierarchically in sub-groups to allow broader themes to include their sub-groups. For example, the sub-category of the “health system” included the category of “human

resources” in a lower hierarchical level, since human resources are a part of the health system (WHO, 2007b).

The full list of categories within the “systemic inputs” group can be found in Annex I, together with the overall code book, and, since “systemic inputs” are the main focus of this review, details will be provided in the result section.

The second major category used for indexing data was “mediators of effects”. During data extraction process, it was possible to notice that “systemic inputs” were seldom directly connected with CHWs performance, and that their influence was often mediated. Mediating factors were found to be causally interconnected with both “systemic inputs” and CHWs’ performance.

The relationship between “systemic inputs”, mediators and performance is defined by causal pathways and temporal connections. Consequentiality across categories was reflected into a hierarchical organization of data, where factors that logically came first, such as “systemic inputs”, precede the others (Table 6). The organization in causal hierarchies was crucial for mapping factors during Stage 5 of data analysis.

Table 6 Main categories and hierarchical organization

Within categories ↓ Across categories  Level I Level II Systemic inputs* Mediators of effects System Inputs Factors Sub-categories *see Annex I for more details 2.1.8.2 Mediators of effect

Deeply focusing on mediators of effects is not the objective of this review, rather their identification and summary profile a necessary intermediate step. Their recognition is crucial for an appropriate organization of findings within a logic thematic model, which can portray the complexity of dynamics and causal mechanisms connecting contextual factors to CHWs performance along the CHWs’ program implementation process (Naimoli et al, 2014).

The identification of these sub-groups was the result of the iterative process of data extraction across the included studies, and their definition was backed up by matching the evidence from official MoH documents on CHW program, its underlying assumptions, structure and organization (MdS, 2012), and key findings of the literature on CHWs’ performance (Naimoli et al., 2014).

If systemic inputs are the focus of this review, elements and processes that enables their connections and concrete translation with CHWs’ performance should be stated and clarified for a better understanding of the how and why systemic factors can turn into facilitators or barriers. This clarifying step could boost a more constructive and informed work on programme improvements, although for its complexity would maybe require a separate study.

Within this review, three major mediators were identified, which involve the main participants underlying the assumptions, structure and organization of CHWs programme in Brazil from an health system perspective (MdS, 2012), namely CHWs, FHTs’ health professionals (especially nurses and doctors) and the overall FHT as a group of individuals. These mediators are represented by CHWs’ knowledge, attitudes and practices (KAP); FHTs’ health professionals knowledge, attitudes and practices, and finally on the overall team’s knowledge, attitudes and practice, which will be referring as team work. These dimensions embrace the behavioral and emotional aspects, as well as the cognitive and the practical ones of subjects involved in CHWs’ work. While the formers attempt to capture the connection between systemic inputs and CHWs’ performance through the lens of individual attitudes to the surrounding environment, the second and the third concern the relevance and appropriateness of people in terms of their knowledge and practice, respectively, for supporting an optimal performance. Attitudes, knowledge and practice were found to be connected to the objectives and mission of CHWs’ programme, to its organization and instruments, up to the expected and achieved final products (Naimoli et al., 2014).

CHWs knowledge, attitudes and practices

Across all studies, CHWs’ KAP were found to lie between systemic inputs and CHWs’ performance. The quality of CHWs’ activities was found to be the result, amongst other factors, of the appropriateness of individual CHWs’ KAP for their tasks and mission. At the same time, however, CHWs' KAP were also found to be subjected and influenced by

external systemic inputs. Within the CHW program in Brazil, the features that were found to be relevant within CHWs’ KAP are described in Box 2.

Box 2 CHWs’ KAP relevant within the CHW program in Brazil CHWs knowledge:

- Biomedical principles and causal mechanisms behind the health and disease process; - Social determinants of health and causal mechanisms behind the health and disease

process;

- Communication and relational principles;

- Context, including epidemiological and community profile and dynamics; - Ethical professionalism and boundaries of CHWs mission.

CHWs attitudes:

- Professional motivation;

- Professional frustration and stress; - Personal self-esteem;

- Professional confidence and autonomy; - Interest in professional development;

- Engagement with the job and work environment; - Openness to new tasks and working methods; - Openness to self and team evaluation;

- Attitude to team work;

- Attitude towards community of users (judgment and ties). CHWs practice:

- Properly carrying out tasks; - Planning work;

- Work in team;

- Communicate appropriately with patients;

- Provide adequate and comprehensive counselling (oriented to treatment, disease prevention, health promotion and education);

- Translate theoretical knowledge into practice;

- Manage ethical dilemmas and inter-professional issues; - Understand and diagnose problems across the community; - Problem solving towards personal and community issues; - Link other services and sectors.

FHTs knowledge, attitudes and practices of other health professionals

The inclusion of the category “FHTs KAP of other health professionals” under “mediators of effects” was backed up not only with the analysis of the evidence available within the review, but also with the formal inclusion of FHTs as a key component of CHW program in Brazil.

Under the NPHCP, CHWs’ work is by definition strictly dependent on the FHT whom they belong, since key activities linked with CHWs, such as their management and

coordination, and team work, are attributions of the health professionals working in team with them, especially nurses and doctors. Therefore, CHWs’ performance should be analyzed also in its relationship with the whole FHT and its members.

Similarly to CHWs’ KAP, however, FHTs KAP were found to be shaped by external systemic inputs and therefore organized under this broader category. Within the CHW program in Brazil, the features that were found to be relevant for FHT’s KAP are described in Box 3.

Box 3 FHTs’ KAP relevant within the CHW program in Brazil FHTs knowledge:

- Biomedical principles and causal mechanisms behind the health and disease process; - Social determinants of health principles and causal mechanisms behind the health and

disease process;

- Communication and relational principles;

- Context, including epidemiological and community profile and dynamics; - Ethical professionalism and boundaries of CHWs’ mission;

- Pedagogical, educational and supervision principles and methods. FHTs attitudes:

- Professional motivation,

- Professional frustration and stress,

- Engagement with the job and work environment; - Attitude to team work;

- Leadership;

- Attitude towards community of users and CHWs (judgment and ties); - Willingness to support and facilitate CHWs’ work.

FHTs practice:

- Properly carrying out tasks;

- Leader, supportive and manage groups;

- Using effective training methods and to contextualize educational objectives; - Supervising CHWs work;

- Supporting a holistic view of health and disease process;

- Strengthen soft skills (relational and communicational skills) in team members; - Understand and value CHWs’ roles and responsibilities.

Team work

For all reasons described previously, within CHW program in Brazil, “team work” was found to be crucially linked with CHWs’ performance, but also strictly influenced by systemic inputs. It was under these circumstances that it was considered for inclusion as a sub-category of “mediators of effects”.

Within CHW program implementation, the features that were found to be relevant for team work are described in Box 4.

Box 4 Team work features relevant within the CHW program in Brazil - Clear distribution of work and responsibilities;

- Clear and participatory planning and prioritization processes; - Existence of CPD plans and activities, incl. multi-professional; - Networking and collaboration with other services and sectors; - Uniformity of vision of goals and services;

- Opportunity and space for open discussion; - Existence of improvement cycles (act-reflect-act); - Shared case review and problem solving;

- Capacity and power of ensuring planned referrals;

- Capacity of developing a reliable community situational analysis;

- Capacity of developing or contributing to community/micro-area plans. 2.1.8.3 Logic connections between systemic inputs and CHWs’ performance

Coherently to what was defined within the preliminary thematic framework (Table 5), during Stage 3 of data synthesis, logic connections between systemic inputs and CHWs’ performance were categorized as “effects” and further classified as “barriers” when inputs were found to hamper CHWs’ performance directly, or through their indirect influence on mediators, or, contrarily, as “facilitators” when they ease it.

During Stage 4 of data synthesis, however, it was found that the same input could behave differently, and act contradictorily on CHWs’ performance as a facilitator and as a barrier across all evidence collected. To account for this bidirectional relation, logic connections between systemic inputs and CHWs’ performance were further classified as “homogenous” or “heterogeneous”.

Often, but not always, it is not the factor itself which acts as a barrier or a facilitator to CHWs’ performance, but rather the way the corresponding health system component/function is implemented in practice. For example, the presence of adequate support and supervision is a facilitator, its absence or inadequacy is a barrier. To account for this, we used the following classification in our narrative summaries:

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↑

↓when the prevailing effect emerging from studies is positive; ↑↓ when the prevailing effect emerging from studies is negative.

Logic connections were classified as homogeneous when the same input had similar effects at CHWs, FHTs or community level, and thus on CHWs’ performance. That is, the same alterations of factors and their features consistently perform across all settings and experiences as a facilitator or barrier for CHWs performance. For example, the initial training for CHWs was defined as a facilitator when promptly delivered, and as a barrier when delayed or missing. They were classified as heterogeneous if the same input had contradictory effects at CHWs, FHTs, team work or community level, and thus on CHWs’ performance. That is, the same alterations of factors and their features perform differently across settings and experiences and could act simultaneously as a facilitator or barrier for CHWs’ performance. For example, work and living in the same place was found to favor CHWs practice, and at the same time to be an obstacle for it.

3. Results

In document Policy options for improving the performance of community health workers (CHWs) in maternal and child health in Brazil: analysis of barriers and facilitators to CHW national programme and evaluation of a community-based trial in Recife (Page 50-56)