John Jules O. Mogaka

Background: Gender is a key factor shaping societal roles and access to resources, with cultural norms often limiting women’s abilities to use digital financial services. Despite the rise of digital payments, little is known about how gender relations influence their adoption and experience, especially among health workers involved in vaccination campaigns. Method: Between January and September 2023, we explored how gender norms and relations influence the uptake and experiences of digital payments among health workers participating in mass polio vaccination campaigns. The qualitative study involved 23 focused group discussions (FGDs; 16 in Uganda and 7 in Malawi) and 82 in-depth interviews (IDIs; 35 in Uganda and 47 in Malawi) with healthcare workers who received digital payments for implementing polio mass vaccination campaigns. IDI participants included village health teams, midwives, nurses, health facility managers, immunisation focal persons and district health officers in Uganda, and community health workers, health facility managers and mobile money operators in Malawi. FGDs were held with midwives, nurses and village health teams in Uganda and community health workers in Malawi. Data were coded using Dedoose software and thematically analysed. Results: Participants highlighted that digital payments were convenient since they were able to receive funds without travelling long distances or queuing at health facilities. Women reported that it gave them more time to engage in alternative activities, improve their financial autonomy and ability to participate in decision-making around use of household funds. Structural challenges leading to delayed disbursement of funds were reported to reinforce gender norms around financial dependency on men to meet operational campaign costs (eg, transport). Reported limited ownership of mobile money accounts, a prerequisite for digital payments, led to the exclusion of some women. Conclusion: Our findings suggest that digital payments could help improve financial autonomy and participation in decision-making around use of household funds among women involved in immunisation campaigns. However, our findings show that digital payments are implemented in the context of prevailing harmful gender norms that, if not addressed, have the potential to compromise women’s agency. This underscores the importance of integrating gender-transformative programming in planning for digital payments during vaccination campaigns.

Background: Digital health technologies hold transformative potential for improving maternal and child health (MCH) in low-resource settings. This study evaluates their impact in Uganda through the FamilyConnect (FC) application—an Unstructured Supplementary Service Data-based mobile platform delivering targeted messages to pregnant women and caregivers, implemented in 42 districts since 2016. Methods: A mixed-methods cross-sectional design was used in nine randomly sampled FC districts. Quantitative data from 83 health facilities (2017–2022) assessed changes in MCH indicators via Interrupted Time Series (ITS) analysis. Additional data included surveys with 317 mothers, interviews with 409 health workers, 34 district managers, 3 national Ministry of Health staff, and 109 focus group participants. Results: FC significantly improved antenatal care (ANC) utilization: total ANC visits rose by 19.35%, with first-trimester visits increasing 85.81%. ITS showed annual ANC attendance grew by 5.5% (vs. 1.5% pre-intervention). HIV prevalence at ANC declined from 5.4% (2017) to 3.4% (2022). However, postnatal care visits declined 15.47%, male partner ANC attendance dropped 33.54%, and postnatal family planning uptake fell 58.50%—possibly due to substitution with remote guidance via FC. Success factors included translation into local languages, use of Community Health Workers (VHTs), and integration with other programs. Key barriers were phone scarcity (35% of women shared devices), poor network connectivity (notably in Karamoja), app downtime, domestic conflict, and health system issues like staff shortages and supply stockouts. Conclusions: FC shows promise in improving ANC and disease prevention, but scale-up requires addressing sociocultural, infrastructural, and systemic barriers, expanding language coverage, engaging men, improving device access, and strengthening health systems.

Background: Community Engagement is an important ethical imperative in research. Although substantial research emphasizes its real value and strategic importance, much of the available literature focuses primarily on the success of community participation, with little emphasis given to specific community engagement processes, mechanisms and strategies in relation to intended outcomes in research environments. The systematic literature review’s objective was to explore the nature of community engagement processes, strategies and approaches in health research settings in low- and middle-income countries.Methods: The systematic literature review design was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched for peer-reviewed, English-language literature published between January 2011 and December 2021 through three databases on the internet (PubMed, Web of Science and Google Scholar). The terms "community engagement," "community involvement," "participation," "research settings," and "low- and middle-income countries" were merged in the search.Results: The majority of publications [8/10] were led by authors from low- and middle-income countries, with many of them, [9/10] failing to continuously include important aspects of study quality. Even though consultation and information sessions were less participatory, articles were most likely to describe community engagement in these types of events. The articles covered a wide range of health issues, but the majority were concerned with infectious diseases such as malaria, human immunodeficiency virus, and tuberculosis, followed by studies on the environment and broader health factors. Articles were largely under-theorized.Conclusions: Despite the lack of theoretical underpinnings for various community engagement processes, strategies and approaches, community engagement in research settings was variable. Future studies should go deeper into community engagement theory, acknowledge the power dynamics underpin community engagement, and be more practical about the extent to which communities may participate.

Background: Community health worker (CHW) programmes, when adequately integrated into mainstream health systems, can provide a viable, affordable and sustainable path to strengthened health systems that better meets demands for improved child health, especially in resource-constrained settings. However, studies that report on how CHW programmes are integrated into respective health systems in sub-Saharan Africa (SSA) are missing.Aim: This review presents evidence on CHW programmes’ integration into National Health Systems for improved health outcomes in SSA.Setting: Sub-Saharan Africa.Method: Six CHW programmes representing three sub-Saharan regions (West, East, and Southern Africa) were purposively selected based on their deemed integration into respective National Health Systems. A database search of literature limited to the identified programmes was then conducted. Screening and literature selection was guided a scoping review framework. Abstracted data were synthesised and presented in a narrative form.Results: A total of 42 publications met the inclusion criteria. Reviewed papers had an even focus on all six CHW programmes integration components. Although some similarities were observed, evidence of integration on most CHW programme integration components varied across countries. The linkage of CHW programmes to respective health systems runs across all reviewed countries. Some CHW programme components such as CHW recruitment, education and certification, service delivery, supervision, information management, and equipment and supplies are integrated into the health systems differently across the region.Conclusion: Different approaches to the integration of all the components depict complexity in the field of CHW programme integration in the region.Contribution: The study presents synthesized evidence on CHW programmes integration into national health systems in SSA.

Background: The paucity of Human Resources for Health (HRH) is a major global health challenge. The World Health Organization (WHO) recognizes the potentials that Community Health Workers (CHWs) have in closing the gap of an inadequate supply of human resources for health (HRH). However, weak CHW integration into national health systems curtails effective implementation of CHW delivered high impact interventions in resource constrained settings. This study assessed the extent of integration of the CHW Recruitment, Education, and Certification (REC) component into the national health system’s HRH building block, using Botswana’s CHW program as a case study. Methods: The study used mixed methods. Data collated from CHW training program documentary abstraction, five key informant interviews were analyzed thematically. Data collected through the survey with 123 CHWs were analyzed quantitatively. A recently developed Community Health Workers Program Integration Scorecard Metrics (CHWP-ISM) that comprises of the WHO building blocks and corresponding CHW integration metrics, with process, evidence, and status of integration parameters, was used to determine the extent of integration. Results: An analysis of Botswana’s CHW REC component using the CHWP-ISM scale showed that the component was 80% integrated into the national HS. Whereas the CHW training program was fully government sponsored and accredited, some aspects of the program’s selection and recruitment criteria and training modalities were lacking integration. Although CHW training was exclusively offered at a local private training institute, findings from documentation reviews, interviewed KIIs and the survey show that the training accreditation, regulation and funding was the responsibility of the central government. Conclusion: The application of the CHWP-ISM scale to assess extent of CHW program integration into HS identified important CHW human resource integration gaps in CHW selection criteria and recruitment process as well non-inclusion of CHWs post-training accreditation by national accreditation board in government policy documents.

UNSTRUCTURED This is a peer review report.

Schistosomiasis, a neglected tropical disease (NTD), causes morbidity and mortality in over 250 million people globally. And 700 million people are at risk of contracting it. It is caused by a parasite of the genus Schistosoma. Freshwater snails of the family Planorbidae are of public health significance as they are intermediate hosts of these highly infective flukes. Accurate diagnostic techniques to detect schistosome infections in intermediate host snails (IHS) and environmental surveillance are needed to institute measures for the interruption of transmission and eventual elimination. We carried out a systematic review of the literature to assess advantages and limitations of different diagnostic techniques for detecting schistosome infections in snails. Literature from Scopus, Web of Science, and PubMed databases from 2008 to 2020 were searched using combinations of predefined search terms with Boolean operators. The studies revealed that conventional diagnostics are widely used, although they are labor-intensive, have low specificity and sensitivity levels, and cannot detect prepatent infections. Whereas more advanced techniques such as immunological, nucleic-acid amplification, and eDNA diagnostics have high sensitivity and specificity levels, they are costly, hence, not suitable for field applications and large-scale surveys. Our review highlights the importance of designing and developing innovative diagnostics that are high in specificity and sensitivity as well as affordable and technically feasible for use in field laboratories and for large-scale surveys.

Background: The effectiveness of community health workers (CHWs) in delivering community-based preventive services is often curtailed by inadequate or complete lack of integration of the CHW programmes into national health systems. Although literature has defined the context and guidelines for integrating CHW programmes into health systems, indicators to quantitatively assess the extent of integration are inadequately addressed.Aim: This article presents an integration scale – CHW Programme Integration Scorecard Metrics (CHWP-ISM) – for measuring the extent of CHW programme integration into national health systems.Setting: Literature review and policy documents were focused on sub-Saharan Africa, while interview participants were drawn from six African countries.Methods: A deductive–inductive approach to item and measurement scale development was employed. Information obtained from a combination of diverse literature sources, subject matter expert (SME) interviews and documentary abstraction from publicly available policy documents advised item generation for the proposed CHWP-ISM. The study qualitatively captured the sectoral CHW integration, thematically analysed the data and culminated in the quantitative integration metrics.Results: Analysis of the responses from six SMEs and abstraction from policy documents resulted in the compilation of metrics with a total of 100 indicators for the CHWP-ISM scale that could be used to assess the level of CHW programmes integration into national health systems. The indicators were categorised along the six World Health Organization’s (WHO) health systems building blocks. Subject matter expert responses corresponded well with abstracted results from the 18 country CHW programmes, indicating content validity.Conclusion: The proposed scorecard metrics can be used to quantitatively rate the extent of CHW programmes integration into health systems, in an attempt to strengthen health systems to improve health outcomes.

Background: Through recent advances in omics technologies, precision medicine (PM) promises to fundamentally change the way we approach health, disease and illness. Imperative applications of omics-based biomarkers are gradually moving from research to clinical settings, with huge long-term clinical and public health implications. Whereas much of research in PM is mainly focused on basic biomedical discoveries, currently there is little research on the clinical implementation of omics biomarkers, especially at health systems level. Aim and Methods: This study investigated the application of multidimensional item response theory (IRT) models to validate a hypothesized PM implementation measurement model. This is a contribution to PM implementation at health systems level. Data obtained through an item-sort procedure involving 496 observations from 124 study participants formed the basis of a 22-item PMI measurement model. Conclusion: Statistical significance of the bifactor model suggests PM implementation may have to be examined using factors that reflect a single common underlying implementation construct, as well as factors that reflect unique variances for the identified four content-specific factors.