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

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.

Study Overview

• Status: Completed
• Conditions: Health Behavior; Health Care Utilization; Incentives
• Intervention / Treatment: Behavioral: CHW Incentives Intervention

Detailed Description

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:

1. 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?
2. What is the behavioral mechanisms through which new incentives may work or fail to work?
3. 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).

• Study Type: Interventional
• Enrollment (Actual): 769
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Uganda
  • Kampala, Uganda
    • Makerere University School of Public Health

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

Description

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.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention-Randomized Parishes; 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; 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.
No Intervention: Control-Randomized Parishes; 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?

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

Collaborators and Investigators

• Sponsor: Johns Hopkins Bloomberg School of Public Health
• Collaborators: Makerere University

Study record dates

Study Major Dates

• Study Start (Actual): August 23, 2021
• Primary Completion (Actual): March 15, 2023
• Study Completion (Actual): March 15, 2023

Study Registration Dates

• First Submitted: November 1, 2021
• First Submitted That Met QC Criteria: December 15, 2021
• First Posted (Actual): January 4, 2022

Study Record Updates

• Last Update Posted (Actual): July 25, 2023
• Last Update Submitted That Met QC Criteria: July 24, 2023
• Last Verified: July 1, 2023

More Information

Terms related to this study

• Keywords: Motivation; Retention; Performance; Uganda; Community Health Workers; Incentives
• Other Study ID Numbers: IRB00015042

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: We will not be sharing individual participant data. All data that will be shared will be at the aggregate-level so that any identifying information is not identifiable and does not place the participant at additional risk.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No