1 million community health workers in sub-Saharan Africa by 2015

Impact of a community health worker led intervention for improved blood pressure control in urban Nepal: an open-label cluster randomised controlled trial

Background

Effective control of hypertension remains challenging in low and middle-income countries. We tested the effectiveness of comprehensive approaches to hypertension management including six home visits by community health workers with regular follow up by a trained healthcare provider on blood pressure levels in Nepal.

Methods

We implemented a non-blinded, open-label, parallel-group, two-arm cluster randomised controlled trial, with 1:1 allocation ratio in Budhanilakantha municipality, Kathmandu, Nepal. Ten public health facilities and their catchment area were randomly allocated to receive comprehensive intervention or only usual hypertension care. We recruited 1252 individuals aged 18 years and older with hypertension. The primary outcome was systolic blood pressure. Secondary outcomes were diastolic blood pressure, proportion with controlled blood pressure, waist to hip ratio, body mass index, physical activity, diet quality score, daily salt intake, adherence to antihypertensives, hypertension knowledge and perceived social support. Primary analysis was by intention-to-treat using a linear mixed model.

Findings

Participants were, on average 57 years old, 60% females, 84% married, 54% Brahmin/Chettri ethnicity and 33% were illiterate. The decrease in mean systolic blood pressure (1.7 mm Hg, 95% CI -0.1, 3.4) and diastolic blood pressure (1.6 mm Hg, 95% CI 0.5, 2.6) was more in the intervention arm compared to the control. The proportion with blood pressure control (OR 1.5 95% CI 1.0, 2.1) and engaging in adequate physical activity (≥600 Metabolic equivalents of task per week) (OR 2.2, 95% CI 1.6, 3.1) were higher in the intervention arm compared to control. The change in hypertension knowledge score was higher and daily salt intake was lower in the intervention arm compared to control. Waist to hip ratio increased more and global dietary requirement scores decreased more in the intervention group and there was no effect on the body mass index and adherence to antihypertensives.

Interpretation

Community health workers facilitated home support and routine follow-up care by healthcare providers was effective in controlling blood pressure in urban Nepal. These findings suggest comprehensive interventions targeting individual, community and health system barriers are feasible in low resource settings, but larger implementation trials are needed to inform future scale-up.

Funding

This work was supported by Norwegian University of Science and Technology, Trondheim, Norway (Project number 981023100).

Expanding the roles of malaria post workers in Thailand: A qualitative study of stakeholder perspectives

In Thailand, since the 2000s, malaria post (MP) workers have been tasked with promptly detecting and treating all malaria cases to prevent onward transmission in the communities. Expanding their roles to provide health services beyond malaria has been proposed as a strategy to sustain their activities until elimination is reached. This article examines the perspectives of stakeholders on community-based malaria care to assess prospects for expanding the role of MPs. The study incorporated in-depth interviews (IDIs) and focus group discussions (FGDs). In forested communities and local health facilities in northeast Thailand bordering Lao PDR and Cambodia, where malaria transmission is low, IDIs were conducted with 13 MPs and 23 community members. An additional 14 policymakers and implementers across the health sector in Thailand were interviewed. The respondents highlighted how in these border areas population groups most at risk of malaria, namely forest goers and migrants, are reluctant to visit public health facilities. In these areas, MP workers are well integrated in their communities and remain relevant although the communities no longer see malaria as spriority. Common conditions such as dengue, diabetes, insect bites, diarrhea, mental illness and substance abuse, were identified as local health concerns needing potential add-on services from MP workers. Although challenges in terms of training, supervision, and financing were raised, opportunities included additional funds from local administrative offices to maintain and integrate malaria activities with other health programmes. Changes to the roles of MPs should be adapted to changing local needs, some of which were identified in this study, should avoid duplication and potential tensions with other local health programmes, and need to build on the capacity of the community and primary care system. These enabling factors are worthy of consideration by any malaria programmes looking into maintaining their village malaria workers in the Greater Mekong Subregion.

Sustaining village malaria worker programmes with expanded roles: Perspectives of communities, healthcare workers, policymakers, and implementers in Vietnam

BACKGROUND

In Vietnam, multiple types of community-based malaria workers are recruited to promote access to malaria testing and treatment for at-risk mobile and migrant populations. However, as the country approaches elimination, these roles are at risk from declining investment. This article characterises the different types of workers and relevant health policy in Vietnam, and explores stakeholder perspectives on sustaining and expanding the roles of these workers in the malaria elimination context.

METHODS

We conducted a rapid policy document review to describe the policy background of community-based health care in Vietnam and identify key informants. In-depth interviews were conducted with policymakers and implementers (n = 11) in different government sectors, international, and civil society organizations. We also conducted interviews (n = 8) and two focus group discussions with community members (n = 12), and interviews with health workers (n = 9) in 18 communities in Phu Yen and Binh Thuan provinces in the central region.

RESULTS

Our study identified three main types of malaria workers: village health workers (VHWs), malaria post workers (MPWs) and other groups of workers supported by civil society organisations (CSO). Workers reported being willing to maintain their current roles and potentially provide additional services that respond to community needs, although they were concerned about excess workload and inadequate income. Besides working in a variety of jobs to secure their incomes, mainly in agriculture, VHWs in particular were primarily tasked with supporting the delivery of a wide range of health services from commune health stations. Faced with reduced patients, MPWs and CSO-supported workers could be tasked with the following potential roles: case notification for infectious diseases, real-time data collection and reporting, and screening for non-malaria illnesses using other rapid test kits. There was agreement that the community-based health network is crucial to health care delivery in remote communities and to ensure comprehensive access to care among vulnerable populations. However, policymakers and implementers stressed concerns about their limited skillsets, the inadequate budget to support these workers, and the regulation constraining them from performing diagnosis and treatment activities, highlighting the priority to maintain the capacity of workers and funding allocation through provincial advocacy and multi-programme collaboration.

CONCLUSIONS

This study highlights the crucial role of community-based health workers in eliminating malaria in Vietnam. Sustained efforts are needed to maintain accessible case detection and treatment while addressing local health concerns beyond malaria. Implementing these strategies requires prioritizing the mapping of groups most in need and developing enablers to raise community awareness and maintain the capacity of these workers. Ensuring political advocacy, financial resources, and coordination between multiple groups are key to maximizing impact and integrating malaria activities into the broader health system.

Interviewer biases in medical survey data: The example of blood pressure measurements

Health agencies rely upon survey-based physical measures to estimate the prevalence of key global health indicators such as hypertension. Such measures are usually collected by nonhealthcare worker personnel and are potentially subject to measurement error due to variations in interviewer technique and setting, termed "interviewer effects." In the context of physical measurements, particularly in low- and middle-income countries, interviewer-induced biases have not yet been examined. Using blood pressure as a case study, we aimed to determine the relative contribution of interviewer effects on the total variance of blood pressure measurements in three large nationally representative health surveys from the Global South. We utilized 169,681 observations between 2008 and 2019 from three health surveys (Indonesia Family Life Survey, National Income Dynamics Study of South Africa, and Longitudinal Aging Study in India). In a linear mixed model, we modeled systolic blood pressure as a continuous dependent variable and interviewer effects as random effects alongside individual factors as covariates. To quantify the interviewer effect-induced uncertainty in hypertension prevalence, we utilized a bootstrap approach comparing subsamples of observed blood pressure measurements to their adjusted counterparts. Our analysis revealed that the proportion of variation contributed by interviewers to blood pressure measurements was statistically significant but small: ∼ 0.24 - - 2.2 % depending on the cohort. Thus, hypertension prevalence estimates were not substantially impacted at national scales. However, individual extreme interviewers could account for measurement divergences as high as 12%. Thus, highly biased interviewers could have important impacts on hypertension estimates at the subdistrict level.

Strategies for Sustained Empowerment of Community Health Workers: A Qualitative Analysis of the Comprehensive Rural Health Project in Jamkhed, India

To understand the core aspects of an empowerment-based Community Health Worker (CHW) training program, we studied the model of the Comprehensive Rural Health Project (CRHP) in Jamkhed, India-an organization known for facilitating empowerment of women as Village Health Workers (VHWs) and agents of community change. We define empowerment as a means by which individuals gain health and development-related skills and knowledge to facilitate positive change within their lives and communities. Using VHW training observations and semi-structured interviews with health workers and senior trainers, 6 themes were developed and applied in 4 focus group sessions with 18 multigenerational VHWs trained by the CRHP. Transcripts were qualitatively analyzed under 6 themes-selection, baseline training, continuing education and support, community participation, community empowerment, and commitment and longevity. Empowerment of VHWs was found to be an intentional process involving the creation of safe and supportive environments conducive to long-term participatory and experiential learning with professionals who facilitate and mentor. The impact of the baseline training is maintained through ongoing program-VHW interactions and knowledge reinforcement in both the field and training center. Importantly, these interactions reinforce VHWs' credibility and confidence in communities served. Community participation was found to be of key importance starting at the selection phase. The methods used for selection, training and ongoing support are critical to developing a cadre of competent, effective and motivated VHWs as well as fostering long-lasting self-development and leadership skills. Downstream effectiveness of community empowerment on health outcomes is demonstrated through indicators such as access to safe deliveries, declining child malnutrition rates, high vaccination rates as well as reductions in stigmatization of illness and caste discrimination.

User-Centered Design of a Gamified Mental Health App for Adolescents in Sub-Saharan Africa: Multicycle Usability Testing Study

BACKGROUND

There is an urgent need for scalable psychological treatments to address adolescent depression in low-resource settings. Digital mental health interventions have many potential advantages, but few have been specifically designed for or rigorously evaluated with adolescents in sub-Saharan Africa.

OBJECTIVE

This study had 2 main objectives. The first was to describe the user-centered development of a smartphone app that delivers behavioral activation (BA) to treat depression among adolescents in rural South Africa and Uganda. The second was to summarize the findings from multicycle usability testing.

METHODS

An iterative user-centered agile design approach was used to co-design the app to ensure that it was engaging, culturally relevant, and usable for the target populations. An array of qualitative methods, including focus group discussions, in-depth individual interviews, participatory workshops, usability testing, and extensive expert consultation, was used to iteratively refine the app throughout each phase of development.

RESULTS

A total of 160 adolescents from rural South Africa and Uganda were involved in the development process. The app was built to be consistent with the principles of BA and supported by brief weekly phone calls from peer mentors who would help users overcome barriers to engagement. Drawing on the findings of the formative work, we applied a narrative game format to develop the Kuamsha app. This approach taught the principles of BA using storytelling techniques and game design elements. The stories were developed collaboratively with adolescents from the study sites and included decision points that allowed users to shape the narrative, character personalization, in-app points, and notifications. Each story consists of 6 modules ("episodes") played in sequential order, and each covers different BA skills. Between modules, users were encouraged to work on weekly activities and report on their progress and mood as they completed these activities. The results of the multicycle usability testing showed that the Kuamsha app was acceptable in terms of usability and engagement.

CONCLUSIONS

The Kuamsha app uniquely delivered BA for adolescent depression via an interactive narrative game format tailored to the South African and Ugandan contexts. Further studies are currently underway to examine the intervention's feasibility, acceptability, and efficacy in reducing depressive symptoms.

The implementation and effectiveness of multi-tasked, paid community health workers on maternal and child health: A cluster-randomized pragmatic trial and qualitative process evaluation in Tanzania

Community health worker programs have proliferated worldwide based on evidence that they help prevent mortality, particularly among children. However, there is limited evidence from randomized studies on the processes and effectiveness of implementing community health worker programs through public health systems. This paper describes the results of a cluster-randomized pragmatic implementation trial (registration number ISRCTN96819844) and qualitative process evaluation of a community health worker program in Tanzania that was implemented from 2011-2015. Program effects on maternal, newborn and child health service utilization, childhood morbidity and sick childcare seeking were evaluated using difference-in-difference regression analysis with outcomes measured through pre- and post-intervention household surveys in intervention and comparison trial arms. A qualitative process evaluation was conducted between 2012 and 2014 and comprised of in-depth interviews and focus group discussions with community health workers, community members, facility-based health workers and staff of district health management teams. The community health worker program reduced incidence of illness and improved access to timely and appropriate curative care for children under five; however, there was no effect on facility-based maternal and newborn health service utilization. The positive outcomes occurred because of high levels of acceptability of community health workers within communities, as well as the durability of community health workers' motivation and confidence. Implementation factors that generated these effects were the engagement of communities in program startup; the training, remuneration and supervision of the community health workers from the local health system and community. The lack of program effects on maternal and newborn health service utilization at facilities were attributed to lapses in the availability of needed care at facilities. Strategies that strengthen and align communities' and health systems core capacities, and their ability to learn, adapt and integrate evidence-based interventions, are needed to maximize the health impact of community health workers.

Task-Shifting: Can Community Health Workers Be Part of the Solution to an Inactive Nation?

Background: In low-to-middle income countries (LMICs), there is a growing burden of non-communicable diseases (NCDs) placing strain on the facilities and human resources of healthcare systems. Prevention strategies that include lifestyle behavior counseling have become increasingly important. We propose a potential solution to the growing burden of NCDs through an expansion of the role for community health workers (CHWs) in prescribing and promoting physical activity in public health settings. This discussion paper provides a theoretical model for task-shifting of assessment, screening, counseling, and prescription of physical activity to CHWs. Five proposed tasks are presented within a larger model of service delivery and provide a platform for a structured, standardized, physical activity prevention strategy aimed at NCDs using CHWs as an integral part of reducing the burden of NCDs in LMICs. However, for effective implementation as part of national NCD plans, it is essential that CHWs received standardized, ongoing training and supervision on physical activity and other lifestyle behaviors to optimally impact community health in low resource settings.

Effectiveness of a community health worker-led low-sodium salt intervention to reduce blood pressure in rural Bangladesh: protocol for a cluster randomized controlled trial

BACKGROUND

High blood pressure is a major public health problem in low- and middle-income countries. Low-sodium salt substitute (LSSS) is a promising population-level blood pressure-lowering intervention requiring minimal behavioral change. The optimal method of delivering LSSS to individuals, however, is currently unknown. Community health workers (CHWs) have successfully been used to implement health interventions in Bangladesh and may provide a venue for the dissemination of LSSS.

METHODS

We aim to conduct a cluster-randomized controlled trial involving 309 households in rural Bangladesh previously identified and characterized by the BRAC James P Grant School of Public Health, BRAC University (BRAC JPGSPH). These households will be randomly assigned to three arms: (1) control, i.e., no intervention; (2) information only, i.e., community health workers will provide basic information on high blood pressure, the health consequences of excessive salt consumption, and feedback to the participant on the likely quantity of salt s/he consumes (estimated using a questionnaire); (3) free LSSS arm: the same information as in arm 2 will be provided, but participants will receive 6 months of free low-sodium salt along with education on the benefits of LSSS. One male and one female adult (age ≥ 18 years) in each household will be invited to participate, the exclusion criteria being households with members known to have high serum potassium levels, are taking medications known to elevate potassium levels (e.g., ACE inhibitors, ARBs, potassium-sparing diuretics), are already taking potassium supplements, or those who have known kidney disease or abnormal serum creatinine at baseline. The primary endpoint will be blood pressure at 6 months post-intervention.

DISCUSSION

Recent large clinical trials of LSSS in China and India have shown not only blood pressure improvements, but also stroke, major cardiac event, and all-cause mortality reductions. Nevertheless, how to best translate this intervention to population-level effectiveness remains unclear. Our study would test whether a community health worker-based program could be effectively used to disseminate LSSS and achieve measurable blood pressure benefits.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05425030. Registered on June 21, 2022.

Motivation and job satisfaction of community health workers in Ethiopia: a mixed-methods approach

BACKGROUND

Ethiopia has been providing health care to its rural population since 2004 using female Community Health Workers called Health Extension Workers (HEWs). The HEWs are credited with several achievements in improving the country's health indicators. However, information about the HEWs' motivation and job satisfaction is limited. The aim of this study was to assess the HEWs' motivation and job satisfaction, as well as the factors that influence them.

METHODS

A mixed-methods study was nested within a national health extension program assessment conducted from March 01 to May 31, 2019. A structured questionnaire which looked at motivation and satisfaction with Likert type single-question and multiple-item measures was used to collect quantitative data from 584 HEWs. Focus group discussion and in-depth interviews were used to gather qualitative data. Means and percentages were used to descriptively summarize important variables. Linear regression was used to identify factors associated with job satisfaction. The qualitative data was analysed thematically.

RESULTS

Overall, 48.6% of HEWs were satisfied with their job, with a mean score of 2.5 out of 4.0. The result showed a high level of satisfaction with autonomy (72%), relationships with co-workers (67%), and recognition (56%). Low level of satisfaction was linked to pay and benefits (13%), opportunities for promotion (29%), and education (34%). Regression analysis showed that HEWs in the age category of 30 years and older had lower satisfaction scores as compared to HEWs in the age category of 18-24 years (adjusted β = - 7.71, 95% CI: - 14.42, - 0.99). The qualitative result revealed that desire to help their community, recognition or respect gained from the community, and achievement were the major motivating factors. In contrast, inadequate pay and benefit, limited education and career advancement opportunities, workload, work environment, limited supportive supervision, and absence of opportunity to change workplace were the demotivating factors.

CONCLUSIONS

The overall job satisfaction of HEWs was low; extrinsic factors, such as inadequate pay, limited education and career advancement opportunities were the major sources of demotivation. Policy makers and human resource managers should revise their human resource policies and guidelines to address the main sources of low level of job satisfaction and demotivation.

Acceptability and feasibility of home-based hypertension and physical activity screening by community health workers in an under-resourced community in South Africa

Background

Low-middle-income countries (LMICs) face increasing burdens from non-communicable disease (NCDs) requiring primary care task shifting to community health workers (CHWs). This study explored community members' perceptions of NCD-focused, CHW-led home visits in a historically disadvantaged township of South Africa.

Methods

Trained CHWs visited community member homes, performing blood pressure and physical activity (PA) screenings, followed by brief counselling and a satisfaction survey. Semi-structured interviews were conducted within 3 days of the visit to learn about their experiences.

Results

CHWs visited 173 households, with 153 adult community members consenting to participate (88.4%). Participants reported that it was easy to understand CHW-delivered information (97%), their questions were answered well (100%), and they would request home service again (93%). Twenty-eight follow-up interviews revealed four main themes: 1) acceptance of CHW visits, 2) openness to counselling, 3) satisfaction with screening and a basic understanding of the results, and 4) receptiveness to the PA advice.

Conclusion

Community members viewed CHW-led home visits as an acceptable and feasible method for providing NCD-focused healthcare services in an under-resourced community. Expanding primary care reach through CHWs offers more accessible and individualized care, reducing barriers for individuals in under-resourced communities to access support for NCD risk reduction.

Evaluation of healthcare facilities and personnel distribution in Lagos State: implications on universal health coverage

BACKGROUND

Nigeria is considering making Universal Health Coverage (UHC) a common policy goal to ensure that citizens have access to high-quality healthcare services without crippling debt. Globally, there is an acute shortage of human resources for Health (HRH), and the most significant burden is borne by low-income countries, especially in sub-Saharan Africa. This shortage has considerably constrained the achievement of health-related development goals and impeded accelerated progress toward universal health coverage. We examine the existing human resource capacity and the distribution of health facilities in Lagos state in this study, discussing the implications of our findings.

METHODS

The study is descriptive using secondary data analysis. We leverage census-based primary data collected by NOIPoll on health facility assessments in Lagos state. The collected data was analyzed using counts, ratios, rates, and percentages.

RESULTS

We observe a ratio of 5,014 people to 1 general medical doctor, 2,942 people to 1 specialist, 2,165 people to 1 nurse, and 5,117 people to 1 midwife, which are far higher than the WHO recommendation. We also observe that the ratio of nurses to general medical practitioners is 2.2:1 in urban areas and 2.7:1 in rural. In contrast, the ratio of nurses to specialist medical doctors is 1.3:1 in the urban area and 1.5:1 in the rural areas of Lagos state. The overall nurse per general medical practitioner ratio is 2.3:1 and 1.4:1 for specialist medical doctors. 77.2% of the health facilities surveyed were in the urban areas, with private-for-profit facilities accounting for 82.9%, government facilities accounting for 15.4%, and NGOs/faith clinics accounting for 1.7%. Primary healthcare facilities account for 75.3% of the facilities surveyed, secondary and tertiary facilities account for 24.6% and 0.08%, respectively. Alimosho LGA has the most health facilities (77.38% PHCs, and 22.62% SHCs) and staff strength specifically for general medical practitioners, specialists, nurses, and midwives (16.9%, 19.9%, 16.7%, 17.1%, respectively). Eti-Osa LGA has the best density ratio for generalist doctors, specialist doctors, and nurses per 10,000 (4.42, 12.96, and 11.34 respectively), while Ikeja has the best midwife population density ratio 5.46 per 10,000 population.

CONCLUSION

The distribution of health personnel and facilities in Lagos State is not equitable, with evident variation between rural and urban areas. This inequitable distribution could affect the physical distance of health facilities to residents, leading to decreased utilization, ultimately poor health outcomes, and impaired access. Much like child mortality, maternal mortality also exhibits a correlation with healthcare worker density. As the physician density increases linearly, the maternal mortality rate decreases exponentially. However, due to the low number of healthcare workers in Lagos state, doctors, nurses, and midwives are frequently unavailable during childbirth, resulting in increasing infant, neonatal, and maternal death. As such, the government should adopt the UHC strategy in its distribution of facilities and personnel in the state for adequate coverage and optimal performance of the facilities. Also, additional investments are needed in some parts of the state to improve access to tertiary health facilities and leverage private sector capacity.

Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia

National community health worker (CHW) programmes were central to the vision of primary health care that emerged from the Alma-Ata declaration of 1978. CHWs were identified as agents who could offer basic medical treatment and promote community participation and empowerment. Despite the ambitions of this era, many national CHW programmes were neglected, starved of funding, or discontinued in the decades that followed. These programmes were difficult to sustain in a context of rising debt and structural adjustment, but they also suffered due to poor implementation and a lack of clarity about the role and identity of CHWs. Nevertheless, national CHW programmes have returned to the policy agenda in the past fifteen years and key figures and organisations within global health have begun to argue that they offer a way of strengthening health systems and achieving universal health coverage (UHC). Based on ethnographic research conducted between 2019 and 2020, this article examines a new national CHW programme that has been introduced in Zambia. However, as I show in this article, Zambia's new CHW programme has suffered from many of the same key problems that affected the programmes of the Alma-Ata era: insufficient funding, poor implementation, and a lack of clarity about the role of CHWs. This article shows how these mistakes have been repeated and asks why the lessons of the Alma-Ata era have been lost. Three central problems are identified: national CHW programmes continue to be underfunded and regarded as a "cheap" solution; global health organisations and actors today prioritise technical and quantitative approaches when they design and implement these programmes and therefore overlook the historical experiences and qualitative research of the past thirty years; and, finally, policymakers continue to gloss over the tensions and contradictions within the idea of the "community health worker" itself, creating unclear and unrealistic expectations for CHWs.

The Laro Kwo Project: A train the trainer model combined with mobile health technology for community health workers in Northern Uganda

Community Health Workers (CHWs) in low and middle income countries (LMICs) provide invaluable health resources to their community members. Best practices for developing and sustaining CHW training programs in LMICs have yet to be defined using rigorous standards and measures of effectiveness. With the expansion of digital health to LMICs, few studies have evaluated the role of participatory methodologies combined with the use of mobile health (mHealth) for CHW training program development. We completed a three-year prospective observational study aligned with the development of a community-based participatory CHW training program in Northern Uganda. Twenty-five CHWs were initially trained using a community participatory training methodology combined with mHealth and a train-the-trainer model. Medical skill competency exams were evaluated after the initial training and annually thereafter to assess retention with use of mHealth. After three years, CHWs who advanced to trainer status redeveloped all program materials using a mHealth application and trained a new cohort of 25 CHWs. Implementation of this methodology coupled with longitudinal mHealth training demonstrated an improvement in medical skills over three years among the original cohort of CHWs. Further, we found that the train-the-trainer model with mHealth was highly effective, as the new cohort of 25 CHWs trained by the original CHWs exhibited higher scores when tested on medical skill competencies. The combination of mHealth and participatory methodologies can facilitate the sustainability of CHW training programs in LMIC. Further investigations should focus on comparing specific mHealth modalities for training and clinical outcomes using similar combined methodologies.

How valid are women's reports of the antenatal health services they receive from Community Health Workers in Gombe State north-eastern Nigeria?

BACKGROUND

Community health workers (CHWs) in low- and middle-income countries are key to increasing coverage of maternal and newborn interventions through home visits to counsel families about healthy behaviours. Household surveys enable tracking the progress of CHW programmes but recent evidence questions the accuracy of maternal reports. We measured the validity of women's responses about the content of care they received during CHW home visits and examined whether the accuracy of women's responses was affected by CHW counselling skills.

METHODS

We conducted a criterion validity study in 2019, in Gombe State-Nigeria, and collected data from 362 pregnant women. During accompanied CHW home visits the content of CHW care and the presence or absence of 18 positive counselling skills were observed and documented by a researcher. In a follow-up interview three months later, the same women were asked about the care received during the CHW home visit. Women's reports were compared with observation data and the sensitivity, specificity, and area under receiver curve (AUC) calculated. We performed a covariate validity analysis that adjusted for a counselling skill score to assess the variation in accuracy of women's reports with CHW counselling skills.

RESULTS

Ten indicators were included in the validity analysis. Women consistently overestimated the content of care CHWs provided and no indicator met the condition for individual-level accuracy set at AUC ≥ 0.6. The CHW counselling skill score ranged from 9-18 points from a possible 18, with a mean of 14.3; checking on client history or concerns were the most frequently missed item. There was evidence that unmarried women and the relatively most poor women received less skilled counselling than other women (mean counselling scores of 13.2 and 13.7 respectively). There was no consistent evidence of an association between higher counselling skill scores and better accuracy of women's reports.

CONCLUSIONS

The validity of women's responses about CHW care content was poor and consistently overestimated coverage. We discuss several challenges in applying criterion validity study methods to examine measures of community-based care and make only cautious interpretation of the findings that may be relevant to other researchers interested in developing similar studies.

Cultural Adaptation and Validation of the General Self-Efficacy Scale in Ugandan Community Health Workers

Self-efficacy is central to community health workers' capacity and motivation to deliver evidence-based care; thus, validated measures of self-efficacy are needed to assess the effectiveness of community health worker programs. In this study, we culturally adapted and evaluated the General Self-Efficacy Scale among community health workers in Uganda using multiple methods. We adapted the ten-item General Self-Efficacy Scale through cross-cultural discussions within our multidisciplinary research team, translation from English into Luganda and back-translation into English, and six cognitive interviews with community health workers. We administered the adapted scale in a staged, two-part cross-sectional study, including a total of 147 community health workers. Exploratory factor analysis yielded three factors, which we labeled problem-solving, persistence, and resourcefulness. This three-factor solution had good model fit (standardized root mean square residual = 0.07) and explained 53.4% of the variance. We found evidence of convergent validity, as scores for the total scale were positively correlated with years of experience (r = 0.48; p < .001) and perceived social support (r = 0.39, p < .001). Scores were also higher among those with higher educational attainment in one-way analysis of variance and Bonferroni-corrected post hoc tests [F (2,72) = 9.16, p < .001]. We also found evidence of discriminant validity, as scores for the total scale were not correlated with age (r = - 0.07, p = .55), in agreement with literature showing that general self-efficacy is an age-independent construct. The internal consistency of the adapted scale was within the acceptable range for a pilot study (Cronbach's α = 0.61). This evaluation of a Uganda-adapted General Self-Efficacy Scale demonstrated promising psychometric properties; however, larger studies with repeated measures are warranted to further assess the adapted scale's factor structure, validity, reliability, and stability over time.

Knowledge, causes, and experience of inter-professional conflict and rivalry among healthcare professionals in Nigeria

Introduction

The healthcare workforce is regarded as an essential component of any functioning health system, and a lack of optimal collaboration among this group can result to poor quality healthcare services to the population. In Nigerian setting, the health sector is faced with challenges of inter-professional conflict and rivalry. This study aimed at understanding knowledge, causes, and experience of inter-professional conflict and rivalry among healthcare professionals in Nigeria.

Methods

A cross sectional study was undertaken to administer questionnaires to healthcare personnel in various healthcare facilities in Nigeria. Data were analysed using Statistical Package for Social Sciences.

Results

A total of 2207 valid responses were received, and male participants were in majority as indicated by 63.7% of the sample. Collectively, doctors and pharmacists represented two-thirds of the sample, and majority of the participants were in the public sector (82.5%). Disparity in salary structure was the highest source of conflict. Whilst almost all the participants indicated that inter-professional rivalry and conflict are prevalent in health sector, about three-quarters of them (73.2%) disagreed that this practice is productive. A considerable number of the respondents had experienced inter-professional conflict and rivalry.

Conclusion

Evidence from this study can help policymakers in developing framework that can be utilised in addressing rivalry and conflict in the healthcare sector.

Developing organizational learning for scaling-up community-based primary health care in Ghana

INTRODUCTION

Achieving effective community-based primary health care requires evidence for guiding strategic decisions that must be made. However, research processes often limit data collection to particular organizational levels or disseminate results to specific audiences. Decision-making that emerges can fail to account for the contrasting perspectives and needs of managers at each organizational level. The Ghana Health Service (GHS) addressed this problem with a multilevel and sequential research and action approach that has provided two decades of implementation learning for guiding community-based primary health care development.

METHOD

The GHS implementation research initiatives progressed from (i) a participatory pilot investigation to (ii) an experimental trial of strategies that emerged to (iii) replication research for testing scale-up, culminating in (iv) evidence-based scale-up of a national community-based primary health care program. A reform process subsequently repeated this sequence in a manner that involved stakeholders at the community, sub-district, district, and regional levels of the system. The conduct, interpretation, and dissemination of results that emerged comprised a strategy for achieving systems learning by conducting investigations in phases in conjunction with bottom-up knowledge capture, lateral exchanges for fostering peer learning at each system level, and top-down processes for communicating results as policy. Continuous accumulation of qualitative data on stakeholder reactions to operations at each organizational level was conducted in conjunction with quantitative monitoring of field operations.

RESULTS

Implementation policies were enhanced by results associated with each phase. A quasi-experiment for testing the reform process showed that scale-up of community-based primary health care was accelerated, leading to improvements in childhood survival and reduced fertility.

CONCLUSION

Challenges to system learning were overcome despite severe resource constraints. The integration of knowledge generation with ongoing management processes institutionalized learning for achieving evidence-driven program action.

Inclusive partnership and community mobilization approaches to improve maternal health care access among internal migrants in nine Indian cities

Background

Disparities in healthcare access to internal migrants exist, and the gaps may widen further if appropriate steps are not taken. Innovative approaches are needed to better align the healthcare services with the migrants’ needs.

Aim

The aim was to develop and test a supportive strategy of healthcare, which would achieve the desired level of access and delivery of maternal healthcare services to internal migrants living in nine Indian cities.

Methods

This intervention with the quasi-experimental design was conducted with pre- vs post-intervention comparisons within the interventional groups and with the control group. The intervention was implemented with an inclusive partnership approach. Advocacy and community mobilization were the main intervention components.

Findings

An increased proportion of women sought antenatal care during the intervention. More women initiated seeking antenatal care in the first trimester. Due to intervention, health workers’ prenatal (41.7% in the post- against 14.7% in the pre-interventional phase) and postnatal home visits increased (11.6% to 34.7%) considerably.

Conclusions

Interventions with inclusive partnership would improve healthcare access to vulnerable communities such as migrants. Hence, efforts to strengthen the government healthcare system through novel strategies are crucial to provide better healthcare to migrants.

Scorecard metrics for assessing the extent of integration of community health worker programmes into national health systems

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.

Community health worker home visiting in deeply rural South Africa: 12-month outcomes

Home visiting by community health workers (CHW) improves child outcomes in efficacy trials, there is however limited evidence of impact evaluating CHW programmes when operating outside of a research project. A CHW programme, previously demonstrated efficacious in a peri-urban township, was evaluated in a deeply rural context in a non-randomised comparative cohort study. Two non-contiguous, rural areas in the Eastern Cape of South Africa of about equal size and density were identified and 1469 mother-infant pairs were recruited over 33 months. In one area, CHWs conducted perinatal home visits (intervention group). Mothers in the comparison group received standard clinic care. Maternal and child outcomes were compared between the groups at one year. Mothers in the intervention group had significantly fewer depressive symptoms than mothers in the comparison group. Children of intervention mothers attained a higher proportion of their developmental milestones, compared to children in the comparison group. There were no other significant differences between mothers and children in the two groups. It is important to establish key parameters for implementing efficacious CHW programmes, especially as the numbers of CHWs are rapidly increased and are becoming critical components of task-shifting strategies of health departments in low and middle income countries (LMIC).

Community's experience and perceptions of maternal health services across the continuum of care in Ethiopia: A qualitative study

BACKGROUND

Continuum of care is an effective strategy to ensure that every woman receives a series of maternal health services continuously from early pregnancy to postpartum stages. The community perceptions regarding the use of maternal services across the continuum of care are essential for utilization of care in low-income settings but information in that regard is scanty. This study explored the community perceptions on the continuum of care for maternal health services in Ethiopia.

METHODS

This study employed a phenomenological qualitative research approach. Four focus group discussions involving 26 participants and eight in-depth interviews were conducted with women who recently delivered, community health workers, and community leaders that were purposively selected for the study in West Gojjam zone, Amhara region. All the interviews and discussions were audio-taped; the records were transcribed verbatim. Data were coded and analyzed thematically using ATLAS.ti software.

RESULTS

We identified three primary themes: practice of maternal health services; factors influencing the decision to use maternal health services; and reasons for discontinuation across the continuum of maternal health services. The study showed that women faced multiple challenges to continuously uptake maternal health services. Late antenatal care booking was the main reasons for discontinuation of maternal health services across the continuum at the antepartum stage. Women's negative experiences during care including poor quality of care, incompetent and unfriendly health providers, disrespectful care, high opportunity costs, difficulties in getting transportation, and timely referrals at healthcare facilities, particularly at health centers affect utilization of maternal health services across the continuum of care. In addition to the reverberation effect of the intrapartum care factors, the major reasons mentioned for discontinuation at the postpartum stage were lack of awareness about postnatal care and service delivery modality where women are not scheduled for postpartum consultations.

CONCLUSION

This study showed that rural mothers still face multiple challenges to utilize maternal health services as recommended by the national guidelines. Negative experiences women encountered in health facilities, community perceptions about postnatal care services as well as challenges related to service access and opportunity costs remained fundamental to be reasons for discontinuation across the continuum pathways.

Role of community health volunteers in identifying people with elevated blood pressure for diagnosis and monitoring of hypertension in Malawi: a qualitative study

Background

In recent years, there has been greater recognition of the important role of community health volunteers in many countries and their important role informs many health programs. This include health education, provision of services such as screening, monitoring and referral to health facilities. Their roles are better understood in the areas of communicable diseases like HIV infection, Tuberculosis and Malaria however little is known about their role in non-communicable diseases. This study seeks to explore perception of CHVs’ functions, tasks, and their fulfilment in identifying people with elevated blood pressure for diagnosis and monitoring of hypertension in Lilongwe, Malawi.

Methods

This was a qualitative naturalistic research design utilizing observation and semi-structured interviews with community health volunteers working in Lilongwe, Malawi. Interviews were carried out with the researcher. Participants were recruited from the ZaMaC project. An interview guide was developed with a category-guided deductive approach. The interviews were recorded through note taking. Data analysis was performed using content analysis approach.

Results

Community health volunteers have multiple roles in prevention and monitoring of hypertension. They act as health educators and provide lifestyle counselling. They screened for hypertension and monitored blood pressure and assisted community members to navigate the health system such as linkage to health facilities. These roles were shaped in response to community needs.

Conclusion

This study indicates the complexities of the roles of community health volunteer in identifying people with elevated BP for diagnosis and monitoring of hypertension. Understanding community health volunteers’ roles provides insight into their required competencies in provision of their daily activities as well as required training to fill in their knowledge gaps.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02171-7.

Caregivers' perspectives of the challenges faced with survivors of traumatic brain injury: A scoping review

INTRODUCTION

Traumatic Brain Injury (TBI) has wide-ranging neuropsychological, physical, social and financial implications. The impact on caregivers of moderate to severe TBI survivors, particularly in low- and middle-income countries, is under-investigated.

AIM

Identify and describe the experiences of caregivers' of moderate to severe TBI survivors postdischarge from healthcare facilities.

METHODS

A scoping review was conducted utilising seven electronic databases. Two reviewers screened articles using eligibly criteria related to setting (postdischarge), caregiving (informal), age of TBI survivors (>  18 years) and injury severity (moderate-severe). Studies published in English between 1999 -2018 were included.

RESULTS

Fourteen articles met the inclusion criteria. Articles reporting on the same sample were merged during data charting. The final analyses included 11 articles comprised of qualitative, quantitative and mixed-methods studies. Ten themes were identified: psychological distress, social functioning, financial burden, family experiences, coping strategies, access to services, time burdens and physical, cognitive and behavioural difficulties. Characteristics of caregivers and TBI survivors were also reported.

CONCLUSION

Caregivers of moderate to severe TBI survivors experience challenges in various life domains, and there is limited research concerning caregivers in low- and middle-income countries. Future research should focus on understanding more nuanced experiences across various environments, which may increase comprehensive, flexible and long-term support.

Burnout among primary health care workers in Brazil: results of a multilevel analysis

PURPOSE

Burnout among health care workers may hamper the quality of care and effectiveness of health systems. Hence, we examined the prevalence of burnout in primary care teams, including community health workers; and investigated associations between individuals' characteristics, team and primary care center factors, and burnout.

METHODS

We carried out a cross-sectional study among primary care teams in the city of São Paulo, Brazil (n = 2940). We randomly selected 66 primary care centers. The Maslach burnout inventory was used to investigate burnout. We used multilevel modelling to examine the associations between individuals' characteristics, team and primary care center variables with burnout.

RESULTS

We addressed 351 primary care teams, with 11.4% of participants presenting severe burnout. The variance in burnout among primary care workers was partially explained by individuals' characteristics, and by team and primary care center factors. Severe burnout was associated with the following: (1) individuals' characteristics: being black, being younger, a higher length of employment in primary care, and presenting a lack of feedback from supervisors; (2) team factors: working in deprived areas and not receiving the support of a multidisciplinary team; and (3) primary care center factors: inadequate infrastructure (less than one office available per team), and having a bad/very bad relationship with the community council.

CONCLUSIONS

To reduce burnout among primary care teams, stakeholders should: (1) train managers/supervisors on leadership styles that prioritize performance feedback, support, and communication skills; (2) allocate catchment areas to teams according to each community's vulnerability; (3) provide a multidisciplinary team to support primary care workers; and (4) offer suitable facilities and infra-structure.

Improving maternal, newborn and child health outcomes through a community-based women's health education program: a cluster randomised controlled trial in western Kenya

Introduction

Community-based women’s health education groups may improve maternal, newborn and child health (MNCH); however, evidence from sub-Saharan Africa is lacking. Chamas for Change (Chamas) is a community health volunteer (CHV)-led, group-based health education programme for pregnant and postpartum women in western Kenya. We evaluated Chamas’ effect on facility-based deliveries and other MNCH outcomes.

Methods

We conducted a cluster randomised controlled trial involving 74 community health units in Trans Nzoia County. We included pregnant women who presented to health facilities for their first antenatal care visits by 32 weeks gestation. We randomised clusters 1:1 without stratification or matching; we masked data collectors, investigators and analysts to allocation. Intervention clusters were invited to bimonthly, group-based, CHV-led health lessons (Chamas); control clusters had monthly, individual CHV home visits (standard of care). The primary outcome was facility-based delivery at 12-month follow-up. We conducted an intention-to-treat approach with multilevel logistic regression models using individual-level data.

Results

Between 27 November 2017 and 8 March 2018, we enrolled 1920 participants from 37 intervention and 37 control clusters. A total of 1550 (80.7%) participants completed the study with 822 (82.5%) and 728 (78.8%) in the intervention and control arms, respectively. Facility-based deliveries improved in the intervention arm (80.9% vs 73.0%; risk difference (RD) 7.4%, 95% CI 3.0 to 12.5, OR=1.58, 95% CI 0.97 to 2.55, p=0.057). Chamas participants also demonstrated higher rates of 48 hours postpartum visits (RD 15.3%, 95% CI 12.0 to 19.6), exclusive breastfeeding (RD 11.9%, 95% CI 7.2 to 16.9), contraceptive adoption (RD 7.2%, 95% CI 2.6 to 12.9) and infant immunisation completion (RD 15.6%, 95% CI 11.5 to 20.9).

Conclusion

Chamas participation was associated with significantly improved MNCH outcomes compared with the standard of care. This trial contributes robust data from sub-Saharan Africa to support community-based, women’s health education groups for MNCH in resource-limited settings.

Trial registration number

NCT03187873.

Characterization and distribution of medicine vendors in 2 states in Nigeria: implications for scaling health workforce and family planning services

BACKGROUND

In 2014, Nigeria issued the task-shifting/sharing policy for essential health services, which aimed to fill the human resource gap and improve the delivery of health services across the country. This study focuses on the characteristics, spread, and family planning (FP) stocking practices of medicine vendors in Lagos and Kaduna, assessing the influence of medical training on the provision and stocking of FP services and commodities by vendors.

METHODS

We conducted a census of all Patent Medicines stores (PMS) followed up with a facility assessment among 10% of the mapped shops, utilizing an interviewer-administered questionnaire. Bivariate analysis was conducted using the Chi-square test, and multiple logistic regression was used to estimate the adjusted odds ratio (OR) and confidence intervals (CI) for the test of significance in the study.

RESULTS

A total of 8318 medicine shops were enumerated (76.2% urban). There were 39 shops per 100,000 population in both states on average. About half (50.9%) were manned by a medicine vendor without assistance, 25.7% claimed to provide FP services to > 2 clients per week, and 11.4% were not registered with the regulatory body or any professional association. Also, 28.2% of vendors reported formal medical training, with 56.3% of these medically trained vendors relatively new in the business, opening within the last 5 years. Vendors utilized open drug markets as the major source of supply for FP products. Medical training significantly increased the stocking of FP products and inhibited utilization of open drug markets.

CONCLUSION

Patent and Proprietary Medicines Vendor (PPMVs) have continued to grow progressively in the last 5 years, becoming the most proximal health facility for potential clients for different health services (especially FP services) across both Northern and Southern Nigeria, now comprising a considerable mass of medically trained personnel, able to deliver high-quality health services and complement existing healthcare infrastructure, if trained. However, restrictions on services within the PPMV premise and lack of access to quality drugs and commodities have resulted in poor practices among PPMVs. There is therefore a need to identify, train, and provide innovative means of improving access to quality-assured products for this group of health workers.

Gender intentional approaches to enhance health social enterprises in Africa: a qualitative study of constraints and strategies

BACKGROUND

Health social enterprises are experimenting with community health worker (CHW) models that allow for various income-generating opportunities to motivate and incentivize CHWs. Although evidence shows that improving gender equality contributes to the achievement of health outcomes, gender-based constraints faced by CHWs working with social enterprises in Africa have not yet been empirically studied. This study is the first of its kind to address this important gap in knowledge.

METHODS

We conducted 36 key informant interviews and 21 focus group discussions between 2016 and 2019 (for a total of 175 individuals: 106 women and 69 men) with four health social enterprises in Uganda and Kenya and other related key stakeholders and domain experts. Interview and focus group transcripts were coded according to gender-based constraints and strategies for enhanced performance as well as key sites for intervention.

RESULTS

We found that CHW programs can be more gender responsive. We introduce the Gender Integration Continuum for Health Social Enterprises as a tool that can help guide gender equality efforts. Data revealed female CHWs face seven unique gender-based constraints (compared to male CHWs): 1) higher time burden and lack of economic empowerment; 2) risks to personal safety; 3) lack of career advancement and leadership opportunities; 4) lack of access to needed equipment, medicines and transport; 5) lack of access to capital; 6) lack of access to social support and networking opportunities; and 7) insufficient financial and non-financial incentives. Data also revealed four key areas of intervention: 1) the health social enterprise; 2) the CHW; 3) the CHW's partner; and 4) the CHW's patients. In each of the four areas, gender responsive strategies were identified to overcome constraints and contribute to improved gender equality and community health outcomes.

CONCLUSIONS

This is the first study of its kind to identify the key gender-based constraints and gender responsive strategies for health social enterprises in Africa using CHWs. Findings can assist organizations working with CHWs in Africa (social enterprises, governments or non-governmental organizations) to develop gender responsive strategies that increase the gender and health outcomes while improving gender equality for CHWs, their families, and their communities.

Bugs in the Bed: Addressing the Contradictions of Embedded Science with Agile Implementation Research

Implementation research often fails to have its intended impact on what programs actually do. Embedding research within target organizational systems represents an effective response to this problem. However, contradictions associated with the approach often prevent its application. We present case studies of the application of embedded implementation research in Bangladesh, Ghana, and Tanzania where initiatives to strengthen community-based health systems were conducted using the embedded science model. In 2 of the cases, implementation research standards that are typically embraced without question were abandoned to ensure pursuit of embedded science. In the third example, statistical rigor was sustained, but this feature of the design was inconsistent with embedded science. In general, rigorous statistical designs employ units of observation that are inconsistent with organizational units that managers can control. Structural contradictions impede host institution ownership of research processes and utilization of results. Moreover, principles of scientific protocol leadership are inconsistent with managerial leadership. These and other embedded implementation science attributes are reviewed together with contradictions that challenged their pursuit in each case. Based on strategies that were effectively applied to offsetting challenges, a process of merging research with management is proposed that is derived from computer science. Known as "agile science," this paradigm combines scientific rigor with management decision making. This agile embedded research approach is designed to sustain scientific rigor while optimizing the integration of learning into managerial decision making.

Liberia's Community Health Assistant Program: Scale, Quality, and Resilience

Liberia's community health program went from concept to nationwide scale in 4 years due to the Liberian Government's vision and its partnership with implementing organizations and donors. The next community health policy will tackle the unfinished agenda related to quality, resilience, and sustainability. Liberia's experience offers valuable lessons for innovating, and institutionalizing a compensated, effective cadre of community health assistants.

Come together to promote health: case study and theoretical perspectives from a Kenyan community-based program

Over the past four decades, group-based microfinance programs have spread rapidly throughout south Asia, sub-Saharan Africa and Latin America. Recent evaluations of the programs have identified social capital as a common byproduct of frequent association by members, increasing trust, belonging and normative influence. Concurrently, social capital is increasingly recognized as an important health determinant. We present an overview of a program intervention operating in Kenya that utilizes a microfinance approach to produce social capital, and seeks to leverage that social capital to promote health at three levels-the village, group, and individual. A theory of change is presented for each of these three levels, demonstrating conceptually and with program examples how social capital can be applied to promote health. Related social theories and approaches, further research and program directions are given for each of the three levels. We identify potential to improve a broad range of health outcomes through this innovative model, which requires engagement with health promotion researchers and planners in low- and middle-income countries for further refinement and validation.

Integrated care by community health workers in Malawi: Rehabilitation and blood pressure monitoring

Background

Community health workers (CHWs) are essential providers of integrated care for people in low-resourced settings with a high burden from noncommunicable diseases (NCDs).

Aims

The purpose of this study was to evaluate a CHW training program in rural Malawi integrating blood pressure (BP) monitoring into rehabilitation care.

Methods

This was a retrospective cross-sectional study. The participants were a convenience sample of home-based palliative care CHWs at the local hospital (n = 59). Data collected included: a written pre- and post-knowledge test, skills competency checklist and a post-training program survey. Descriptive frequencies and paired t-tests (a = 0.05) were used for quantitative analyses. Themes in narrative responses in the post-training survey were analyzed qualitatively.

Results

Participant knowledge regarding BP monitoring procedures improved significantly on the post-test (M = 8.24, SD = 1.654) compared to the pre-test (M = 6.59, SD = 1.683), Z (49) = −5.569, p < 0.001. The pre-and post-tests were scored 0–10 points. All participants demonstrated competency in 100% of the skills. Participants reported the lack of transportation, teamwork and resources as barriers to their work. They reported trainings and opportunities to collaborate as facilitators to their work.

Discussion

This study demonstrated the effectiveness of a training program for CHWs which integrated BP monitoring with rehabilitation care for people with NCDs. This retention of knowledge and application to clinical practice serve as strong indicators of the feasibility and sustainability of the CHW training and care delivery program in resource-limited settings.

Conclusion

Our findings help demonstrate that training CHWs can be an effective way to help bridge the gap in health care access for people with disabilities in resource-limited countries.

A Cluster-Randomized Trial to Test Sharing Histories as a Training Method for Community Health Workers in Peru

Women naturally communicate using life narratives. Through systematic recall and sharing memories of their own childbearing and child rearing experiences, community health workers (CHWs) become engaged and empowered to change their own and other mothers’ health behaviors. Training CHW with sharing histories can improve capabilities as change agents for better child health.

Background:

Community health workers (CHWs) are increasingly deployed to support mothers’ adoption of healthy home practices in low- and middle-income countries. However, little is known regarding how best to train them for the capabilities and cultural competencies needed to support maternal health behavior change. We tested a CHW training method, Sharing Histories (SH), in which CHWs recount their own childbearing and childrearing experiences on which to build new learning.

Methods:

We conducted an embedded cluster-randomized trial in rural Peru in 18 matched clusters. Each cluster was a primary health facility catchment area. Government health staff trained female CHWs using SH (experimental clusters) or standard training methods (control clusters). All other training and system-strengthening interventions were equal between study arms. All CHWs conducted home visits with pregnant women and children aged 0–23 months to teach, monitor health practices and danger signs, and refer. The primary outcome was height-for-age (HAZ)<−2 Z-scores (stunting) in children aged 0–23 months. Household surveys were conducted at baseline (606 cases) and 4-year follow-up (606 cases).

Results:

Maternal and child characteristics were similar in both study arms at baseline and follow-up. Difference-in-differences analysis showed mean HAZ changes were not significantly different in experimental versus control clusters from baseline to endline (P=.469). However, in the subgroup of literate mothers, mean HAZ improved by 1.03 on the Z-score scale in experimental clusters compared to control clusters from baseline to endline (P=.059). Using generalized estimating equations, we demonstrated that stunting in children of mothers who were literate was significantly reduced (Beta=0.77; 95% confidence interval=0.23, 1.31; P<.01), adjusting for covariates.

Conclusion:

Compared with standard training methods, SH may have improved the effectiveness of CHWs as change agents among literate mothers to reduce child stunting. Stunting experienced by the children of illiterate mothers may have involved unaddressed determinants of stunting.

Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa: a meta-synthesis protocol

INTRODUCTION

In sub-Saharan Africa (SSA), Human Immunodeficiency Virus (HIV) is the leading cause of morbidity and mortality. Community healthcare workers (CHWs) worldwide have been reported to be effective in strengthening the HIV programme by providing services such as adherence support, HIV education and safe sex education as part of their roles. The main aim of this meta-synthesis is to synthesise qualitative evidence on studies that have been conducted in SSA countries to understand the barriers to and facilitators of providing HIV services by CHWs across all settings METHODS AND ANALYSIS: This meta-synthesis will be guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An initial search was conducted on 15 November 2019 for studies published between 2009 and 2019 using the population exposure outcome nomenclature. We searched the EBSCOHost- (ERIC; Health Source-Nursing/Academic Edition), Google Scholar and PubMed databases for the relevant studies. The Ritchie and Spencer framework will be used for data synthesis and the Supporting the Use of Research Evidence Framework analysis will be used to analyse data. We will conduct critical appraisal on selected studies using the Qualitative Assessment and Review Instrument to limit risk of bias.

ETHICS AND DISSEMINATION

This review does not involve any human participants and therefore ethical approval will not be required. We will publish the protocol as well as the findings in any relevant journal and various media namely conferences; symposia, local and international health stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42020160012.

CONCLUSION

Evidence from this review will provide synthesised evidence to the utilisation of CHWs in HIV services in SSA.

Enhancing Knowledge in Informal Settlements: Assessing Health Beliefs and Behaviors in Nigeria: A cross-sectional survey assessment of perceptions, practices, and resources in underserved urban communities in Lagos

Background

Community Health Education (CHE) programs have been shown to be effective in relieving the burden on healthcare systems in Sub-Saharan Africa.

Objective

This project aimed to determine the baseline level of health literacy, behavioral practices, and accessibility to resources in a set of 16 informal settlements located around Lagos, Nigeria in order to identify topics that should be emphasized in a new teaching curriculum directed at local Community Health Educators.

Methods

In June of 2017, a unique cross-sectional survey composed of 37 questions was conducted in informal settlements around Lagos. Sites selected were areas in which future CHE trainings were planned to take place and survey participants were chosen by trained community health educators based on convenience sampling with snowball effect. Survey questions included both multiple-choice and open-ended questions and were asked in the local language. We collected demographic information and assessed health literacy, health behaviors, and community practices. Results were analyzed using descriptive statistics to assess for differences between demographic groups.

Findings

Our survey collected 348 total responses. Respondents displayed a high level of knowledge regarding the benefits of hand washing (97.1%) and childhood immunizations (81.0%). Knowledge around infectious diseases and reproductive health was lower, including a large proportion of people (50%) incorrectly indicating that HIV could be spread through a mosquito bite. Malaria was reported to be the most prevalent disease affecting both adults (40.0%) and children (58.3%). Health access was limited, with most people not reporting access to a nearby health center (55.8%).

Conclusions

Areas of knowledge that should be emphasized in future versions of CHE training curricula include infectious diseases, reproductive health, and reinforcement of the importance of sanitation and clean water. The curriculum should address the reality of limited health access and develop strategies to improve this.

"They have been neglected for a long time": a qualitative study on the role and recognition of rural health motivators in the Shiselweni region, Eswatini

BACKGROUND

Community health workers (CHWs) are increasingly engaged to address human resource shortages and fill primary healthcare gaps. In Eswatini, a cadre of CHWs called Rural Health Motivators (RHM) was introduced in 1976 to respond to key public health challenges. However, the emergence of health needs, particularly HIV/TB, has been met with inadequate programme amendments, and the role of RHMs has become marginalised following the addition of other CHWs supported by non-governmental organisations. This study was implemented to understand the role of RHMs in decentralised HIV/TB activities. In this paper, we explore the findings in relation to the recognition of RHMs and the programme.

METHODS

This exploratory qualitative study utilised individual in-depth interviews, group and focus group discussions, participatory methods (utilising a game format) and observations. Participants were purposively selected and comprised RHM programme implementers, community stakeholders and local and non-governmental personnel. Data collection took place between August and September 2019. Interviews were conducted in English or siSwati and transcribed. SiSwati interviews were translated directly into English. All interviews were audio-recorded, manually coded and thematically analysed. Data was validated through methodical triangulation.

RESULTS

Suboptimal organisational structure and support, primarily insufficient training and supervision for activities were factors identified through interviews and observation activities. Significant confusion of the RHM role was observed, with community expectations beyond formally endorsed tasks. Community participants expressed dissatisfaction with receiving health information only, preferring physical assistance in the form of goods. Additionally, gender emerged as a significant influencing factor on the acceptability of health messages and the engagement of RHMs with community members. Expectations and structurally limiting factors shape the extent to which RHMs are recognised as integral to the health system, at all social and organisational levels.

CONCLUSIONS

Findings highlight the lack of recognition of RHMs and the programme at both community and national levels. This, along with historical neglect, has hindered the capacity of RHMs to successfully contribute to positive health outcomes for rural communities. Renewed attention and support mechanisms for this cadre are needed. Clarification of the RHM role in line with current health challenges and clearer role parameters is essential.

Community health workers impact on maternal and child health outcomes in rural South Africa - a non-randomized two-group comparison study

BACKGROUND

Home visits by paraprofessional community health workers (CHWs) has been shown to improve maternal and child health outcomes in research studies in many countries. Yet, when these are scaled or replicated, efficacy disappears. An effective CHW home visiting program in peri-urban Cape Town found maternal and child health benefits over the 5 years point but this study examines if these benefits occur in deeply rural communities.

METHODS

A non-randomized, two-group comparison study evaluated the impact of CHW in the rural Eastern Cape from August 2014 to May 2017, with 1310 mother-infant pairs recruited in pregnancy and 89% were reassessed at 6 months post-birth.

RESULTS

Home visiting had limited, but important effects on child health, maternal wellbeing and health behaviors. Mothers reported fewer depressive symptoms, attended more antenatal visits and had better baby-feeding practices. Intervention mothers were significantly more likely to exclusively breastfeed for 6 months (OR: 1.8; 95% CI: 1.1, 2.9), had lower odds of mixing formula with baby porridge (regarded as detrimental) (OR: 0.4; 95% CI: 0.2, 0.8) and were less likely to consult traditional healers. Mothers living with HIV were more adherent with co-trimoxazole prophylaxis (p < 0.01). Intervention-group children were significantly less likely to be wasted (OR: 0.5; 95% CI 0.3-0.9) and had significantly fewer symptoms of common childhood illnesses in the preceding two weeks (OR: 0.8; 95% CI: 0.7,0.9).

CONCLUSION

The impact of CHWs in a rural area was less pronounced than in peri-urban areas. CHWs are likely to need enhanced support and supervision in the challenging rural context.

The long-run and short-run influence of environmental pollution, energy consumption, and economic activities on health quality in emerging countries

This study investigates the effect of energy utilization, greenhouses gasses emissions, and economic activities on health risks such as mortality rate and incidence of respiratory diseases in emerging Asian economies. The study analyzes a panel data from 1995 to 2018 to examine the long-run and short-run influence of environmental pollution on health issues. The empirical findings highlight that greenhouse gasses emissions, fossil fuel consumption, and natural resources depletion in the region are key factors to increasing health risks in the long-run period, while the use of clean energy and improvement in per capita economic growth is helping to improve the health status of the households. In a short period, greenhouse gasses emission is the only significant factor responsible for the high mortality rate and occurrence of respiratory diseases in the emerging economies of Asia. According to the results, there is a need for government intervention programs to rescue the region from the negative effects of environmental pollution and the utilization of nonrenewable energy. In emerging Asian countries, the combustion of fossil fuels, environmental pollution, and limited access to clean energy are such factors responsible for high mortality rate and stimulating incidence of respiratory diseases in the individuals. The study suggests that alternative green energy can prove helpful to control greenhouse gasses emissions and to control health issues by improving environmental quality. The study further suggests that the use of clean energy from water, wind, and sunlight may prove helpful to meet the energy requirement at the domestic level and improve the health status of the individuals by reducing the incidence of respiratory diseases in emerging countries of Asia.

Reducing the Cost of Remoteness: Community-Based Health Interventions and Fertility Choices

Distance to health centers can represent a significant healthcare cost for poor households. Community-based health interventions and community health workers can be an alternative to deficient formal health care provision among remote populations. We analyze the effects on fertility outcomes of a large-scale community-based health worker program that aims to reach remote areas distant from health facilities in Madagascar. We use a triple difference model that exploits time and geographic variation in the program rollout and the geocoded household distance to the closest health facility. Our findings indicate that the program decreased the probability of conception among women in treated areas but did not have a differential effect among women living in remote areas. A potential mechanism underlying this fertility reduction is that the program increased women's modern contraceptive use.

Factors influencing institutional delivery and the role of accredited social health activist (ASHA): a secondary analysis of India human development survey 2012

Background

India has focused on incentivizing institutional delivery and introducing the ASHA worker as a key strategy to improve maternal health outcomes. We examined the determinants of institutional delivery and the role of the ASHA worker in shaping choice regarding place of delivery.

Methods

We used data from the India Human Development Survey-II conducted in 2011–12, and extracted an analytic sample of women (N = 8711) who reported having at least one child since 2005. Logistic regression was used to examine influence of socio-demographic factors, frequency of antenatal care (ANC) contacts and exposure to ASHA worker on institutional delivery.

Results

About 15% of the respondents had eight or more ANC contacts. The odds of having an institutional delivery were higher among those respondents who had 8 or more ANC contacts (OR = 3.39, p < 0.001, 95% CI: 2.26, 5.08), and those who had 4–7 ANC contacts (OR = 1.72, p < 0.001, 95% CI: 1.48, 1.99) as compared to those with less than 4 ANC contacts. About 26% of the respondents had any exposure to an ASHA worker. After controlling for ANC contacts, these respondents had three times the odds of institutional delivery (OR = 3.04, p < 0.001, 95% CI: 2.37, 3.89) compared to those who had no exposure to ASHA workers. Further, several sociodemographic variables were associated with institutional delivery. While age of spouse, age at marriage, level of education and urban residence were positively associated with institutional delivery; age of respondent and number of children were inversely associated with institutional delivery.

Conclusions

Both frequency of ANC contacts and exposure to ASHA worker independently emerge as important determinants of institutional delivery. Furthermore, ASHA workers may have a crucial role in promoting antenatal care, thereby strengthening the association between ANC contacts and institutional delivery.

Home visits by community health workers in rural South Africa have a limited, but important impact on maternal and child health in the first two years of life

BACKGROUND

More than 50% of Africa's population lives in rural areas, which have few professional health workers. South Africa has adopted task shifting health care to Community Health Workers (CHWs) to achieve the Sustainable Development Goals, but little is known about CHWs' efficacy in rural areas.

METHODS

In this longitudinal prospective cohort study, almost all mothers giving birth (N = 470) in the Zithulele Hospital catchment area of the OR Tambo District were recruited and repeatedly assessed for 2 years after birth with 84.7-96% follow-up rates. During the cohort assessment we found that some mothers had received standard antenatal and HIV care (SC) (n = 313 mothers), while others had received SC, supplemented with home-visiting by CHWs before and after birth (HV) (n = 157 mothers, 37 CHWs). These visits were unrelated to the cohort study. Multiple linear and logistic regressions evaluated maternal comorbidities, maternal caretaking, and child development outcomes over time.

RESULTS

Compared to mothers receiving SC, mothers who also received home visits by CHWs were more likely to attend the recommended four antenatal care visits, to exclusively breastfeed at 3 months, and were less likely to consult traditional healers at 3 months. Mothers in both groups were equally likely to secure the child grant, and infant growth and achievement of developmental milestones were similar over the first 2 years of life.

CONCLUSION

CHW home visits resulted in better maternal caretaking, but did not have direct benefits for infants in the domains assessed. The South African Government is planning broad implementation of CHW programmes, and this study examines a comprehensive, home-visiting model in a rural region.

Technology and rehabilitation training for community health workers: Strengthening health systems in Malawi

Community health workers (CHWs) have been effectively utilised in resource-limited settings to combat a growing demand for health access that cannot be met by the current workforce. The purpose of this study was to evaluate a CHW training programme in Malawi that integrated technology into rehabilitation care delivery. This was a retrospective cross-sectional study of a training programme conducted in December 2018. The participants were a convenience sample of all active home-based palliative care CHWs at St. Gabriel's Hospital (n = 60). The data collected included the following: a written pre- and post-knowledge test, skills competency checklist and a post-training programme survey. Descriptive frequencies described skill competency and quantitative responses from the post-training programme survey. Paired t test (α = 0.05) analysis determined the significance of knowledge acquisition. Themes in the narrative responses in the post-training survey were identified. Both training programme groups showed significantly greater knowledge on the post-test (M = 9.50, SD = 0.861; M = 9.43, SD = 0.971) compared to the pre-test (M = 7.97, SD = 1.351; M = 7.90, SD = 1.900); t(29) = 6.565, p < .001; t(29) = 4.104, p < .001 for Group 1 and Group 2, respectively. All participants demonstrated skill competency in 100% of the skills. All participants responded that the training programme helped them review skills and understand how to use technology 'A lot' on a Likert scale (no, a little, some, a lot). Facilitators of their work included training programmes, phones, communication with the hospital and collaboration amongst CHWs. Barriers included transportation needs, lack of patient care supplies and lack of caregiver compliance. Overall, utilisation of their knowledge and skills from the training programmes helped their patients make improvements in mobility and function that are meaningful to their quality of life in the village. This study highlights the importance of assessing programmes in low-resource settings with a focus on feasibility and developing local capacity.

Expanding Medical Education for Local Health Promoters Among Remote Communities of the Peruvian Amazon: An Exploratory Study of an Innovative Program Model

PURPOSE

Community health workers (CHWs) play integral roles in primary health care provision in low- and middle-income countries (LMICs). This is particularly true in underdeveloped areas where there are acute shortages of health workers. In this study, we evaluated the development and community utilization of a CHW training program in the Loreto province of Peru. Additionally, a community-oriented training model was designed to augment access to basic health information in underserved and isolated areas of the Amazon.

METHODS

Health resource utilization was compared in each community by surveying community members before and after implementation of the CHW training program, which utilized a community participatory program development (CPPD) model.

RESULTS

All communities demonstrated significantly increased CHW utilization (p = 0.026) as their initial point of contact for immediate health concerns following CHW training implementation. This increase in CHW utilization was accompanied by trends toward decreased preferences for local shamans or traveling to the closest health post as the initial health resource.

CONCLUSION

The community-focused, technology-oriented model utilized in this study proved an effective way to promote the use of CHWs in the Amazon region of Loreto, and could prove valuable to CHW capacitation efforts within other Peruvian provinces and in other LMICs around the world.

A Community-Based Intervention for Managing Hypertension in Rural South Asia

BACKGROUND

The burden of hypertension is escalating, and control rates are poor in low- and middle-income countries. Cardiovascular mortality is high in rural areas.

METHODS

We conducted a cluster-randomized, controlled trial in rural districts in Bangladesh, Pakistan, and Sri Lanka. A total of 30 communities were randomly assigned to either a multicomponent intervention (intervention group) or usual care (control group). The intervention involved home visits by trained government community health workers for blood-pressure monitoring and counseling, training of physicians, and care coordination in the public sector. A total of 2645 adults with hypertension were enrolled. The primary outcome was reduction in systolic blood pressure at 24 months. Follow-up at 24 months was completed for more than 90% of the participants.

RESULTS

At baseline, the mean systolic blood pressure was 146.7 mm Hg in the intervention group and 144.7 mm Hg in the control group. At 24 months, the mean systolic blood pressure fell by 9.0 mm Hg in the intervention group and by 3.9 mm Hg in the control group; the mean reduction was 5.2 mm Hg greater with the intervention (95% confidence interval [CI], 3.2 to 7.1; P<0.001). The mean reduction in diastolic blood pressure was 2.8 mm Hg greater in the intervention group than in the control group (95% CI, 1.7 to 3.9). Blood-pressure control (<140/90 mm Hg) was achieved in 53.2% of the participants in the intervention group, as compared with 43.7% of those in the control group (relative risk, 1.22; 95% CI, 1.10 to 1.35). All-cause mortality was 2.9% in the intervention group and 4.3% in the control group.

CONCLUSIONS

In rural communities in Bangladesh, Pakistan, and Sri Lanka, a multicomponent intervention that was centered on proactive home visits by trained government community health workers who were linked with existing public health care infrastructure led to a greater reduction in blood pressure than usual care among adults with hypertension. (Funded by the Joint Global Health Trials scheme; COBRA-BPS ClinicalTrials.gov number, NCT02657746.).

Nonrenewable energy-environmental and health effects on human capital: empirical evidence from Pakistan

This research work reconnoiters the impact of nonrenewable energy (NRE) consumptions, environmental pollution, and mortality rate on human capital in the presence of economic growth and two common diseases, measles and tuberculosis (TB) in Pakistan. The study uses data from 1995 to 2017 and employs the Autoregressive Distributive Lag (ARDL) model to investigate cointegration and long-run dynamics. Results indicate that nonrenewable energy (oil, coal, and gas) increase air pollution, measles, TB cases, and mortality rate, which affect the human capital in Pakistan. The results of the ARDL confirm the long-run and short-run effects of fossils fuels, air pollution, and diseases on human capital. The results of the Granger Causality confirm the feedback hypothesis between nonrenewable consumption and human capital, between air pollution and human capital. Measles and TB diseases Granger cause human capital. The study recommends some essential points for energy management, environmental management, and diseases control programs to uplift the human capital in Pakistan.

Development assistance for community health workers in 114 low- and middle-income countries, 2007-2017

OBJECTIVE

To estimate the level and trend of development assistance for community health worker-related projects in low- and middle-income countries between 2007 and 2017.

METHODS

We extracted data from the Organisation for Economic Co-operation and Development's creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries over 2007-2017. We produced estimates for projects specifically described by relevant keywords and for projects which could include components on CHWs. We analysed the pattern of development assistance by purpose, donors, recipient regions and countries, and trends over time.

FINDINGS

Between 2007 and 2017, total development assistance targeting CHW projects was around United States dollars (US$) 5 298.02 million, accounting for 2.5% of the US$ 209 277.99 million total development assistance for health. The top three donors (Global Fund to Fight AIDS, Tuberculosis and Malaria, the government of Canada and the government of the United States of America) provided a total of US$ 4 350.08 million (82.1%) of development assistance for these projects. Sub-Saharan Africa received a total US$ 3 717.93 million, the largest per capita assistance over 11 years (US$ 0.39; total population: 9 426.25 million). Development assistance to projects that focused on infectious diseases and child and maternal health received most funds during the study period.

CONCLUSION

The share of development assistance invested in the CHW projects was small, unstable and decreasing in recent years. More research is needed on tracking government investments in CHW-related projects and assessing the impact of investments on programme effectiveness.

Sequelae of Lassa Fever: Postviral Cerebellar Ataxia

Lassa fever is a zoonotic disease endemic in some West African countries. It is exported to countries in America, Asia, and Europe. Antivirals against Lassa fever are important to provide a cure in patients with the disease and provide protection against it. In addition, due to the potential utilization of Lassa virus as a bioterrorism agent, vaccines against the disease can be utilized as a counterterrorism measure. Developing antiviral compounds and vaccines against the disease requires understanding of the pathogenesis of Lassa fever and its disease course, including the signs, symptoms, complications, and sequelae. An important sequela of Lassa fever is ataxia. A few cases of postviral ataxia following Lassa fever have been described in the literature. This review focuses on highlighting these cases, the gaps in scientific knowledge where further research is needed, and possible ways of diagnosing postviral ataxia after Lassa fever in resource-limited settings.

Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa

INTRODUCTION

In 2011, in line with principles for Universal Health Coverage, South Africa formalised community health workers (CHWs) into the national health system in order to strengthen primary healthcare. The national policy proposed that teams of CHWs, called Ward-based Primary Healthcare Outreach Teams (WBPHCOTs), supervised by a professional nurse were implemented. This paper explores WBPHCOTs' and managers' perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of implementation guided by the Implementation Stages Framework.

METHODS

We conducted a qualitative study consisting of five focus group discussions and 14 in-depth interviews with CHWs, team leaders and managers. A content analysis of data was conducted.

RESULTS

There were significant weaknesses in early implementation resulting from a vague national policy and a rushed implementation plan. During the installation stage, adaptations were made to address gaps including the appointment of subdistrict managers and enrolled nurses as team leaders. Staff preparation of CHWs and team leaders to perform their roles was inadequate. To compensate, team members supported each another and assisted with technical skills where they could. Structural issues, such as CHWs receiving a stipend rather than being employed, were an ongoing implementation challenge. Another challenge was that facility managers were employed by the local government authority while the CHW programme was perceived to be a provincial programme.

CONCLUSION

The implementation of complex programmes requires a shared vision held by all stakeholders. Adaptations occur at different implementation stages, which require a feedback mechanism to inform the implementation in other settings. The CHW programme represented a policy advance but lacked detail with respect to human resources, budget, supervision, training and sustainability, which made it a difficult furrow to plough. This study points to how progressive reform remains fraught without due attention to the minutiae of practice.