Who is a community health worker? - a systematic review of definitions

Applying a Primary Health Care Approach to Closing the Human Resource for Health Gaps for Immunization

This perspective is focused on the evidence on human resources for health (HRH) solutions for immunization, as a part of a primary health care (PHC) approach.. In the wake of the COVID-19 pandemic and 50 years since the Expanded Program on Immunization (EPI) clocks 50 years since its inception. was initiated, evidence and experience demonstrate the significant HRH gaps in many countries and globally, and how countries are seeking innovative ways of closing them with limited resources. The aim of this perspective article is to highlight the growing gap between the needs and the realities related to health workforce for PHC, including immunization, and to call for increasing the visibility of HRH within global and national immunization agendas. This perspective highlights key guidelines and tools to improve HRH, such as integrating immunization and primary health care, addressing the mental health needs of the health workforce, addressing gender-related issues, rationalizing the roles and composition of PHC workforce teams, and meeting the surge requirements related to health emergencies.

Acceptability of a community health worker- led health literacy intervention on lifestyle modification among hypertensive and diabetes patients in the City of Harare, Zimbabwe

Deploying community health workers (CHWs) is a vital strategy to improve health at a community level in low- and middle-income countries. Whilst there is substantial evidence on the effectiveness of CHWs interventions, there is a need for more research on the mechanisms through which these interventions work. Understanding the acceptability of these interventions is one way of assessing the mechanisms through which they work. This article examines the acceptability of a community health worker- led health literacy intervention on lifestyle modification among hypertensive and diabetes patients based on the perspectives of the CHWs, community nurses and diabetes and hypertensive patients. A qualitative study was imbedded within a cluster randomized trial to assess the effectiveness community health worker- led health literacy intervention on lifestyle modification among hypertensive and diabetes patients in the City of Harare, Zimbabwe. Data were gathered through semi-structured interviews with 3 community health nurses and 15 diabetes and hypertension patients as well as 2 focus group discussions with CHWs. Data were analyzed manually using the thematic analysis method. There was consensus that the intervention had many benefits amongst CHWs and community nurses. However, among patients, there were mixed perceptions regarding the benefits of the intervention. The main challenges that were mentioned by CHWs include resistance to advice by patients, insufficient resources, and lack of acceptance at some of the patient's homes. All participants believed the intervention was acceptable. Our study provides vital information that should be considered in upscaling CHW led interventions.

Community health worker perspectives: examining current responsibilities and strategies for success

BACKGROUND

Community health worker (CHW) interventions have demonstrated positive impacts globally, with the COVID-19 pandemic further highlighting the potential of CHWs at the frontline to support prevention, outreach, and healthcare delivery. As the workforce expands, understanding the work and capabilities of CHWs is key to design successful interventions. This study examines the perspectives of experienced CHWs in Chicago about their current work and strategies for success.

METHODS

As part of a community-academic partnership in Chicago, semi-structured interviews were completed with individuals who held positions aligned with CHW. Interviews were conducted between January and April 2022. Questions focused on participants' work and factors contributing to their effectiveness to gain insights into workforce strategies for success to be applied in healthcare and community settings. De-identified transcripts were analyzed using inductive reasoning with codes organized into themes and subthemes under two domains identified a priori. The themes informed a logic model focused on the early stages to support the success of CHWs in their role.

RESULTS

Fourteen individuals participated in the study. The two predetermined domains in this study were: current work of CHWs and strategies for CHWs to be successful. Five themes were identified about CHWs' current work: providing services, building alliances with clients, establishing and maintaining collaborations, collecting data, and experiencing challenges in role. From their perspectives, all these responsibilities enhance client care and support workforce sustainability efforts. Five themes emerged about strategies for the success of CHWs: background of CHWs, champions to support work of CHWs, materials to perform work of CHWs, preparation for CHW role, and characteristics of CHWs. Participants described key traits CHWs should possess to be hired, individuals who can champion and advocate for their work, and specific materials needed to fulfill responsibilities. They reported that training and familiarity with the community were integral to developing and refining the qualities and skills necessary to be effective in their role.

CONCLUSION

CHWs play an increasingly important role in enhancing healthcare delivery and improving health outcomes. This study offers a framework for policymakers, communities, and organizations to utilize for preparing CHWs to succeed in their roles.

The role of community health workers in promoting oral health at school settings: A scoping review

OBJECTIVES

The scoping review aimed to examine the literature on the role of Community Health Workers (CHW) in oral health interventions within school settings. The objectives were to identify the characteristics of school oral health interventions where CHWs played a role; and to assess the outcomes derived from CHW participation in school oral health.

METHODS

The scoping review was guided by the Levac et al (2010) framework. Articles selected for this review included all forms of study designs and gray literature. The search strategy included CHW and other non-dental personnel providing oral health activities within schools and the outcomes of these interventions from 1995. Databases included Pubmed, ProQuest, Scopus and EBSCO Host.

RESULTS

There were eleven (n = 11) peer reviewed articles included. Only one study in this review related to CHW involvement in school oral health settings. The remaining involved teachers (n = 4), peer learners (n = 3) or a combination of both (n = 3). Characteristics of the interventions ranged from oral health screenings, education, supervised brushing, and community engagements. Three outcomes emerged; widening access to oral health services, acceptability of non-oral health personnel and learners in promoting oral health and improvement of oral health self-care.

CONCLUSIONS

The review brought to light the benefits of utilizing non-dental personnel such as teachers and peer learners in augmenting staff capacity for school oral health interventions. In addition, the findings highlighted the need to further research on the feasibility and acceptability of integrating CHW in school oral health settings.

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polyps removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk.

DESIGN AND METHODS

We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-month follow-up, and Life Simple7 (LS7)-a cardiovascular disease (CVD) risk score-at 6 months and 1 year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed-methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors.

DISCUSSION

Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction.

TRIAL REGISTRATION

NCT05174286; clinicaltrials.gov; August 31st, 2023.

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

Background: Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polys removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk. Design and Methods: We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-months follow up, and Life Simple7 (LS7) - a cardiovascular disease (CVD) risk score - at 6 months and 1-year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed- methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors. Discussion: Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction. Trial registration: NCT05174286.

AOA Critical Issues Symposium: Promoting Health Equity

ABSTRACT

Promoting equitable health care is to ensure that everyone has access to high-quality medical services and appropriate treatment options. The definition of health equity often can be misinterpreted, and there are challenges in fully understanding the disparities and costs of health care and when measuring the outcomes of treatment. However, these topics play an important role in promoting health equity. The COVID-19 pandemic has made us more aware of profound health-care disparities and systemic racism, which, in turn, has prompted many academic medical centers and health-care systems to increase their efforts surrounding diversity, equity, and inclusion. Therefore, it is important to understand the problems that some patients have in accessing care, promote health care that is culturally competent, create policies and standard operating procedures (at the federal, state, regional, or institutional level), and be innovative to provide cost-effective care for the underserved population. All of these efforts can assist in promoting equitable care and thus result in a more just and healthier society.

Heart 2 Heart: Pilot Study of a Church-Based Community Health Worker Intervention for African Americans with Hypertension

African Americans (AAs) have higher prevalence of uncontrolled hypertension than Whites, which leads to reduced life expectancy. Barriers to achieving blood pressure control in AAs include mistrust of healthcare and poor adherence to medication and dietary recommendations. We conducted a pilot study of a church-based community health worker (CHW) intervention to reduce blood pressure among AAs by providing support and strategies to improve diet and medication adherence. To increase trust and cultural concordance, we hired and trained church members to serve as CHWs. AA adults (n = 79) with poorly controlled blood pressure were recruited from churches in a low-income, segregated neighborhood of Chicago. Participants had an average of 7.5 visits with CHWs over 6 months. Mean change in systolic blood pressure across participants was - 5 mm/Hg (p = 0.029). Change was greater among participants (n = 45) with higher baseline blood pressure (- 9.2, p = 0.009). Medication adherence increased at follow-up, largely due to improved timeliness of medication refills, but adherence to the DASH diet decreased slightly. Intervention fidelity was poor. Recordings of CHW visits revealed that CHWs did not adhere closely to the intervention protocol, especially with regard to assisting participants with action plans for behavior change. Participants gave the intervention high ratings for acceptability and appropriateness, and slightly lower ratings for feasibility of achieving intervention behavioral targets. Participants valued having the intervention delivered at their church and preferred a church-based intervention to an intervention conducted in a clinical setting. A church-based CHW intervention may be effective at reducing blood pressure in AAs.

The effectiveness of community health worker training, equipping, and deployment in reducing COVID-19 infections and deaths in rural Western Kenya: A comparison of two counties

COVID-19 and other pandemics remain significant threats to population health, particularly in rural settings where health systems are disproportionately weak. There is a lack of evidence on whether trained, equipped, and deployed community health workers (CHWs) can lead to significant reductions in COVID-19 infections and deaths. Our objective was to measure the effectiveness of deploying trained and equipped CHWs in reducing COVID-19 infections and deaths by comparing outcomes in two counties in rural Western Kenya, a setting with limited critical care capacity and limited access to COVID-19 vaccines and oral COVID-19 antivirals. In Siaya, trained CHWs equipped with thermometers, pulse oximeters, and KN95 masks, visited households to convey health information about COVID-19 prevention. They screened, isolated, and referred COVID-19 cases to facilities with oxygen capacity. They measured and digitally recorded vital signs at the household level. In Kisii county, the standard Kenya national COVID-19 protocol was implemented. We performed a comparative analysis of differences in CHW skills, activity, and COVID-19 infections and deaths using district health information system (DHIS2) data. Trained Siaya CHWs were more skilled in using pulse oximeters and digitally reporting vital signs at the household level. The mean number of oxygen saturation measurements conducted in Siaya was 24.19 per COVID-19 infection; and the mean number of temperature measurements per COVID-19 infection was 17.08. Siaya CHWs conducted significantly more household visits than Kisii CHWs (the mean monthly CHW household visits in Siaya was 146,648.5, standard deviation 11,066.5 versus 42,644.5 in Kisii, standard deviation 899.5, p value = 0.01). Deploying trained and equipped CHWs in rural Western Kenya was associated with lower risk ratios for COVID-19 infections and deaths: 0.54, 95% CI [0.48-0.61] and 0.29, CI [0.13-0.65], respectively, consistent with a beneficial effect.

Barriers and facilitators to the delivery of age-friendly health services in Primary Health Care centres in southwest, Nigeria: A qualitative study

BACKGROUND

With the rapid growth of Nigeria's older population, it has become important to establish age-friendly healthcare systems that support care for older people. This study aimed to explore the barriers and facilitators to the delivery of age-friendly health services from the perspectives of primary healthcare managers in Lagos State, Nigeria.

METHOD

We conducted 13 key informant interviews including medical officers of health, principal officers of the (Primary Health Care) PHC Board and board members at the state level. Using a grounded theory approach, qualitative data analysis was initially done by rapid thematic analysis followed by constant comparative analysis using Dedoose software to create a codebook. Three teams of two coders each blind-coded the interviews, resolved coding discrepancies, and reviewed excerpts by code to extract themes.

RESULTS

The main barriers to the delivery of age-friendly services included the lack of recognition of older adults as a priority population group; absence of PHC policies targeted to serve older adults specifically; limited training in care of older adults; lack of dedicated funding for care services for older adults and data disaggregated by age to drive decision-making. Key facilitators included an acknowledged mission of the PHCs to provide services for all ages; opportunities for the enhancement of older adult care; availability of a new building template that supports facility design which is more age-friendly; access to basic health care funds; and a positive attitude towards capacity building for existing workforce.

CONCLUSION

While we identified a number of challenges, these offer opportunities to strengthen and prioritize services for older adults in PHCs and build on existing facilitators. Work is needed to identify and test interventions to overcome these challenges and improve the responsiveness of the PHC system to older adults through the delivery of age-friendly health services in PHCs in Lagos, Nigeria.

A qualitative analysis of community health worker perspectives on the implementation of the preconception and pregnancy phases of the Bukhali randomised controlled trial

Community health workers (CHWs) play an important role in health systems in low- and middle-income countries, including South Africa. Bukhali is a CHW-delivered intervention as part of a randomised controlled trial, to improve the health trajectories of young women in Soweto, South Africa. This study aimed to qualitatively explore factors influencing implementation of the preconception and pregnancy phases of Bukhali, from the perspective of the CHWs (Health Helpers, HHs) delivering the intervention. As part of the Bukhali trial process evaluation, three focus group discussions were conducted with the 13 HHs employed by the trial. A thematic approach was used to analyse the data, drawing on elements of a reflexive thematic and codebook approach. The following six themes were developed, representing factors impacting implementation of the HH roles: interaction with the existing public healthcare sector; participant perceptions of health; health literacy and language barriers; participants' socioeconomic constraints; family, partner, and community views of trial components; and the HH-participant relationship. HHs reported uses of several trial-based tools to overcome implementation challenges, increasing their ability to implement their roles as planned. The relationship of trust between the HH and participants seemed to function as one important mechanism for impact. The findings supported a number of adaptations to the implementation of Bukhali, such as intensified trial-based follow-up of referrals that do not receive management at clinics, continued HH training and community engagement parallel to trial implementation, with an increased emphasis on health-related stigma and education. HH perspectives on intervention implementation highlighted adaptations across three broad strategic areas: navigating and bridging healthcare systems, adaptability to individual participant needs, and navigating stigma around disease. These findings provide recommendations for the next phases of Bukhali, for other CHW-delivered preconception and pregnancy trials, and for the strengthening of CHW roles in clinical settings with similar implementation challenges. Trial registration: Pan African Clinical Trials Registry; PACTR201903750173871, Registered March 27, 2019.

Individual and Systemic Barriers Blocking Community Health Workers from Helping the Seriously Ill

Background: Palliative care is a valuable component of health care that improves a patient's quality of life, yet its availability to patients with serious chronic illness remains relatively low. Due to their knowledge of community preferences and ability to improve patient education and access to care, community health workers (CHWs) can increase palliative care usage by patients. Notably, barriers to CHWs helping patients with serious chronic illness remain poorly understood. Objective: Explore the perception of barriers CHWs feel they face when attempting to support the health care of patients with serious chronic illness. Design: Qualitative semistructured individual interviews of CHWs and qualitative descriptive analysis. Setting/Subjects: Twelve CHWs who have worked with patients with serious chronic illness were recruited from the Johns Hopkins Healthcare LLC and the Baltimore Alliance for Careers in Healthcare organizations to virtually participate. Results: CHWs perceived both active and passive barriers that obstructed their efforts to work with seriously ill patients. CHWs shared that these barriers were dependent on themselves, their peers, and their work environments. Prevalent themes included interprofessional conflict, poor health care worker understanding of the CHW's role, and lack of access to quality resource organizations. CHWs noted job-specific training, better means to identify needed resources for patients, and inclusive health care teams as solutions to support their professional goals, while helping patients with serious illness. Conclusions: There are multiple perceived barriers to CHWs helping seriously ill patients. CHWs aiding patients with serious illness can be supported through better job training, better resource management tools, and improved communication between health care team members.

Evidence on the impact of community health workers in the prevention, identification, and management of undernutrition amongst children under the age of five in conflict-affected or fragile settings: a systematic literature review

BACKGROUND

Malnutrition, specifically undernutrition, is a significant global challenge that contributes to nearly half of deaths in children under the age of five. The burden of undernutrition is disproportionately borne by conflict-affected, fragile settings (CAFS); children living in a conflict zone being more than twice as likely to suffer from malnourishment. Community health worker (CHW) models have been employed in CAFS to improve healthcare coverage and identify and treat illnesses. However, there lacks systematic evidence on the impact of CHW models in preventing, identifying, and managing child undernutrition in CAFS. We conducted this review to systematically evaluate evidence of CHW models in preventing, identifying, and managing undernutrition in children under the age of five in CAFS.

METHODOLOGY

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards. The search strategy was developed using the Population-Intervention-Comparisons-Outcomes-Setting framework as a guide. Searches were performed using Ovid online database search platform, searching the databases of Ovid MEDLINE(R), COCHRANE, Embase Classic, Embase, Econlit, Global Health, SCOPUS, and Social Policy and Practice. Peer-reviewed publications were eligible for inclusion if they evaluated an intervention using a CHW model that aims to prevent, identify, or manage some form of undernutrition in children under five in a CAFS.

RESULTS

We identified 25 studies-spanning 10 countries-that were included in the systematic review. CHW models were implemented alongside a variety of interventions, including behaviour change communication, supplementary foods, nutrition counselling, and integrated community health programmes. Key barriers in implementing successful CHW models include disruption of programmes due to active conflict, states of emergency, militancy, or political unrest; weak links between the community-based interventions and public health system; weak health system capacity that impeded referral and follow-ups; and cost of care and care-seeking. Key facilitators include CHWs' connection to the community, close proximity of programmes to the community, supervision, and investment in high quality training and tools.

CONCLUSIONS

The findings suggest that CHW models may be effective, cost-effective, acceptable, feasible, and scalable in the prevention, identification, and management child undernutrition in CAFS. The study findings also confirmed a need for greater evidence in the field. These findings may inform policymaking, programme implementation, and design to strengthen best practices for CHW models addressing child undernutrition in CAFS.

Financing Thresholds for Sustainability of Community Health Worker Programs for Patients Receiving Medicaid Across the United States

States have turned to novel Medicaid financing to pay for community health worker (CHW) programs, often through fee-for-service or capitated payments. We sought to estimate Medicaid payment rates to ensure CHW program sustainability. A microsimulation model was constructed to estimate CHW salaries, equipment, transportation, space, and benefits costs across the U.S. Fee-for-service rates per 30-min CHW visit (code 98960) and capitated rates were calculated for financial sustainability. The mean CHW hourly wage was $23.51, varying from $15.90 in Puerto Rico to $31.61 in Rhode Island. Overhead per work hour averaged $43.65 nationwide, and was highest for transportation among other overhead categories (65.1% of overhead). The minimum fee-for-service rate for a 30-min visit was $53.24 (95% CI $24.80, $91.11), varying from $40.44 in South Dakota to $70.89 in Washington D.C. The minimum capitated rate was $140.18 per member per month (95% CI $105.94, $260.90), varying from $113.55 in South Dakota to $176.58 in Washington D.C. Rates varied minimally by metro status but more by panel size. Higher Medicaid fee-for-service and capitated rates than currently used may be needed to support financial viability of CHW programs. A revised payment estimation approach may help state officials, health systems and plans discussing CHW program sustainability.

Increasing U.S. Maternal Health Equity Among Immigrant Populations Through Community Engagement

Immigrant women in the United States are at an elevated risk of poor maternal health outcomes due to cultural, linguistic, or socioeconomic barriers that may lead to critical delays in obtaining adequate health care. Ensuring access to high-quality, culturally appropriate perinatal health care is crucial to improve the health and well-being of immigrant mothers and their children. Various aspects of perinatal health care for immigrant women can be improved through community engagement strategies. Barriers can be addressed by involving community members in designing and delivering culturally appropriate maternal health services. Some strategies discussed in this commentary include working with community health workers, encouraging telehealth through community health workers, providing breastfeeding and mental health support within cultural norms, and involving community-based doulas and midwives.

Proof of concept of a sexual health outreach program led by community health workers in homeless hostels in the greater Paris region

Context

Homeless individuals face exacerbated risks of infectious diseases, including sexually transmitted infections (STIs). Programs led by Community Health Workers (CHWs) have demonstrated potential to enhance healthcare access for marginalized groups such as homeless families. This study aims to evaluate the feasibility and effectiveness of a novel CHW-based outreach program addressing sexual health issues among individuals residing in homeless hostels.

Methods

Twelve social homeless hostels in the greater Paris region were selected as program implementation sites. An outreach program was developed consisting of two interventions: sexual health workshops and STI screening sessions (HIV and hepatitis B and C) accompanied by individual interviews, both conducted by CHWs within each hostel over an 8-week period and scheduled weekly. Feasibility, participation and engagement were evaluated using complementary methods including qualitative field observations, semi-structured interviews and focus groups with CHWs, satisfaction questionnaires for participants, and quantitative outcome data collection of each intervention.

Results

A total of 80 program activities (workshops and screening sessions) were conducted. Among the participants, 542 women and 30 men engaged in workshops. During the 30 Rapid Diagnostic Testing sessions, 150 individuals underwent testing for HIV, hepatitis B, and/or hepatitis C. Positivity rates were 6.7% for hepatitis B and 0.9% for hepatitis C. No HIV infections were detected. Participant satisfaction rates were consistently high (>76%) across workshops. Qualitative analysis unveiled two critical axes influencing program feasibility and effectiveness: program organization and CHW involvement.

Discussion

This assessment of the program highlights its feasibility among a population that is difficult to reach through conventional healthcare efforts. The intervention's potential effectiveness is suggested by self- and CHW-reported improvements in sexual health literacy and high rates of referral to the healthcare system, as well as holistic well-being considerations. CHW involvement is a vital determinant of program success, as are robust coordination among stakeholders, deep understanding of the target population, and strong partner engagement.

Conclusion

This outreach program amplifies the voices of often-overlooked populations while empowering them to navigate health and social challenges. Although these workshops serve as lifelines for those frequently excluded from mainstream services, long-term improvements to the health and wellbeing of homeless populations will necessitate systemic governmental intervention.

Training-of-trainers program for community health workers involved in an innovative and community-based intervention against malaria among goldminers in the Guiana shield: a quality and effectiveness evaluation

Introduction

An innovative and community-based intervention is implemented in the Guiana Shield to eliminate malaria among people involved in artisanal and small-scale gold mining. The intervention consists of the distribution of malaria self-management kits to goldminers and the presumptive treatment for individuals at risk of carrying Plasmodium vivax hypnozoites. The intervention is possible owing to community health workers (CHWs) who are previously trained to master all intervention procedures, including health education activities and goldmining training. This study aimed to evaluate the training program provided to CHWs in terms of quality and effectiveness.

Methods

A training-of-trainers program for CHWs has been developed based on the CDC framework. A mixed-method case study was implemented in two steps between February and March 2023. The evaluation was based on a knowledge survey, satisfaction test, observations, and semi-structured interviews. Quantitative and qualitative data were analyzed and triangulated.

Results

A total of 20 CHWs participated in the training and the first-step evaluation. For the second step, four semi-structured interviews were conducted. The Qualitative data showed that group dynamics and adaptations were central elements of a high-quality training program. Quantitative analysis found that CHWs' satisfaction was elevated (> 4/5 overall), especially regarding format and learning results. Improvements in knowledge level demonstrated good effectiveness (pre-training vs. post-training, p < 0.05). Nevertheless, some difficulties persisted regarding tasks of the intervention procedure, such as informed consent and smartphone application procedures (with an inaccuracy rate of 29.2% and 16.7%, respectively). Further on-the-job training permitted to address these issues. The project team's previous experience and the Guiana Shield countries' commitment to the WHO-E-2025-initiative were identified as levers for the quality of the training, while the complexity of the project context was a challenge.

Discussion

High-quality, effective, and appropriate training programs are required for effective and sustainable interventions involving CHW profiles. Training design is a crucial point to address to accomplish quality and effectiveness. The training-of-trainers model has been shown to allow a high level of satisfaction, good learning results, and satisfactory implementation in the field. Initial and continuing training is an indispensable continuum to sustain good practices in the field and CHWs' motivation. Training evaluation permits standardizing methods and facilitates transferability.

Determinants of community-based health insurance membership renewal decision among rural households in Kellem Wollega zone, Oromia regional state, Ethiopia: a community-based cross-sectional study

Background

Despite the fact that community-based health insurance (CBHI) is a promising program to achieve the goal of universal health coverage (UHC), it faces challenges that are not only due to low enrollment but also due to membership renewal decision that impact its sustainability. Hence, the study aimed to identify the determinants of CBHI membership renewal decision among rural households in Kellem Wollega zone, Ethiopia.

Methods

The study was conducted in Kellem Wollega, Ethiopia, among rural households from March 30-April 30, 2022, using a community-based cross-sectional study design. An interviewer-administered structured questionnaire through face-to-face interviews was used. Using a systematic random sampling method, 551 households were selected making 540 (98%) response rates. The data was entered into EPI Data 3.1 and analyzed using SPSS 25 software. Descriptive statistics, binary, and multiple logistic regressions were performed. Using multiple logistic regressions, a significant association between the CBHI membership renewal decision and independent variables was identified, declaring the statistical significance level using a 95% confidence interval (CI) at p < 0.05.

Results

The overall rate of CBHI membership renewal decision among households was estimated to be 365 (67.6%, 95% CI = 63.7-71.5%). The factors that significantly influenced the households' membership renewal decision were family size (AOR = 0.46, 95% CI = 0.25-0.86), low literacy status (AOR = 0.28 95% CI = 0.12-0.64), lower than middle-level of wealth index (AOR = 9.80, 95% CI = 2.75-34.92), premium affordability (AOR = 4.34, 95% CI = 2.08-9.04), unavailability of services (AOR = 0.26, 95% CI = 0.12-0.55), trusting in health facilities (AOR = 5.81, 95% CI = 2.82-11.94), favorable providers' attitude toward members (AOR = 8.23, 95% CI = 3.96-19.64), good quality of service (AOR = 4.47, 95% CI = 2.28-8.85) and health care seeking behavior (AOR =3.25, 95% CI = 1.32-7.98).

Conclusion

The overall CBHI membership dropout decision rate among rural households was high, which could affect health service provision and utilization. Therefore, the insurance scheme and contracted health facilities should consider and work on family size and wealth status when membership premiums are calculated, the education level of households when creating awareness about the scheme, building trust in the contracted health facilities by providing all promised benefit packages of health services with good quality, and improving the attitude of health care providers towards the scheme members.

Pharmacy technicians trained as community health workers: A prospective multicenter cohort study

BACKGROUND

Community health workers (CHWs) are health professionals who are experts in linking patients to health resources. Although CHWs are employed in a variety of health institutions, access to their services may be challenging for patients in underserved locations. Community pharmacies are uniquely positioned to mitigate this barrier as they provide readily accessible care for patients residing in these areas.

OBJECTIVES

To 1) quantify and report the CHW services provided by certified pharmacy technicians (CPhTs) in an underserved population and 2) provide an initial framework for the implementation of CHW services in community pharmacies or similar health care settings.

METHODS

This prospective cohort study reports the findings of training CPhTs as CHWs in 3 independent community pharmacies from January 1, 2021 to July 1, 2021. CPhT-CHWs conducted monthly visits by phone, patient home, or pharmacy and documented services using a standardized assessment form. Descriptive statistics were used to summarize the baseline characteristics of the patient population, service codes, types of services and referrals made, and time spent per visit by CPhT-CHWs.

RESULTS

A total of 198 patient visits by phone, patient home, or at the pharmacy were completed in a 6-month timespan. During these visits, the CPhT-CHW provided 351 services (203 primary services and 149 secondary services) and completed 51 referrals. The average time spent per visit (standard deviation) was 15.5 (11.5) 68.9 (35.4), and 30.6 (16.8) minutes for phone, home, and pharmacy visits, respectively. Patient home visits resulted in the highest average primary services per visit, longest time spent with the patient, and accounted for a majority of social services.

CONCLUSION

CPhT-CHWs were able to use various methods to contact these patients to further develop patient-to-provider and patient-to-pharmacy relationships. Training CPhTs as CHWs can be an effective way to increase patient contact and provide additional health services.

Mitigation through on-site testing & education among formerly incarcerated individuals against Covid-19 - The MOSAIC study: Design and rationale

BACKGROUND

Many of the largest COVID-19 outbreaks in the United States have occurred at carceral facilities. Criminal legal system (CLS)-involved individuals typically face structural barriers accessing medical care post-release. Improving COVID-19 testing and education for CLS-involved individuals could improve health outcomes for this vulnerable population and the communities to which they return. Community-based organizations (CBO) and community health workers (CHWs) fill care gaps by connecting CLS-involved individuals with essential re-entry services. The MOSAIC study will: 1) test an onsite CHW-led SARS-CoV-2 testing and education intervention in a reentry CBO and 2) model the cost-effectiveness of this intervention compared to standard care.

METHODS

We will recruit 250 CLS-involved individuals who have left incarceration in the prior 90 days. Participants will be randomized to receive onsite Point-of-Care testing and education (O-PoC) or Standard of Care (SoC). Over one year, participants will complete quarterly questionnaires and biweekly short surveys through a mobile application, and be tested for SARS-CoV-2 quarterly, either at the CBO (O-PoC) or an offsite community testing site (SoC). O-PoC will also receive COVID-19 mitigation counseling and education from the CHW. Our primary outcome is the proportion of SARS-CoV-2 tests performed with results received by participants. Secondary outcomes include adherence to mitigation behaviors and cost-effectiveness of the intervention.

DISCUSSION

The MOSAIC study will offer insight into cost effective strategies for SARS-CoV-2 testing and education for CLS-involved individuals. The study will also contribute to the growing literature on CHW's role in health education, supportive counseling, and building trust between patients and healthcare organizations.

Does mHealth influence community health worker performance in vulnerable populations? A mixed methods study in a multinational refugee settlement in Uganda

Community Health Workers (CHWs) provide healthcare in under-served communities, including refugee settlements, despite various challenges hindering their performance. Implementers have adopted mobile wireless technologies (m-Health) to improve the performance of CHWs in refugee settlements. We assessed the CHWs' performance and associated factors in a multi-national refugee settlement, operating mHealth and paper-based methods. This cross-sectional study employed quantitative and qualitative data collection methods. Data for 300 CHWs was collected from implementing partners' (IPs) databases. Nine focus group discussions (FGDs) with the CHWs and community members, two in-depth interviews (IDIs) with CHW leaders, and eight key informant interviews (KIIs) with six IPs and two local leaders were conducted. The qualitative data were analysed thematically using AtlasTi version 9 while the quantitative data were analysed at the univariate, bivariate and multivariable levels using Stata version14. The study found that only 17% of the CHWs performed optimally. The factors that significantly influenced CHW performance included education level: secondary and above (APR: 1.83, 95% CI: 1.02-3.30), having a side occupation (APR: 2.02, 95% CI: 1.16-3.52) and mHealth use (APR: 0.06, 95% CI: 0.02-.0.30). The qualitative data suggested that performance was influenced by the number of households assigned to CHWs, monetary incentives, adequacy of materials and facilitation. Particularly, mHealth was preferred to paper-based methods. Overall, the CHWs' performance was sub-optimal; only 2 in 10 performed satisfactorily. The main factors that influenced performance included the level of education, use of mHealth, having another occupation, workload and incentivisation. CHWs and IPs preferred mHealth to paper-based methods. IPs should work to improve refugee settlement working conditions for the CHWs and adopt mHealth to improve CHW performance.

Comparing the roles of community health workers for malaria control and elimination in Cambodia and Tanzania

The reduction of deaths from malaria in sub-Saharan Africa (SSA) is stalling, whereas many countries in Southeast Asia are approaching malaria elimination. We reviewed the role of community health worker (CHW) programmes in malaria control and elimination between regions, with a more detailed description of the programmes in Tanzania and Cambodia. Compared with Tanzania, Cambodia has a much more developed CHW network, which has been pivotal in the near elimination of malaria. In Tanzania, the malaria burden has remained similar over the last decade and treatment continues to rely on healthcare facilities, which provide more limited access to early diagnosis and treatment. Overall, the proportion of malaria cases treated by CHWs is substantially lower in SSA than in Southeast Asia. Even though networks of CHWs are resource intensive and malaria epidemiology differs substantially between countries, there is a strong case for expanding CHW networks in rural SSA to improve early access to effective malaria treatment and reduce the malaria burden.

The development of a clinical research educational training for community health workers using the joint task force for clinical trial competency framework

Introduction: The NYU Clinical & Translational Science Institute, in collaboration with a number of community-engaged initiatives, developed a training for community health workers (CHWs) to enhance health literacy about clinical research. This innovative research training provides CHWs with a basic level of competency in clinical research to convey the importance of research to communities and better advocate for their health needs. CHWs are an underutilized resource to engage diverse populations in clinical research. The training also addresses the need to expand and diversify the clinical research workforce-integrating CHWs into research teams and connecting underserved populations with research opportunities to enhance quality of care. Methods: Structured individual interviews and focus group sessions were held with CHWs as well as clinical research faculty and staff to identify knowledge gaps in clinical research and identify best practices for educating community members on research. Using the Joint Task Force (JTF) for Clinical Trial Competency framework, an online course was developed consisting of 28 modules offered asynchronously for internal and external audiences. Topics include the fundamentals of clinical research, scientific concepts and research design, research ethics, study management, clinical study operations, communications, and teamwork, as well as the importance of diversity and equity in research and the barriers to participation. Results: Learning was evaluated using multiple choice questions after each module to ensure the fundamental level of knowledge was obtained. A separate survey, completed at the conclusion of the course, evaluated the quality of training. Discussion: The course aims to enhance the knowledge and skills of CHWs to help promote greater understanding of clinical research within the communities they serve, including the risks and benefits of clinical research and opportunities for participation. As members of the research team, community stakeholders can help design interventions tailored to the unique needs, culture, and context of their communities. In addition, this research training equips trainees with skills to engage the community actively, involving them in the research process and ensuring community priorities are represented in research through more community engaged processes.

Lay community mental health workers (cadres) in Indonesian health services: A qualitative exploration of the views of people with mental health problems and their families

INTRODUCTION

In community-based mental health services, lay workers recruited and trained to support mental health programs, known as mental health cadres, have an important role in supporting the care of families and people with mental disorders. This study aims to explore the experiences of people with mental disorders and their families about the role of mental health cadres in improving mental health and caring for people with mental disorders.

METHODS

This study employed a qualitative descriptive design for data gathering. Focus groups were conducted between August 2020 and January 2021 with 19 people with mental health difficulties (people diagnosed with schizophrenia) and 25 family members who are the primary caregivers of people with mental disorders from three provinces in Indonesia: West Java, East Java, and Aceh. Participants were purposively sampled with inclusion and exclusion criteria used were people with mental disorders and their families who regularly interact with mental health cadres. Data were analyzed using inductive thematic analysis through six stages of coding and theme development.

RESULTS

Several themes were identified. The most significant theme was emotional support provided by cadres in terms of reception from cadres about people with mental health problems (59.1%), tangible support in which cadres help people with mental disorders get treatment (52.27%), and cadre roles as duties/mandates (51.36%) was factors that facilitated the success. The finding of this study indicated that cadres were considered to provide a range of different support to people with mental health disorders and their families. In carrying out their role, there were factors that participants felt increased success in implementing the role of cadres. The cadre-patient/family relationship was influenced by perceived shame, trust relationship, and stigma. This research also revealed patient and family expectations about cadres' roles.

CONCLUSIONS

Exploring the experiences of people with mental disorders and their families who received support from cadres could examine the factor that increases success in implementing cadre roles and barriers to mental health services by cadres, which are shame, mistrust, and stigma in the community. Therefore, paying attention to the expectations of people with mental health problems and their families about the cadre's roles in improving mental health services in the community is essential.

Community Dermatology: Current Status and the Way Forward

Community health interventions in dermatology have the potential to deliver healthcare to large populations. Such interventions can bridge the gap between increasing demands from vast populations and limited availability and asymmetric geographical distribution of specialist doctors. This narrative review aims to delineate various areas in which community dermatology initiatives are useful, the different approaches used, and the factors which could determine their effectiveness. We did a PubMed search using the search terms, "Community Health Services"[Mesh]) AND "Dermatology"[Mesh]. A further literature search was performed by cross-referencing these articles. In addition to its primary purpose of increasing access, community involvement can augment medical education, foster research, and help to develop more patient-centered clinical guidelines, understand disease trends and influences of the environment on various diseases, and formulate population-centered health policy. Task shifting, development of culture-sensitive and gender-sensitive community healthcare teams, disease-specific patient support groups, and use of advances in technology such as telemedicine are some of the important methods used in community dermatology. Task shifting may be performed at different levels - general practitioners, pharmacists, nurses, and community health workers. Community interventions harness volunteerism among health professionals as well as various stakeholders in the community. Partnering with non-governmental organizations, involving members of the community, and being a part of a long-term public health program help to sustain community interventions. The interventions should adapt to the ethical and cultural norms of the community. Continuity of care, fidelity, and evidence support are crucial for the success of community interventions in dermatology.

Effects of a Community Health Worker-Led Health Literacy Intervention on Lifestyle Modification Among Patients With Hypertension and Diabetes in the City of Harare, Zimbabwe: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Hypertension and diabetes are among the most common noncommunicable diseases in Zimbabwe. These 2 conditions are largely prevented and controlled by lifestyle modifications, such as healthy eating habits, physical activity, and avoiding the use of tobacco and alcohol.

OBJECTIVE

This study aims to evaluate the effects of a community health worker (CHW)-led health literacy intervention on lifestyle modification among patients with diabetes and hypertension in the City of Harare, Zimbabwe, in terms of (1) adherence to recommended lifestyle changes, (2) blood pressure and blood glucose levels, and (3) medication adherence.

METHODS

This is a 6-month-long cluster randomized controlled trial, which will be conducted in primary health care clinics in the city of Harare. A total of 14 clinics will be randomly allocated into either the intervention or control group. A total of 680 (49 participants per clinic) adult patients with hypertension and diabetes will be enrolled for the trial. Participants in the intervention arm will receive a simple health literacy intervention on lifestyle modification, which will be delivered by trained CHWs, while those in the control arm will receive usual care. The intervention consists of 4 face-to-face interactive educational sessions and monthly support visits by trained CHWs and will be carried out over a period of 6 months. The primary study outcomes will be blood pressure and blood glucose levels and levels of adherence to the recommended lifestyle modifications. Other outcomes will include adherence to medication. Data management and analysis will be done using Epi Info software, and the data will be analyzed using the intention-to-treat principle.

RESULTS

Recruitment of study participants commenced on June 1, 2023, and was completed on July 30, 2023. Baseline data are being collected after participants' recruitment, and the final data collection will be completed by January 31, 2024.

CONCLUSIONS

There is an information dearth regarding the effectiveness of CHW-led interventions for the management and control of hypertension in Zimbabwe. Our study offers an opportunity to show the effectiveness of CHWs in addressing the gaps in the management of hypertension and diabetes. The findings from our study will provide crucial evidence on the effectiveness and feasibility of a simple intervention delivered by CHWs in resource-constrained areas.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47512.

Addressing knowledge gaps: the key role of community health workers and healthcare providers in human papillomavirus prevention and vaccine uptake in a border community

The Human Papillomavirus (HPV) is the most common sexually transmitted infection and nearly every person who is sexually active will get HPV at some point in their lifetime without having the HPV vaccine. Healthcare Providers (HCPs) and Community Health Workers (CHWs) play an essential role in promoting the HPV vaccine and providing education about HPV in communities. Three focus groups with CHWs (n = 17) and HCPs (n = 7) were conducted and led by trained facilitators. In addition to participating in the focus group, CHWs and HCPs completed a brief questionnaire. Focus groups were voice recorded and transcribed for qualitative analysis. Independent coders conducted content analysis to identify the salient themes of the focus groups. Several important findings emerged from this study highlighting the barriers to HPV knowledge, gaps in the self-perceived role of HPV cancer prevention, and opportunities to action. Financial, knowledge, patriarchy, behaviors, attitudes, and fears were identified as the perceived patient-related barriers to promoting HPV cancer prevention. Both CHWs and HCPs explained that their female patients are often discouraged by their husbands from seeking out sexual health-related healthcare. Finding suggest the need for community tailored education on HPV and "best practice" trainings for HPV prevention that is applicable to both CHWs and HCPs.

Heterogeneity in defining multiple trauma: a systematic review of randomized controlled trials

INTRODUCTION

While numerous randomized controlled trials (RCTs) have been conducted in the field of trauma, a substantial portion of them are yielding negative results. One potential contributing factor to this trend could be the lack of agreement regarding the chosen definitions across different trials. The primary objective was to identify the terminology and definitions utilized for the characterization of multiple trauma patients within randomized controlled trials (RCTs).

METHODS

A systematic review of the literature was performed in MEDLINE, EMBASE and clinicaltrials.gov between January 1, 2002, and July 31, 2022. RCTs or RTCs protocols were eligible if they included multiple trauma patients. The terms employed to characterize patient populations were identified, and the corresponding definitions for these terms were extracted. The subsequent impact on the population recruited was then documented to expose clinical heterogeneity.

RESULTS

Fifty RCTs were included, and 12 different terms identified. Among these terms, the most frequently used were "multiple trauma" (n = 21, 42%), "severe trauma" (n = 8, 16%), "major trauma" (n = 4, 8%), and trauma with hemorrhagic shock" (n = 4, 8%). Only 62% of RCTs (n = 31) provided a definition for the terms used, resulting a total of 21 different definitions. These definitions primarily relied on the injury severity score (ISS) (n = 15, 30%), displaying an important underlying heterogeneity. The choice of the terms had an impact on the study population, affecting both the ISS and in-hospital mortality. Eleven protocols were included, featuring five different terms, with "severe trauma" being the most frequent, occurring six times (55%).

CONCLUSION

This systematic review uncovers an important heterogeneity both in the terms and in the definitions employed to recruit trauma patients within RCTs. These findings underscore the imperative of promoting the use of a unique and consistent definition.

The Experiences of Community Health Workers in Preventing Noncommunicable Diseases in an Urban Area, the Philippines: A Qualitative Study

(1) Background: Barangay health workers (BHWs) play important roles as community health workers in preventing noncommunicable diseases (NCDs), where the shortage of health professionals is felt more acutely in the Philippines. However, there is little research on the experiences of BHWs as community health workers in preventing NCDs. This study aimed to clarify the roles and difficulties of BHWs in conducting activities for the prevention of NCDs. (2) Methods: Qualitative data were collected from 25 BHWs. (3) Results: The mean age of the participants was 50.4 ± 9.5 years, 23 were women, and the mean length of time as a BHW was 9.1 ± 7.7 years. Three major themes about the role of BHWs in preventing NCDs-"screening for NCDs", "assisting patients with management of their conditions", and "promoting healthy behaviors"-and four major themes about the difficulties-"insufficient awareness of preventative behaviors", "economic burdens", "lack of resources for managing NCDs", and "difficulty of access to medical care facilities"-were identified. (4) Conclusions: Through the findings of this study, focusing interventions aimed at addressing the difficulties for the prevention of NCDs among BHWs may help reduce health inequities.

The role of community health advisors' cancer history in implementation and efficacy of a cancer control intervention

Community health advisors (CHAs) play a key role in promoting health in medically underserved communities, including in addressing cancer disparities. There is a need to expand the research on what characteristics make for an effective CHA. We examined the relationship between CHA personal and family history of cancer, and implementation and efficacy outcomes in a cancer control intervention trial. Twenty-eight trained CHAs implemented a series of three cancer educational group workshops for N = 375 workshop participants across 14 churches. Implementation was operationalized as participant attendance at the educational workshops, and efficacy as workshop participants' cancer knowledge scores at the 12-month follow-up, controlling for baseline scores. CHA personal history of cancer was not significantly associated with implementation, nor knowledge outcomes. However, CHAs with family history of cancer had significantly greater participant attendance at the workshops than CHAs without family history of cancer (P = 0.03) and a significant, positive association with male workshop participants' prostate cancer knowledge scores at 12 months (estimated beta coefficient = 0.49, P < 0.01) after adjusting for confounders. Findings suggest that CHAs with family history of cancer may be particularly suitable for cancer peer education, although further research is needed to confirm this and identify other factors conducive to CHA success.

The role of community health workers in primary healthcare in the WHO-EU region: a scoping review

BACKGROUND

Existing evidence on the role of community health workers (CHWs) in primary healthcare originates primarily from the United States, Canada and Australia, and from low- and middle-income countries. Little is known about the role of CHWs in primary healthcare in European countries. This scoping review aimed to contribute to filling this gap by providing an overview of literature reporting on the involvement of CHWs in primary healthcare in WHO-EU countries since 2001 with a focus on the role, training, recruitment and remuneration.

METHODS

This systematic scoping review followed the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses, extension for Scoping Reviews. All published peer-reviewed literature indexed in PubMed, Web of Science, and Embase databases from Jan 2001 to Feb 2023 were reviewed for inclusion. Included studies were screened on title, abstract and full text according to predetermined eligibility criteria. Studies were included if they were conducted in the WHO-EU region and provided information regarding the role, training, recruitment or remuneration of CHWs.

RESULTS

Forty studies were included in this review, originating from eight countries. The involvement of CHWs in the WHO-EU regions was usually project-based, except in the United Kingdom. A substantial amount of literature with variability in the terminology used to describe CHWs, the areas of involvement, recruitment, training, and remuneration strategies was found. The included studies reported a trend towards recruitment from within the communities with some form of training and payment of CHWs. A salient finding was the social embeddedness of CHWs in the communities they served. Their roles can be classified into one or a combination of the following: educational; navigational and supportive.

CONCLUSION

Future research projects involving CHWs should detail their involvement and elaborate on CHWs' role, training and recruitment procedures. In addition, further research on CHW programmes in the WHO-EU region is necessary to prepare for their integration into the broader national health systems.

Primary healthcare delivery models in African conflict-affected settings: a systematic review

BACKGROUND

In conflict-affected settings, access to primary healthcare for displaced populations is constrained by multiple challenges. These include geographical, cultural, communication, logistical and financial barriers, as well as risks posed to health workers and the population by insecurity. Different models of care are used to provide primary healthcare to affected communities. However, there is a paucity of evidence on how these models are selected and implemented by organisations working in conflict and displacement-affected settings. Our aim was to explore the different primary healthcare delivery models used in conflict-affected settings to understand gaps in existing healthcare delivery models.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The review protocol was registered with the International Prospective Register of Systematic Reviews. We searched six databases for manuscripts published from January 1992 to December 2020. Publications were included if they reported primary healthcare models of care in conflict-affected settings of Africa. Data was analyzed descriptively and thematically using tables, charts and text.

RESULTS

Forty-eight primary research articles were included for analysis from which thirty-three were rated as "high" quality. The results showed that the models of care in place in these conflict-affected settings include health facility-based, community-based, mobile clinics, outreach and home visits. Primary healthcare for internally displaced persons and refugees is provided by a wide range of actors including national and international organisations. A range of services is offered, most commonly nutrition, mental health and sexual/reproductive health. Some organisations offer vertical (stand-alone) services, while others use an integrated service delivery model. Multiple cadres of healthcare workers provide services, frequently lay healthcare workers such as Community Health Workers.

CONCLUSION

Understanding the different modalities of primary healthcare delivery in conflict-affected settings is important to identify existing practices and gaps in service delivery. Service delivery using community health workers in conflict-affected settings is a low-cost primary care delivery strategy that may help optimize contributions of existing personnel through task shifting.

Addressing Training Gaps: A Competency-Based, Telehealth Training Initiative for Community Health Workers

Background

To overcome vast variations in Community Health Worker (CHW) training, investigators for the CHW Core Consensus Project (CCCP) derived three types of CHW (Category 1, 2, 3) and established competencies for each category. However, studies are needed that implement these competencies in real-world settings.

Objective

Using the six competency domains of the CCCP as a theoretical backbone, we developed and evaluated a training for Category 1 CHWs, individuals whose focus is on community outreach and advocacy.

Methods

We developed five telehealth-based, bilingual (Spanish/English) training sessions and implemented them among Category 1 Latino(a) CHWs. We measured the number of CHWs who achieved ≥70% correct on a domain-based posttest, attendance, and qualitative feedback.

Results

All (18/18) CHWs achieved at least 70% on the posttest (mean: 93.7%; range 73.3-100%). Training attendance was 98.9%. Using a six-point scale, CHWs reported high levels of satisfaction overall (5.72 ± 0.57/6.0), with telehealth (5.72 ± 0.58/6.0), effectiveness of teaching strategies/methods (5.89 ± 0.32/6.0), achieving training objectives (5.96 ± 0.15/6.0), knowledge improvement (5.72 ± 0.57/6.0), and interest (5.78 ± 0.43/6.0).

Conclusion

We successfully developed and evaluated a bilingual training program for Category 1 CHWs to address core competency gaps. High CHW attendance reinforces the value of telehealth modalities and their potential to increase the reach for CHW training. To overcome gaps in chronic disease training, investigations are needed to address additional CHW trainings.

Trial Registration

NCT04835493.

Feasibility and acceptability of involving bilingual community navigators to improve access to health and social care services in general practice setting of Australia

BACKGROUND

Patients from culturally and linguistically diverse (CALD) backgrounds often face difficulties in accessing health and social care services. This study explored the feasibility and acceptability of involving community health workers (CHWs) as bilingual community navigators (BCNs) in general practice setting, to help patients from CALD backgrounds access health and social care services in Australia.

METHODS

This research was conducted in two general practices in Sydney where most patients are from specific CALD backgrounds (Chinese in one practice and Samoan in other). Three CHWs trained as BCNs were placed in these practices to help patients access health and social care service. A mixed-method design was followed to explore the feasibility and acceptability of this intervention including analysis of a record of services provided by BCNs and post-intervention qualitative interviews with patients, practice staff and BCNs exploring the feasibility and acceptability of the BCNs' role. The record was analyzed using descriptive statistics and interviews were audio-recorded, transcribed, and thematically analyzed.

RESULTS

BCNs served a total of 95 patients, providing help with referral to other services (52.6%), information about appointments (46.3%), local resources (12.6%) or available social benefits (23.2%). Most patients received one service from BCNs with the average duration of appointments being half an hour. Overall, BCNs fitted in well within the practices and patients as well as staff of participating practices accepted them well. Their role was facilitated by patients' felt need for and acceptance of BCNs' services, recruitment of BCNs from the patient community, as well as BCNs' training and motivation for their role. Major barriers for patients to access BCNs' services included lack of awareness of the BCNs' roles among some patients and practice staff, unavailability of information about local culture specific services, and inadequate time and health system knowledge by BCNs. Limited funding support and the short timeframe of the project were major limitations of the project.

CONCLUSION

BCNs' placement in general practice was feasible and acceptable to patients and staff in these practices. This first step needs to be followed by accredited training, development of the workforce and establishing systems for supervision in order to sustain the program. Future research is needed on the extension of the intrevention to other practices and culture groups.

Effect of early childhood development interventions delivered by healthcare providers to improve cognitive outcomes in children at 0-36 months: a systematic review and meta-analysis

OBJECTIVE

To determine the effect of early childhood development interventions delivered by healthcare providers (HCP-ECD) on child cognition and maternal mental health.

DESIGN

Systematic review, meta-analysis.

SETTING

Healthcare setting or home.

PARTICIPANTS

Infants under 1 month of age.

INTERVENTIONS

HCP-ECD interventions that supported responsive caregiving, early learning and motor stimulation. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews were searched until 15 November 2021. Studies reporting prespecified outcomes were pooled using standard meta-analytical methods.

MAIN OUTCOME MEASURES

Cognitive development in children at 0-36 months.

RESULTS

Forty-two randomised controlled trials with 15 557 infants were included in the narrative synthesis. Twenty-seven trials were included in the meta-analyses. Pooled data from 13 trials suggest that HCP-ECD interventions may improve cognitive outcomes in children between 0 and 36 months (Bayley Scales of Infant Development version IIII (BSID-III) mean difference (MD) 2.65; 95% CI 0.61 to 4.70; 2482 participants; low certainty of evidence). Pooled data from nine trials suggest improvements in motor development (BSID-III MD 4.01; 95% CI 1.54 to 6.48; 1437 participants; low certainty of evidence). There was no evidence of improvement in maternal mental health (standardised MD -0.13; 95% CI -0.28 to 0.03; 2806 participants; 11 trials; low certainty of evidence).

CONCLUSIONS

We report promising evidence, particularly for cognitive and motor outcomes, of the effect of HCP-ECD interventions. However, effect sizes were small, and the certainty of evidence ranged from very low to moderate. Additional high-quality research is required.

PROSPERO REGISTRATION NUMBER

CRD42019122021.

Making the case for citizenship-oriented mental healthcare for youth in Canada

Purpose

Varying stakeholders have highlighted how recovery-oriented mental health services such as youth mental health services have traditionally focused on supporting individual resources to promote recovery (e.g., agency) to the exclusion of addressing structural issues that influence recovery (e.g. poverty). One response to this criticism has been work helping people with mental health problems recover a sense of citizenship and sense of belonging in their communities. Work on citizenship has yet to influence youth mental healthcare in Canada’s provinces and territories. This paper aims to highlight ways that youth mental healthcare can better help youth recover a sense of citizenship.

Design/methodology/approach

The arguments described in this paper were established through discussion and consensus among authors based on clinical experience in youth mental health and an understanding of Canada’s healthcare policy landscape, including current best practices as well as guidelines for recovery-oriented care by the Mental Health Commission of Canada.

Findings

Here, this study proposes several recommendations that can help young with mental health problems recover their sense of citizenship at the social, systems and service levels. These include addressing the social determinants of health; developing a citizenship-based system of care; addressing identity-related disparities; employing youth community health workers within services; adapting and delivering citizenship-based interventions; and connecting youth in care to civic-oriented organizations.

Originality/value

This paper provides the first discussion of how the concept of citizenship can be applied to youth mental health in Canada in multiple ways. The authors hope that this work provides momentum for adopting policies and practices that can help youth in Canada recover a sense of citizenship following a mental health crisis.

Community Health Workers as Vaccinators: A Rapid Review of the Global Landscape, 2000-2021

INTRODUCTION

Community health workers (CHWs) could expand immunization access in under-reached communities by administering vaccines. This rapid review identifies countries where CHWs administered vaccines and synthesizes health systems factors that may contribute to or detract from the feasibility of CHWs administering vaccines.

METHODS

We conducted a rapid review of peer-reviewed literature from 3 databases and gray literature identified through web searches and by CHW subject matter experts. We treated extracted data on conditions related to vaccine administration by CHWs as qualitative data and conducted deductive content analysis.

RESULTS

We retained 32 documents from 497 initial records and identified 23 CHW cadres that vaccinated in 20 countries, ranging from long-established national programs delivering routine immunizations to pilot projects delivering 1 specific vaccine. CHWs who vaccinate face the following challenges: (1) inadequate supply chain training, (2) inadequate cold chain equipment, (3) transportation for supplies and to communities, (4) heavy existing workload, (5) inadequate or irregular remuneration, (6) inadequate or irregular supervision.

CONCLUSION

To improve immunization coverage in underimmunized and zero-dose communities, countries where CHWs vaccinate should provide CHWs with adequate remuneration, supervision, supply chain support and management, and formal integration within the health system. CHWs administered vaccines in 20 of the 75 countries with documented CHW programs, suggesting the majority of an estimated 3.3 million CHWs globally do not yet administer vaccines. In light of health care workforce shortages and immunization equity gaps, further exacerbated by the COVID-19 pandemic, policymakers should consider task-shifting vaccine administration to CHWs to bolster immunization access for under-reached communities. Additional systematic documentation is needed to further explore best practices to support CHWs as vaccinators, especially related to supply chain, policy, safety, and efficacy.

Community Health Worker Use of Smart Devices for Health Promotion: Scoping Review

BACKGROUND

Community health workers (CHWs) have become essential to the promotion of healthy behaviors, yet their work is complicated by challenges both within and beyond their control. These challenges include resistance to the change of existing behaviors, disbelief of health messages, limited community health literacy, insufficient CHW communication skills and knowledge, lack of community interest and respect for CHWs, and CHWs' lack of adequate supplies. The rising penetration of "smart" technology (eg, smartphones and tablets) in low- and middle-income countries facilitates the use of portable electronic devices in the field.

OBJECTIVE

This scoping review examines to what extent mobile health in the form of smart devices may enhance the delivery of public health messages in CHW-client interactions, thereby addressing the aforementioned challenges and inducing client behavior change.

METHODS

We conducted a structured search of the PubMed and LILACS databases using subject heading terms in 4 categories: technology user, technology device, use of technology, and outcome. Eligibility criteria included publication since January 2007, CHWs delivering a health message aided by a smart device, and face-to-face communication between CHWs and clients. Eligible studies were analyzed qualitatively using a modified version of the Partners in Health conceptual framework.

RESULTS

We identified 12 eligible studies, 10 (83%) of which used qualitative or mixed methods approaches. We found that smart devices mitigate challenges encountered by CHWs by improving their knowledge, motivation, and creativity (eg, through self-made videos); their status within the community; and the credibility of their health messages. The technology stimulated interest in both CHWs and clients-and sometimes even in bystanders and neighbors. Media content produced locally or reflecting local customs was strongly embraced. Yet, the effect of smart devices on the quality of CHW-client interactions was inconclusive. Interactions suffered as CHWs were tempted to replace educational conversations with clients by passively watching video content. Furthermore, a series of technical difficulties experienced especially by older and less educated CHWs compromised some of the advantages brought about by mobile devices. Adequate CHW training ameliorated these difficulties. Only 1 study (8%) considered client health behavior change as an end point, thus revealing a major research gap.

CONCLUSIONS

Smart mobile devices may augment CHWs' field performance and enhance face-to-face interactions with clients, yet they also generate new challenges. The available evidence is scarce, mostly qualitative, and focused on a limited range of health outcomes. Future research should include larger-scale interventions across a wide range of health outcomes and feature client health behavior change as an end point.

A novel approach to frontline health worker support: a case study in increasing social power among private, fee-for-service birthing attendants in rural Bangladesh

BACKGROUND

Expanding the health workforce to increase the availability of skilled birth attendants (SBAs) presents an opportunity to expand the power and well-being of frontline health workers. The role of the SBA holds enormous potential to transform the relationship between women, birthing caregivers, and the broader health care delivery system. This paper will present a novel approach to the community-based skilled birth attendant (SBA) role, the Skilled Health Entrepreneur (SHE) program implemented in rural Sylhet District, Bangladesh.

CASE PRESENTATION

The SHE model developed a public-private approach to developing and supporting a cadre of SBAs. The program focused on economic empowerment, skills building, and formal linkage to the health system for self-employed SBAs among women residents. The SHEs comprise a cadre of frontline health workers in remote, underserved areas with a stable strategy to earn adequate income and are likely to remain in practice in the area. The program design included capacity-building for the SHEs covering traditional techno-managerial training and supervision in programmatic skills and for developing their entrepreneurial skills, professional confidence, and individual decision-making. The program supported women from the community who were social peers of their clients and long-term residents of the community in becoming recognized, respected health workers linked to the public system and securing their livelihood while improving quality and access to maternal health services. This paper will describe the SHE program's design elements to enhance SHE empowerment in the context of discourse on social power and FLHWs.

CONCLUSION

The SHE model successfully established a private SBA cadre that improved birth outcomes and enhanced their social power and technical skills in challenging settings through the mainstream health system. Strengthening the agency, voice, and well-being of the SHEs has transformative potential. Designing SBA interventions that increase their power in their social context could expand their economic independence and reinforce positive gender and power norms in the community, addressing long-standing issues of poor remuneration, overburdened workloads, and poor retention. Witnessing the introduction of peer or near-peer women with well-respected, well-compensated roles among their neighbors can significantly expand the effectiveness of frontline health workers and offer a model for other women in their own lives.

"We just have to help": Community health workers' informal task-shifting and task-sharing practices for hypertension and diabetes care in Nigeria

Introduction

Nigeria's skilled health professional health workforce density is insufficient to achieve its national targets for non-communicable diseases (NCD) which include 25% reduction in the prevalence of diabetes and hypertension, particularly at the primary health care (PHC) level. This places a great demand on community health workers (CHWs) who constitute the majority of PHC workers. Traditionally, CHWs are mainly involved in infectious diseases programmes, and maternal and child health services. Their involvement with prevention and control of NCDs has been minimal. With government prioritization of PHC for combating the rising NCD burden, strengthening CHWs' skills and competencies for NCD care delivery is crucial.

Methods

We conducted a mixed methods study to explore the roles and practices of CHWs in the delivery of hypertension and diabetes care at PHC facilities in four states (two each in northern and southern regions) in Nigeria. We reviewed the National Standing Orders that guide CHWs' practices at the PHC facilities and administered a survey to 76 CHWs and conducted 13 focus groups (90 participants), and in-depth individual interviews with 13 CHWs and 7 other local and state government stakeholders.

Results

Overall, we found that despite capacity constraints, CHWs frequently delivered services beyond the scope of practice stipulated in the National Standing Orders. Such informal task-shifting practices were primarily motivated by a need to serve the community.

Discussion

While these practices may partially support health system functions and address unmet need, they may also lead to variable care quality and safety. Several factors could mitigate these adverse impacts and strengthen CHW roles in the health system. These include a stronger enabling policy environment to support NCD task-sharing, investment in continuous capacity building for CHWs, improved guidelines that can be implemented at the point of care, and improved coordination processes between PHC and higher-level facilities.

"If You Do Not Take the Medicine and Complete the Dose…It Could Cause You More Trouble": Bringing Awareness, Local Knowledge and Experience into Antimicrobial Stewardship in Tanzania

Antimicrobial resistance (AMR) is a global health issue disproportionately affecting low- and middle-income countries. In Tanzania, multi-drug-resistant bacteria (MDR) are highly prevalent in clinical and community settings, inhibiting effective treatment and recovery from infection. The burden of AMR can be alleviated if antimicrobial stewardship (AMS) programs are coordinated and incorporate local knowledge and systemic factors. AMS includes the education of health providers to optimise antimicrobial use to improve patient outcomes while minimising AMR risks. For programmes to succeed, it is essential to understand not just the awareness of and receptiveness to AMR education, but also the opportunities and challenges facing health professionals. We conducted in-depth interviews (n = 44) with animal and human health providers in rural northern Tanzania in order to understand their experiences around AMR. In doing so, we aimed to assess the contextual factors surrounding their practices that might enable or impede the translation of knowledge into action. Specifically, we explored their motivations, training, understanding of infections and AMR, and constraints in daily practice. While providers were motivated in supporting their communities, clear issues emerged regarding training and understanding of AMR. Community health workers and retail drug dispensers exhibited the most variation in training. Inconsistencies in understandings of AMR and its drivers were apparent. Providers cited the actions of patients and other providers as contributing to AMR, perpetuating narratives of blame. Challenges related to AMR included infrastructural constraints, such as a lack of diagnostic testing. While health and AMR-specific training would be beneficial to address awareness, equally important, if not more critical, is tackling the challenges providers face in turning knowledge into action.

Unsung heroes in health education and promotion: How Community Health Workers contribute to hypertension management

Rural communities are noted as having poor health outcomes. Rural areas experience barriers to care primarily due to a lack of resources, including education, health insurance, transportation, and social support. Additionally, poor health outcomes are a consequence of poor health literacy skills. Community Health Workers (CHWs) are utilized as a resource to combat these issues. This study focused on a CHW led Self-Management Blood Pressure (SMBP) program offered through the University of Texas at Tyler Health Science Center. The goal of the program was to improve management of hypertension through awareness, education, navigation, advocacy, and resource assistance. The SMBP program included structured workshops and regular follow-up with participants including connections to community resources and social support. CHWs worked closely with physicians providing bi-directional feedback on referrals and engagement of communities through outreach events. Furthermore, CHWs aided to bridge cultural or linguistic gaps between service providers and community members. Data is provided indicating this CHW-led intervention played a significant role in improving hypertension through education of how to make lifestyle changes that impact overall health and quality of life. Participants gained knowledge encouraging them to create lifelong healthy habits, coping skills, stress management, self-care, and accountability. Through this innovative approach, participants thrived in the supportive and encouraging environment led by CHWs as well as improved their blood pressure management.

Methods of training lay individuals in the use of evidence-based services for the management of mental and behavioral health disorders: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to describe how lay individuals have been trained in evidence-based therapies to manage mental and behavioral health disorders as defined by the International Classification of Diseases, version 11.

INTRODUCTION

Health service delivery by lay individuals is common in under-resourced areas. Prior systematic reviews have examined the characteristics of lay workers, the types of services they provide, and the efficacy of their services. Our goal is to focus on the methods of training.

INCLUSION CRITERIA

Participants will include lay individuals who provide services to community residents; we will exclude individuals with formal training in health service delivery. We will consider for inclusion studies that include training programs for evidence-based therapies delivered to individuals with mental and behavioral health disorders, and will exclude those involving pharmacology or focusing on cognitive defects.

METHODS

We conducted a preliminary search of the literature on PubMed and CINAHL for articles related to the inclusion criteria and published in the past 10  years. Scanning the title, abstract, keywords, and MeSH terms, we generated comprehensive lists of terms and added search terms from 6 recent systematic reviews. Our search strategy will include MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science, and gray literature. We will also consult with experts and review the reference lists of articles selected for final inclusion. Articles published in English or Spanish between 1960 and the present will be considered for inclusion. Data analysis will use a mix of descriptive and qualitative approaches, with data presented graphically or in diagrammatic or tabular format.

The impact of the COVID-19 pandemic in the frontline health workforce: Perceptions of vulnerability of Brazil's community health workers

The COVID-19 pandemic has resulted in calls for an increased integration of community health workers (CHWs) into the health system response. Historically, CHWs can play an important role in ensuring the sustainability of health policy implementation - by addressing social determinants of health and maintaining care for ongoing health problems. Their frontline work, with close contact to populations, places CHWs in a position of increased vulnerability to becoming infected and to being the target of abuse and violence. These vulnerabilities compound underlying problems faced by CHWs, who often come from poor backgrounds, are insufficiently paid and receive inadequate training. Speaking to a scarcity of studies on how CHWs are impacted by the pandemic, this paper conducts a systematic study of CHWs in Brazil. Based on quantitative and qualitative data collected during June and July 2020, it considers perceptions and experiences of CHWs, comparing them with other health professionals. We study the extent to which the pandemic added to existing vulnerabilities and created new problems and imbalances in the work of CHWs. We conclude that COVID-19 led to a deterioration of the working conditions of CHWs, of their relations with other health professionals, and of their ability to carry out their essential work in the public health system.

Improving cancer care for underserved populations in an academic and community practice setting: protocol for a community health worker pilot navigation programme

INTRODUCTION

Delaying cancer treatment following diagnosis impacts health outcomes, including increasing patient distress and odds of mortality. Interventions to promote timely healthcare engagement may decrease patient-reported stress and improve quality of life. Community health workers (CHWs) represent an enabling resource for reducing delays in attending initial oncology treatment visits. As part of an ongoing programme evaluation coordinated by the Merck Foundation, we will implement a pilot navigation programme comprising CHW-conducted needs assessments for supporting patients and their caregivers. We aim to investigate (1) the programme's influence on patients' healthcare utilisation within the period between their first diagnosis and initial treatment visit and (2) the logistic feasibility and acceptability of programme implementation.

METHODS AND ANALYSIS

We will employ a hybrid implementation design to introduce the CHW navigation programme at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center. CHW team members will use a consecutive sampling approach. Participants will complete the Problem-Checklist, Chronic Illness Distress Scale and the Satisfaction with Life Domains instruments. CHWs will provide tailored guidance by sharing information available on the Johns Hopkins Electronic Resource databases. The investigators will evaluate patients' time to initial oncology treatment and healthcare utilisation by reviewing electronic medical records at 3 and 6 months postintervention. Bivariate analyses will be completed to evaluate the relationships between receiving the programme and all outcome measures.

ETHICS AND DISSEMINATION

This study's protocol was approved by the Johns Hopkins School of Medicine's institutional review board (IRB00160610). Informed consent will be obtained by phone by the CHW navigator. Dissemination planning is ongoing through regular meetings between members of the investigator team and public members of two community advisory groups. Study plans include collaborating with other experts from the Johns Hopkins Institute for Clinical and Translational Research and the Johns Hopkins Center for Health Equity for ideating dissemination strategies.

Intervention components of link worker social prescribing programmes: A scoping review

In the United Kingdom (UK), link worker social prescribing has emerged as an option to improve long-term condition management and address primary care patients' non-medical needs by linking patients with community-based activities and support. Social prescribing is a complex, heterogenous intervention, and there is currently no taxonomy of components to guide its implementation and evaluation. This study aimed to identify and categorise the components of link worker social prescribing schemes in the United Kingdom. A scoping review of peer-reviewed literature was conducted. Six databases were used to identify papers that met inclusion criteria. Eligible articles were original research studies in the United Kingdom describing interventions that included (1) initial referral of adults with chronic physical health conditions and/or unmet social needs from primary care to a link worker or equivalent role, (2) consultation with a link worker or equivalent role and (3) referral to a community-based or government service. Of the 1078 articles identified, 32 met study eligibility criteria, representing 22 social prescribing schemes. We drew from the template for intervention description and replication (TIDieR) to identify, organise and report intervention components. We found wide variations in geography, target populations and intervention components such as activities and procedures conducted by primary care staff and link workers, organisational and staffing configurations and use of tools and financing approaches to facilitate adoption. Intervention components are summarised into a taxonomy to guide future research, policy and practice efforts in addition to supporting standardised intervention reporting.