Can the financial burden of being a community health volunteer in western Kenya exacerbate poverty?

Labour conditions in dual-cadre community health worker programmes: a systematic review

BACKGROUND

Health care delivered by community health workers reduces morbidity and mortality while providing a considerable return on investment. Despite growing consensus that community health workers, a predominantly female workforce, should receive a salary, many community health worker programmes take the form of dual-cadre systems, where a salaried cadre of community health workers works alongside a cadre of unsalaried community health workers. We aimed to determine the presence, prevalence, and magnitude of exploitation in national dual-cadre programmes.

METHODS

We did a systematic review of available evidence from peer-reviewed databases and grey literature from database inception to Aug 2, 2021, for studies on unsalaried community health worker cadres in dual-cadre systems. Editorials, protocols, guidelines, or conference reports were excluded in addition to studies about single-tier community health worker programmes and those reporting on only salaried cadres of community health workers in a dual-cadre system. We extracted data on remuneration, workload, task complexity, and self-reported experiences of community health workers. Three models were created: a minimum model with the shortest time and frequency per task documented in the literature, a maximum model with the longest time, and a median model. Labour exploitation was defined as being engaged in work below the country's minimum wage together with excessive work hours or complex tasks. The study was registered with PROSPERO, CRD42021271500.

FINDINGS

We included 117 reports from 112 studies describing community health workers in dual-cadre programmes across 19 countries. The majority of community health workers were female. 13 (59%) of 22 unsalaried community health worker cadres and one (10%) of ten salaried cadres experienced labour exploitation. Three (17%) of 18 unsalaried community health workers would need to work more than 40 h per week to fulfil their assigned responsibilities. Unsalaried community health worker cadres frequently reported non-payment, inadequate or inconsistent payment of incentives, and an overburdensome workload.

INTERPRETATION

Unsalaried community health workers in dual-cadre programmes often face labour exploitation, potentially leading to inadequate health-care provision. Labour laws must be upheld and the creation of professional community health worker cadres with fair contracts prioritised, international funding allocated to programmes that rely on unsalaried workers should be transparently reported, the workloads of community health workers should be modelled a priori and actual time use routinely assessed, community health workers should have input in policies that affect them, and volunteers should not be responsible for the delivery of essential health services.

FUNDING

None.

The experiences and challenges of community health volunteers as agents for behaviour change programming in Africa: a scoping review

Community health volunteers are considered a vital part of the community health structure in Africa. Despite this vital role in African health systems, very little is known about the community health volunteers’ day-to-day lived experiences providing services in communities and supporting other health workers. This scoping review aims to advance understanding of the day-to-day experiences of community health volunteers in Africa. In doing so, this review draws attention to these under-considered actors in African health systems and identifies critical factors and conditions that represent challenges to community health volunteers’ work in this context. Ultimately, our goal is to provide a synthesis of key challenges and considerations that can inform efforts to reduce attrition and improve the sustainability of community health volunteers in Africa. This scoping review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews checklist to achieve the objectives. A comprehensive search of six databases returned 2140 sources. After screening, 31 peer-reviewed studies were selected for final review. Analytical themes were generated based on the reviewers’ extraction of article data into descriptive themes using an inductive approach. In reviewing community health volunteers’ accounts of providing health services, five key challenges become apparent. These are: (1) challenges balancing work responsibilities with family obligations; (2) resource limitations; (3) exposure to stigma and harassment; (4) gendered benefits and risks; and (5) health-system level challenges. This scoping review highlights the extent of challenges community health volunteers must navigate to provide services in communities. Sustained commitment at the national and international level to understand the lived experiences of community health volunteers and mitigate common stressors these health actors face could improve their performance and inform future programs.

Acceptability and feasibility of community-based provision of urine pregnancy tests to support linkages to reproductive health services in Western Kenya: a qualitative analysis

BACKGROUND

The majority of women living in rural Kenya access antenatal care (ANC) late in pregnancy, and approximately 20% have an unmet need for family planning (FP). This study aimed to determine whether training community health volunteers (CHVs) to deliver urine pregnancy testing (UPT), post-test counselling, and referral to care was an acceptable and feasible intervention to support timely initiation of ANC and uptake of FP.

METHODS

We applied community-based participatory methods to design and implement the pilot intervention between July 2018 and May 2019. We conducted qualitative content analysis of 12 pre-intervention focus group discussions (FGDs) with women, men, and CHVs, and of 4 post-intervention FGDs with CHVs, each with 7-9 participants per FGD group. Using a pragmatic approach, we conducted inductive line-by-line coding to generate themes and subthemes describing factors that positively or negatively contributed to the intervention's acceptability and feasibility, in terms of participants' views and the intervention aims.

RESULTS

We found that CHV-delivered point of care UPT, post-test counselling, and referral to care was an acceptable and feasible intervention to increase uptake of ANC, FP, and other reproductive healthcare services. Factors that contributed to acceptability were: (1) CHV-delivery made UPT more accessible; (2) UPT and counselling supported women and men to build knowledge and make informed choices, although not necessarily for women with unwanted pregnancies interested in abortion; (3) CHVs were generally trusted to provide counselling, and alternative counselling providers were available according to participant preference. A factor that enhanced the feasibility of CHV delivering UPT and counselling was CHV's access to appropriate supplies (e.g. carrying bags). However, factors that detracted from the feasibility of women actually accessing referral services after UPT and counselling included (1) downstream barriers like cost of travel, and (2) some male community members' negative attitudes toward FP. Finally, improved financial, educational, and professional supports for CHVs would be needed to make the intervention acceptable and feasible in the long-term.

CONCLUSION

Training CHVs in rural western Kenya to deliver UPT, post-test counselling, and referral to care was acceptable and feasible to men, women, and CHVs in this context, and may promote early initiation of ANC and uptake of FP. Additional qualitative work is needed to explore implementation challenges, including issues related to unwanted pregnancies and abortion, the financial burden of volunteerism on CHVs, and educational and professional supports for CHVs.

Psychological distress and associated factors among hospital workers in Uganda during the COVID-19 lockdown - A multicentre study

OBJECTIVE

To assess the prevalence of psychological distress (PD), and its associated demographic, psychosocial, hospital and health-related factors among hospital workers in Uganda during the COVID-19 related lockdown.

METHODS

An online cross-sectional study was conducted among three hundred ninety six participants recruited from eight hospitals and PD was assessed using the Kessler 6 distress scale from May to June 2020.

RESULTS

PD was present in 92.7% of the participants with majority (78.3%) having mild to moderate PD whereas 14.4% had severe PD. Severe PD had statistically significant association with having financial liabilities (O.R = 3.69 (1.55-8.77), p = 0.003). However, ability to maintain contact with family members and friends (O.R = 0.43 (0.22-0.84), p value = 0.013), and having enough personal protective equipment and safety tools at work place (O.R = 0.44 (0.23-0.84), p value = 0.012) were protective against severe PD. having excessive worry about getting infected with COVID-19, conflicts within a home, segregation by friends or community, longer working hours or involvement in management of suspected or confirmed case were not associated with severe PD.

CONCLUSION

The findings indicate the need to take into consideration the mental wellbeing of health workers during this COVID-19 outbreak. Whereas hospital workers continue to provide their services during the COVID-19 pandemic and related lockdown, it is important that they maintain contact with social support networks and be provided with counselling and mental health and psychosocial services in order to optimise their mental health during this pandemic.

The Effect of a Learning Partner Model-Based Program on Spreading Cancer Prevention Knowledge Using Community Health Volunteers in Japan

Objectives:

This study examines the implementation and short-term effects of a Learning Partner Model (LPM)-based educational program on cancer prevention and control information for community health volunteers in Japan.

Methods:

The program was undertaken by 3 local governments in collaboration with a government initiative and offered a 90-min group workshop to community health volunteers. Community health volunteers (primary participants) recruited in turn friend or family members (secondary participants) with whom they were prepared to share the content of the workshop with the help of printed materials received in the workshop. We conducted self-administered paper and pencil questionnaire surveys before, immediately after, and 3 months after the workshop. The t-test, Fisher’s exact test, paired t-test, and McNemar test were used to compare the 2 groups’ demographic characteristics and healthy habits at pretest. Repeated measures ANOVA was used to compare cancer prevention knowledge between groups and over time.

Results:

Of 142 participants, 107 pairs of learning partners (primary and corresponding secondary participant) completed all questionnaires. All primary participants and 37.4% of the secondary participants were women, and 57.9% of the learning partners were spouses. The results showed significantly higher correct answers on the cancer-prevention knowledge questions in the post-workshop and follow-up surveys compared to the pre-workshop survey (P < .001). The increase in knowledge was observed in all learning-partner groups in all 3 sites.

Conclusion:

The study demonstrates a promising strategy that can be adapted to the health needs of the community beyond cancer prevention and control, building on the efforts of local governments and government health initiatives.

'It was hell in the community': a qualitative study of maternal and child health care during health care worker strikes in Kenya

BACKGROUND

Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers.

METHODS

We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women's pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches.

RESULTS

Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care.

CONCLUSION

We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.