Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review

How do family members influence smokeless tobacco consumption during pregnancy in India? Perspectives of pregnant women

Smokeless tobacco (ST) use in South Asia is culturally ingrained and socially accepted. A better understanding of these sociocultural influences could inform behavioural approaches to prevent ST use. We sought to understand how family members influence pregnant women's behaviour, attitudes, and perceptions towards ST use. Moreover, we captured the influence of community health workers in this context. A qualitative study using a framework analysis was conducted in selected Indian populations. Eight in-depth interviews among pregnant and postpartum women were conducted in Gujarati, the local language, investigating ST use during pregnancy and the influence of family and peers. All transcripts were transcribed verbatim and translated into English and analyzed in NVivo. The social norms and expectations around ST during pregnancy appeared to have shifted away from promoting towards discouraging its use in the past few years. Women described how their spouses and other family members encouraged them to stop using ST during pregnancy, with some women must hide their ST use from their family members. They also received advice on the harms of ST use from community health workers (Accredited Social Health Activist-ASHA workers). Influenced by the advice received from such workers, several women tried to reduce their ST use during pregnancy. Our findings suggest that the acceptability of ST use in pregnancy may be in decline among families in India. Hence, efforts to promote ST prevention during pregnancy are likely to be "pushing against an open door". Furthermore, community health workers appeared to play an influential role in supporting women to abstain from ST use during pregnancy.

Impact of Suaahara, an at-scale multisectoral nutrition programme, on health workers' maternal and child health, and nutrition knowledge and skills in Nepal

Suaahara, an at-scale multisectoral nutrition programme in Nepal, aimed to advance knowledge and skills of frontline health workers to improve the quality of nutrition and health services at health facility and community levels. This study assessed the impact of Suaahara interventions on knowledge and skills of health facility workers and Female Community Health Volunteers (FCHVs). The study used a quasi-experimental design in which four Suaahara intervention districts were compared with pair-matched comparison districts. One health facility worker and three FCHVs from each survey cluster were included. Baseline survey consisted of 93 health facility workers (2015) and 118 FCHVs (2012), and endline survey (2022) consisted of 40 health facility workers and 120 FCHVs. Difference-in-differences regression models employing intent-to-treat analysis, accounting for clustering at the district level, assessed the impact of intervention. The intervention, relative to comparison, had no effect on health facility workers' knowledge. There was a positive effect, however, on FCHVs' knowledge in intervention relative to comparison areas on exclusive breastfeeding, timing of introduction of complementary feeding, sick child feeding and growth monitoring and promotion (GMP) for children under 2 years. Health facility workers and FCHVs in intervention versus comparison districts had higher endline scores for skills related to measuring the weight of children and pregnant women, measuring the height/length of children, conducting GMP for children under 2 years and identifying malnourished children. Suaahara interventions improved the capacity of health workers, particularly nutrition-related knowledge among FCHVs and GMP-related skills of both health facility workers and FCHVs.

Maternal and child health intervention to promote behaviour change: a population-level cluster-randomised controlled trial in Honduras

OBJECTIVES

To assess the efficacy of a sustained educational intervention to affect diverse outcomes across the pregnancy and infancy timeline.

SETTING

A multi-arm cluster-randomised controlled trial in 99 villages in Honduras' Copán region, involving 16 301 people in 5633 households from October 2015 to December 2019.

PARTICIPANTS

Residents aged 12 and older were eligible. A photographic census involved 93% of the population, with 13 881 and 10 263 individuals completing baseline and endline surveys, respectively.

INTERVENTION

22-month household-based counselling intervention aiming to improve practices, knowledge and attitudes related to maternal, neonatal and child health.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were prenatal/postnatal care behaviours, facility births, exclusive breast feeding, parental involvement, treatment of diarrhoea and respiratory illness, reproductive health, and gender/reproductive norms. Secondary outcomes were knowledge and attitudes related to the primary outcomes.

RESULTS

Parents targeted for the intervention were 16.4% (95% CI 3.1%-29.8%, p=0.016) more likely to have their newborn's health checked in a health facility within 3 days of birth; 19.6% (95% CI 4.2%-35.1%, p=0.013) more likely to not wrap a fajero around the umbilical cord in the first week after birth; and 8.9% (95% CI 0.3%-17.5%, p=0.043) more likely to report that the mother breast fed immediately after birth. Changes in knowledge and attitudes related to these primary outcomes were also observed. We found no significant effect on various other practices.

CONCLUSION

A sustained counselling intervention delivered in the home setting by community health workers can meaningfully change practices, knowledge and attitudes related to proper newborn care following birth, including professional care-seeking, umbilical cord care and breast feeding.

TRIAL REGISTRATION NUMBER

NCT02694679.

Effects of occupational health promotion interventions on health-related outcomes among employees of small businesses and self-employed individuals: A systematic review

BACKGROUND

Compared to workers of larger companies it is less clear what health promoting interventions might be beneficial for employees of small businesses and self-employed individuals.

OBJECTIVE

Our aim was to critically appraise trials investigating health promotion programs among small business workers and self-employed individuals, by means of a systematic review.

METHODS

We conducted a search of primary studies using MEDLINE, Web of Science, LIVIVO and the Cochrane library. Our assessment followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA.

RESULTS

We identified six trials including 5,854 participants from Asia, North America and Australia. Most were of moderate methodological quality, only one was of low quality. Some of the supervised psycho-educational lifestyle programs focusing on individual behavior changes showed benefits in terms of stress reduction and increased physical activity levels among small enterprise employees.

CONCLUSIONS

There is a huge knowledge gap on evidence-based health promotion interventions for self-employed and for small business workers, especially in Europe.

Barriers and benefits of mHealth for community health workers in integrated community case management of childhood diseases in Banda Parish, Kampala, Uganda: a cross-sectional study

BACKGROUND

Low-quality data presents a significant challenge for community health workers (CHWs) in low and middle-income countries (LMICs). Mobile health (mHealth) applications offer a solution by enabling CHWs to record and submit data electronically. However, the barriers and benefits of mHealth usage among CHWs in informal urban settlements remain poorly understood. This study sought to determine the barriers and benefits of mHealth among CHWs in Banda parish, Kampala.

METHODS

This qualitative study involved 12 key informant interviews (KIIs) among focal persons from Kampala City Council Authority (KCCA) and NGOs involved in data collected by CHWs, and officials from the Ministry of Health (MOH) and two mixed-sex Focused Group Discussions (FGDs) of CHWs from Banda parish, Kampala district. Data analysis utilised Atlas Ti Version 7.5.7. Thematic analysis was conducted, and themes were aligned with the social-ecological model.

RESULTS

Three themes of institutional and policy, community and interpersonal, and individual aligning to the Social ecological model highlighted the factors contributing to barriers and the benefits of mHealth among CHWs for iCCM. The key barriers to usability, acceptability and sustainability included high training costs, CHW demotivation, infrastructure limitations, data security concerns, community awareness deficits, and skill deficiencies. Conversely, mHealth offers benefits such as timely data submission, enhanced data quality, geo-mapping capabilities, improved CHW performance monitoring, community health surveillance, cost-effective reporting, and CHW empowering with technology.

CONCLUSION

Despite limited mHealth experience, CHWs expressed enthusiasm for its potential. Implementation was viewed as a solution to multiple challenges, facilitating access to health information, efficient data reporting, and administrative processes, particularly in resource-constrained settings. Successful mHealth implementation requires addressing CHWs' demotivation, ensuring reliable power and network connectivity, and enhancing capacity for digital data ethics and management. By overcoming these barriers, mHealth can significantly enhance healthcare delivery at the community level, leveraging technology to optimize resource utilization and improve health outcomes. mHealth holds promise for transforming CHW practices, yet its effective integration necessitates targeted interventions to address systemic challenges and ensure sustainable implementation in LMIC contexts.

Effectiveness of School-Based Oral Health Education for Children and Adolescents in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

The global burden of oral diseases is high, but access to oral health care is still problematic, especially in low- and middle-income countries. The prevention of oral diseases in the child and adolescent population is the key as it can be prevented and potentially reversed at its early stages. This study aimed to provide evidence on the effectiveness of school-based oral health education in low- and middle-income countries through a systematic review and meta-analysis. Eligible studies had outcomes, such as oral health knowledge, behavior, oral hygiene, gingival health, and caries index, and those published from 1995 to 2019 in English. After screening and reviewing the retrieved articles, 20 studies were included in the systematic review and six eligible studies were selected for meta-analysis. The computed effect size of school-based oral health education in low- and middle-income countries showed improved knowledge, behavior, oral hygiene, and gingival health from the selected studies. However, most of the interventions took place for less than one year, and long-term evidence is still lacking. As repetition and reinforcement are critical in maintaining long-term effects, both country context and sustainability should be considered in school-based oral health education.

Community health volunteers' performance in rural areas of Yemen: a community-based satisfaction survey

Objectives

Many developing countries utilize the services of community health volunteers (CHVs) to enhance healthcare services in underserved regions. Evaluating client satisfaction with CHVs' performance is crucial for ensuring the effective utilization of their services. This study aims to assess clients' satisfaction with the provision of basic reproductive health services by CHVs in the governorates of Ibb and Al Mahweet, Yemen.

Materials and Methods

A cross-sectional study was conducted, collecting data via structured questionnaires administered by trained data collectors to clients of CHVs. A total of 510 households were interviewed, with 255 from each governorate, distributed across 30 clusters (villages). Each governorate comprised 15 clusters in 12 districts (six districts in Ibb and five in Al Mahweet, excluding one district for security reasons). Within each cluster, 17 households were randomly selected for interviews. Descriptive analysis was performed using the SPSS version 22.

Results

The majority of the clients were female (84.7%), most were aged 20-39 years (55.7%), and more than half of them had received at least primary education (54.2%). The study findings indicate that a significant proportion of respondents were highly satisfied with CHVs' performance (93%). Almost all respondents confirmed that CHVs resided in their villages (94%) and were easily accessible for consultation (99%). Most of the respondents (97%) expressed trust in the CHVs, stating that they were helpful to all villagers and treated them well. Additionally, nearly all the respondents reported easy access to services (98.6%), although a considerable percentage experienced a gap of three months or more since their last interaction with a CHV (39.1%).

Conclusion

The CHVs contribute to the well-being of the rural populations in Yemen by delivering satisfactory services, particularly regarding family planning. However, ensuring the sustainability of the CHV programs remains a challenge, which requires attention from the program managers and decision makers in the Yemeni healthcare sector.

Process evaluation of the 'Lafiyan Yara' project on enhancing access to HIV testing services using existing community structures in Nigeria

BACKGROUND

The Lafiyan Yara Project aimed to increase demand for HIV counselling, testing, treatment, and prevention services among pregnant women and children in Taraba State, Nigeria. Implemented from 2019 to 2021, the project utilized existing community structures, including traditional birth attendants, village health workers, and patent and proprietary medicine vendors, for mobilization. This study assessed the project's activities, contributors, relevance, effectiveness, and efficiency.

METHODS

The process evaluation was conducted using focus group discussions and key informant interviews with beneficiaries, community leaders, project staff, health facility personnel, and government officials. Data analysis employed framework analysis.

RESULTS

The Lafiyan Yara project was reported to have achieved notable successes, including increased HIV testing rates among children and pregnant women, improved linkage to care services, reduced mother-to-child transmission of HIV, increased HIV/AIDS awareness and knowledge, and enhanced community engagement and support. Challenges identified included insufficient funding for community mobilizers, training needs for health workers, and inadequate availability of test kits at health facilities. Confidentiality and stigma issues arose during community mobilizations. A key lesson learned was the importance of a comprehensive HIV care approach, emphasizing testing and ensuring support for individuals testing positive.

CONCLUSIONS

The project's approach of leveraging community structures to create demand for HIV services among women and children proved effective, provided proper linkage to care for those testing positive. Addressing stigma and involving husbands/fathers in the community approach are crucial for improving outcomes.

TRIAL REGISTRATION

IPHOAU/12/1384.

Effective interventions for improving routine childhood immunisation in low and middle-income countries: a systematic review of systematic reviews

OBJECTIVE

An umbrella review providing a comprehensive synthesis of the interventions that are effective in providing routine immunisation outcomes for children in low and middle-income countries (L&MICs).

DESIGN

A systematic review of systematic reviews, or an umbrella review.

DATA SOURCES

We comprehensively searched 11 academic databases and 23 grey literature sources. The search was adopted from an evidence gap map on routine child immunisation sector in L&MICs, which was done on 5 May 2020. We updated the search in October 2021.

ELIGIBILITY CRITERIA

We included systematic reviews assessing the effectiveness of any intervention on routine childhood immunisation outcomes in L&MICs.

DATA EXTRACTION AND SYNTHESIS

Search results were screened by two reviewers independently applying predefined inclusion and exclusion criteria. Data were extracted by two researchers independently. The Specialist Unit for Review Evidence checklist was used to assess review quality. A mixed-methods synthesis was employed focusing on meta-analytical and narrative elements to accommodate both the quantitative and qualitative information available from the included reviews.

RESULTS

62 systematic reviews are included in this umbrella review. We find caregiver-oriented interventions have large positive and statistically significant effects, especially those focusing on short-term sensitisation and education campaigns as well as written messages to caregivers. For health system-oriented interventions the evidence base is thin and derived from narrative synthesis suggesting positive effects for home visits, mixed effects for pay-for-performance schemes and inconclusive effects for contracting out services to non-governmental providers. For all other interventions under this category, the evidence is either limited or not available. For community-oriented interventions, a recent high-quality mixed-methods review suggests positive but small effects. Overall, the evidence base is highly heterogenous in terms of scope, intervention types and outcomes.

CONCLUSION

Interventions oriented towards caregivers and communities are effective in improving routine child immunisation outcomes. The evidence base on health system-oriented interventions is scant not allowing us to reach firm conclusions, except for home visits. Large evidence gaps exist and need to be addressed. For example, more high-quality evidence is needed for specific caregiver-oriented interventions (eg, monetary incentives) as well as health system-oriented (eg, health workers and data systems) and community-oriented interventions. We also need to better understand complementarity of different intervention types.

Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh

There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at https://doi.org/10.1186/s13102-024-00824-6 . Name of the trial registry: clinicaltrials.gov. Clinical Trial (CT) registration Date: 01/05/2019.

Implementation framework for income generating activities identified by community health volunteers (CHVs): a strategy to reduce attrition rate in Kilifi County, Kenya

BACKGROUND

Despite the proven efficacy of Community Health Volunteers (CHVs) in promoting primary healthcare in low- and middle-income countries (LMICs), they are not adequately financed and compensated. The latter contributes to the challenge of high attrition rates observed in many settings, highlighting an urgent need for innovative compensation strategies for CHVs amid budget constraints experienced by healthcare systems. This study sought to identify strategies for implementing Income-Generating Activities (IGAs) for CHVs in Kilifi County in Kenya to improve their livelihoods, increase motivation, and reduce attrition.

METHODS

An exploratory qualitative research study design was used, which consisted of Focus group discussions with CHVs involved in health promotion and data collection activities in a local setting. Further, key informant in-depth interviews were conducted among local stakeholder representatives and Ministry of Health officials. Data were recorded, transcribed and thematically analysed using MAXQDA 20.4 software. Data coding, analysis and presentation were guided by the Okumus' (2003) Strategy Implementation framework.

RESULTS

A need for stable income was identified as the driving factor for CHVs seeking IGAs, as their health volunteer work is non-remunerative. Factors that considered the local context, such as government regulations, knowledge and experience, culture, and market viability, informed their preferred IGA strategy. Individual savings through table-banking, seeking funding support through loans from government funding agencies (e.g., Uwezo Fund, Women Enterprise Fund, Youth Fund), and grants from corporate organizations, politicians, and other donors were proposed as viable options for raising capital for IGAs. Formal registration of IGAs with Government regulatory agencies, developing a guiding constitution, empowering CHVs with entrepreneurial and leadership skills, project and group diversity management, and connecting them to support agencies were the control measures proposed to support implementation and enhance the sustainability of IGAs. Group-owned and managed IGAs were preferred over individual IGAs.

CONCLUSION

CHVs are in need of IGAs. They proposed implementation strategies informed by local context. Agencies seeking to support CHVs' livelihoods should, therefore, engage with and be guided by the input from CHVs and local stakeholders.

Implementation of hospital-based sickle cell newborn screening and follow-up programs in Haiti

ABSTRACT

One in 120 children are born with sickle cell disease (SCD) in Haiti. However, health care challenges include isolated newborn screening (NBS) activities and lack of transcranial Doppler (TCD) ultrasound to assess stroke risk. The implementation activities of the Comparative Study of Children in Haiti and Miami with Sickle Cell Disease involved both NBS and TCD ultrasound implementations at 4 Haitian clinical sites. We hypothesized that hospital-based newborn SCD screening and follow-up programs would be feasible at Haiti. A traditional NBS laboratory method with dried blood samples was performed at 3 Port-au-Prince sites, and the traditional method plus point-of-care (POC) testing was used at the 2 northern sites. The rate of clinical follow-up for newborns with SCD as the outcome for the NBS intervention was compared with that of the NBS method. The NBS programs identified SCD in 0.77% of 8224 newborns over a 24-month period. In the rural hospital assigned to the combination screening, 56% of newborns identified with POC testing returned for follow-up, compared with 0% when POC was not available (P = .044). Newborns who tested positive for SCD and children aged <6 years with SCD at the clinical sites were eligible for study follow-up. Accrual was successful: 165 participants (mean age, 42 months; 53% males; 93% hemoglobin SS) were recruited and received oral penicillin. TCD ultrasound screening was hampered by poor internet connections and trained staff leaving Haiti, with only 1 active site conducting screening. Despite challenges, the implementation of NBS and sickle cell programs in Haiti is feasible. We are in the process of understanding how to mitigate implementation limitations.

A repeated cross-sectional study of the association of community health worker intervention with the maternal continuum of care in rural Liberian communities

BACKGROUND

The maternal continuum of care (CoC) (antenatal care, facility-based delivery, postnatal care) is critical to maternal and neonatal health and reducing mortality, but completion in rural areas of low- and middle-income countries is often limited. We used repeated cross-sectional household surveys from a rural Liberian county to explore changes in rates of completion of all steps and no steps in the maternal CoC after implementation of the National Community Health Assistant Program (NCHAP), a community health worker (CHW) intervention designed to increase care uptake for families over five kilometers from a facility.

METHODS

We analyzed repeated cross-sectional household surveys of women aged 18-49 served by NCHAP in Rivercess County, Liberia. We measured survey-weighted, before-to-after implementation difference in completion of all steps and no steps in the maternal CoC. We used multivariable regression to explore covariates associated with completion rates before and after NCHAP implementation.

RESULTS

Data from surveys conducted at three timepoints (2015, n = 354; 2018, n = 312; 2021, n = 302) were analyzed. A significant increase in completing the full maternal CoC (2015:23.6%, 2018:53.4%, change:29.7% points (pp), 95% confidence interval (CI) [21.0,38.4]) and a decrease in completing no steps in the CoC (2015:17.6%, 2018:4.0%, change: -12.4pp [-17.6, -7.2]) after implementation of NCHAP were observed from 2015 to 2018, with rates maintained from 2018 to 2021. Living farther from a facility was consistently associated with less care across the continuum. Following implementation, living in a motorbike accessible community was associated with completing the CoC while living in a mining community was negatively associated with omitting the CoC. Household wealth was associated with differences in rates pre-NCHAP but not post-NCHAP.

CONCLUSIONS

Following NCHAP implementation, completion rate of the full maternal CoC in Rivercess County more than doubled while the rate of completing no steps in the continuum fell below 5%. These rates were sustained over time including during COVID-19 with reduced differences across wealth groups, although far distances remained a risk for less care. CHW programs providing active outreach to remote communities can be important tools for improving uptake of interventions and reducing risk of no formal care during and after pregnancy.

The Creation of a Field Manual for Community Health Workers to Teach Child Health and Development During Home Visits: A Case Study of Participatory Content Creation

Community health workers (CHWs) play a crucial role in improving child health and development in underserved populations. However, CHWs often face challenges in accessing appropriate guidance and materials for their home visits, hindering their ability to deliver accurate and relevant information to families. Extensive searches for existing resources were conducted to search for established field manual guidebooks for CHWs, however, no suitable material was found, highlighting the need for this case study. The exercise aimed to develop a comprehensive field manual guidebook and animated videos to support CHWs in the Amazon of Peru during their home visits. A multidisciplinary team of specialists was assembled to develop the material. The material development process employed a design thinking methodology, incorporating participatory content creation workshops with CHWs and experts in health topics relevant to the Amazon. This approach ensured cultural relevance and sensitivity in conveying information. The team created a list of 38 essential health and early childhood development messages for Amazonian communities. Infographics were designed for each topic, accompanied by easy-to-understand language and images to assist CHWs in conveying information effectively. To provide additional support, seven animated videos were created based on health behavior theory, covering topics such as anemia, healthy diet, diarrhea, breastfeeding, clean water, child-caregiver bond, and early childhood stimulation. The videos were designed for CHWs to share with caregivers during home visits, enhancing information transmission. The resulting guidebook, infographics, and animated videos were presented to CHWs in Loreto, Peru for feedback. Updated versions were printed and distributed to CHWs in seven communities in Loreto.

Preliminary Study: The Effectiveness of Nutrition Education Intervention Targeting Short-Statured Pregnant Women to Prevent Gestational Stunting

A short mother with a height < 150 cm is likely to give birth to a short baby with a body length < 48 cm so that later this short baby will become stunted. The success rate of stunting malnutrition prevention and control with specific methods is 30% and the success rate with sensitive methods is 70%. The size at risk for short pregnant women is equal to 30.5%. A major effort to improve the health status of short pregnant women and prevent stunting is to empower short pregnant women with the help of health professionals. This study aimed to analyze the effectiveness of providing nutrition education to pregnant women who have short stature to prevent gestational stunting. This study used a quantitative approach with a quasi-experimental design in the intervention group and the control group. Research results showed that there are differences in the knowledge, attitudes, and actions of pregnant women about prenatal care services before and after the intervention, as well as knowledge of pregnant women about nutrition before and after intervention. The support of the cadres had a great influence on the intervention group compared with the control group, which received only one module. Pregnant women's knowledge of nutritional diets and pregnant women's knowledge of antenatal care (ANC) services directly influence the delivery timing. Interventions to improve the health status of short pregnant women and prevent stunting neonates can be improved by improving the knowledge, attitudes, and behavior of short pregnant women about antenatal care, and knowledge of pregnant women about nutritional intake. The Short Pregnancy Medical Framework Support Model was developed for use in providing support to short pregnant women to prevent infant stunting.

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

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

Predictors and disparities in neonatal and under 5 mortality in rural Pakistan: cross sectional analysis

Background

Adopted in 2015, the sustainable development goals (SDGs) have set specific targets (SDG 3.2) for countries to reduce their neonatal mortality rate (NMR) to below 12 deaths per 1000 live births and under 5 mortality rate (U5MR) to below 25 deaths per 1000 live births by 2030. For Pakistan to achieve these targets, there is a need to measure these rates and understand the predictors of child mortality at sub-national level. Launched in 2016, the Umeed-e-Nau (UeN) or New Hope project is based on scaling up proven and effective Maternal and Newborn Child Health (MNCH) interventions in 8 of the highest burden districts of the country, using existing public sector platforms in Pakistan at both the community and facility level. The primary aim of the project is to reduce perinatal mortality in these districts by 20% from baseline.

Methods

We report overall neonatal and post neonatal mortality rates for the two years preceding the UeN baseline household survey. Rates were calculated using the synthetic cohort probability method and predictors of neonatal and post neonatal mortality examined using Cox regression. To investigate spatial variations in the mortality rates, we calculated Moran's I at the district level using predicted probabilities of mortality. Finally, we create district level maps of predicted under 5 child mortality using a stochastic partial differentiation approach.

Findings

A total of 26,258 children contributed to the analysis of mortality with 838 deaths in the neonatal period and 2236 under-5 deaths during the observation period from March 1, 2015 to March 17, 2017. Overall, we estimated the NMR to be 29.2 per 1000 live births (95% CI: 26.9-31.4) and the U5MR to be 86.1 per 1000 live births (95% CI: 85.5-86.8). We found evidence of within-district geospatial clustering of under 5 mortality (P < 0.0001) and that social factors (poverty, illiteracy, multiparity), poor coverage of community health workers and distance from health facilities were strongly associated with child mortality.

Interpretation

Important factors associated with neonatal and post-neonatal mortality in our study population included maternal education, parity, household size and gender. Additionally, antenatal care coverage (at least 4 visits) was specifically associated with neonatal mortality only, whereas, LHW coverage and distance to health facility were strongly associated with post-neonatal mortality. These findings emphasise the need for comprehensive, multisectoral strategies to be implemented for future maternal and child health programs and outreach services in rural areas.

Funding

The study was funded by an unrestricted grant from the Bill & Melinda Gates Foundation to the Aga Khan University (Grant OPP 1148892).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of proactive vs fixed community health care delivery on child health and access to care: a cluster randomised trial secondary endpoint analysis

Background

Professional community health workers (CHWs) can help achieve universal health coverage, although evidence gaps remain on how to optimise CHW service delivery. We conducted an unblinded, parallel, cluster randomised trial in rural Mali to determine whether proactive CHW delivery reduced mortality and improved access to health care among children under five years, compared to passive delivery. Here we report the secondary access endpoints.

Methods

Beginning from 26-28 February 2017, 137 village-clusters were offered care by CHWs embedded in communities who were trained, paid, supervised, and integrated into a reinforced public-sector health system that did not charge user fees. Clusters were randomised (stratified on primary health centre catchment and distance) to care during CHWs during door-to-door home visits (intervention) or based at a fixed village site (control). We measured outcomes at baseline, 12-, 24-, and 36-month time points with surveys administered to all resident women aged 15-49 years. We used logistic regression with cluster-level random effects to estimate intention-to-treat and per-protocol effects over time on prompt (24-hour) treatment within the health sector.

Results

Follow-up surveys between February 2018 and April 2020 generated 20 105 child-year observations. Across arms, prompt health sector treatment more than doubled compared to baseline. At 12 months, children in intervention clusters had 22% higher odds of receiving prompt health sector treatment than those in control (cluster-specific adjusted odds ratio (aOR) = 1.22; 95% confidence interval (CI) = 1.06, 1.41, P = 0.005), or 4.7 percentage points higher (adjusted risk difference (aRD) = 0.047; 95% CI = 0.014, 0.080). We found no evidence of an effect at 24 or 36 months.

Conclusions

CHW-led health system redesign likely drove the 2-fold increase in rapid child access to care. In this context, proactive home visits further improved early access during the first year but waned afterwards.

Registration

ClinicalTrials.gov NCT02694055.

Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews

BACKGROUND

Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs.

METHODS

We searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization's (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107).

RESULTS

In a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed.

CONCLUSION

The generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required.

Workload and emerging challenges of community health workers in low- and middle-income countries: A mixed-methods systematic review

BACKGROUND

Community health workers (CHWs) play an important role in improving access to health services to a broader population; particularly to communities living in remote areas. However, the productivity of CHWs is affected by the workload they have. We aimed to summarize and present CHWs' perceived workload in low-and middle-income countries (LMICs).

METHODS

We searched three electronic databases (PubMed, Scopus, and Embase). A search strategy customized for the three electronic databases was developed using the two key terms of the review (CHWs and workload). Primary studies conducted in LMICs that explicitly measured workload of CHWs and published in English were included, without date restrictions. Methodological quality of the articles was assessed by two reviewers independently using mixed-methods appraisal tool. We applied a convergent integrated approach to synthesize the data. This study is registered on PROSPERO, number CRD42021291133.

RESULTS

Of 632 unique records, 44 met our inclusion criteria, and 43 (20 qualitative, 13 mixed-methods, and 10 quantitative studies) passed the methodological quality assessment and were included in this review. In 97.7% (n = 42) of the articles, CHWs reported that they have a high workload. Having multiple tasks was the most commonly reported subcomponent of workload, followed by lack of transport; which was reported in 77.6% (n = 33) and 25.6% (n = 11) of the articles respectively.

CONCLUSION

CHWs in LMICs reported that they have a high workload; mainly related to having to manage multiple tasks and the lack of transport to access households. Program managers need to make careful consideration when additional tasks are shifted to CHWs and the practicability to be performed in the environment they work in. Further research is also required to make a comprehensive measure of the workload of CHWs in LMICs.

Stakeholder perspectives on a door-to-door intervention to increase community engagement for malaria elimination in Zanzibar

BACKGROUND

Malaria remains a major public health problem in sub-Saharan Africa. The 2021 World Health Organization (WHO) World Malaria Report indicates a slowing in the decline of malaria incidence since 2015. Malaria prevalence in Zanzibar has been maintained at less than 1% since 2010, however from 2018 to 2021, the annual number of reported malaria cases has gradually increased from 4106 to 9290. Community engagement has been emphasized by the WHO for reducing malaria transmission. To better understand the potential for a door-to-door approach for malaria, a three-month pilot programme was carried out. This qualitative study aimed at understanding stakeholder experiences with the pilot programme and considerations for its implementation.

METHODS

Through multistage sampling, four shehias (wards-the lowest administrative structure) with comparatively high (> 1.9 per 1000) and four with low (< 1 per 1000) incidence of local malaria cases were selected and involved in a door-to-door pilot intervention. The qualitative study was conducted after the pilot intervention and employed focus group discussions and in-depth interviews. All field notes were written on paper and audiotaped using digital audio-recorders. Summaries were developed by integrating field notes with reviews of recordings; themes were developed based on the topics identified a priori. Responses for each theme were summarized using an iterative process.

RESULTS

Most community members reported high levels of acceptance of door-to-door interventions. Some factors that might affect implementation of door-to-door include, low risk perception of the disease, local beliefs and practice, lack of initiative from the programme level to involve communities, and political instability during the election period. All Community Health Volunteers (CHVs) recommended this approach for community engagement, however, ensuring adequate resources was identified as a key factor for ensuring its sustainability.

CONCLUSION

The door-to-door intervention was perceived as helpful for promoting community engagement. There are several factors to consider including ensuring that CHVs are provided with adequate education, regular supervision, and have access to essential resources. Community leaders should be fully involved in choosing CHVs that are acceptable to the community. To ensure sustainability, the government should allocate sufficient resources and improve coordination systems.

Effect of the mHealth-supported Healthy Future programme delivered by community health workers on maternal and child health in rural China: study protocol for a cluster randomised controlled trial

INTRODUCTION

Millions of young rural children in China still suffer from poor health and malnutrition, partly due to a lack of knowledge about optimal perinatal and child care among rural mothers and caregivers. Meanwhile, there is an urgent need to improve maternal mental health in rural communities. Comprehensive home visiting programmes delivered by community health workers (CHWs) can bridge the caregiver knowledge gap and improve child health and maternal well-being in low-resource settings, but the effectiveness of this approach is unknown in rural China. Additionally, grandmothers play important roles in child care and family decision-making in rural China, suggesting the importance of engaging multiple caregivers in interventions. The Healthy Future programme seeks to improve child health and maternal well-being by developing a staged-based curriculum that CHWs deliver to mothers and caregivers of young children through home visits with the assistance of a tablet-based mHealth system. This protocol describes the design and evaluation plan for this programme.

METHODS AND ANALYSIS

We designed a cluster-randomised controlled trial among 119 rural townships in four nationally designated poverty counties in Southwestern China. We will compare the outcomes between three arms: one standard arm with only primary caregivers participating in the intervention, one encouragement arm engaging primary and secondary caregivers and one control arm with no intervention. Families with pregnant women or infants under 6 months of age are invited to enrol in the 12-month study. Primary outcomes include children's haemoglobin levels, exclusive breastfeeding rates and dietary diversity in complementary feeding. Secondary outcomes include a combination of health, behavioural and intermediate outcomes.

ETHICS AND DISSEMINATION

Ethical approval has been provided by Stanford University, Sichuan University and the University of Nevada, Reno. Trial findings will be disseminated through national and international peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

ISRCTN16800789.

Community health workers' involvement in mother-child care during the 1st year after birth, in Kaya health district, Burkina Faso: A contribution analysis

Introduction

Maternal and infant morbidity and mortality remain high in sub-Saharan Africa. However, actions to strengthen postpartum care are still weak and mainly limited to health facilities (HFs). In Kaya health district, Burkina Faso, community health workers (CHWs) were involved in mother and child care during the 1st year postpartum through home visits, outreach sessions and accompanying mothers to health facilities. The aim of this study was to assess the contribution of CHWs to postpartum women's attendance at the health facilities.

Methods

We conducted an effect assessment using Mayne and Lemire's contribution analysis framework. Qualitative and quantitative data were collected through project documents review and individual semi-structured interviews with key-informants.

Results

All the participants interviewed acknowledged that the number of women, who came to postpartum care, had increased since the implementation of the project activities. Postpartum consultation rates within the 1st week postpartum increased from 29% in 2011 to 80% in 2015 and from 19 to 50% within 6 weeks. Others interventions such as Performance based financing, Save The Children nutritional project and the health services component of Missed Opportunities in Mother and Infant Health (MOMI) were the alternative explanations.

Conclusions

CHWs involvement in women care contributed to improve their adherence to postpartum consultations in Kaya health district.

Factors affecting motivation of close-to-community sexual and reproductive health workers in low-income urban settlements in Bangladesh: A qualitative study

Close-to-community (CTC) health workers play a vital role in providing sexual and reproductive health services in low-income urban settlements in Bangladesh. Retention of CTC health workers is a challenge, and work motivation plays a vital role in this regard. Here, we explored the factors which affect their work motivation. We conducted 22 in-depth interviews in two phases with purposively selected CTC health workers operating in low-income urban settlements in Dhaka, Bangladesh. We analyzed our data using the framework technique which involved identifying, abstracting, charting, and matching themes across the interviews following the two-factor theory on work motivation suggested by Herzberg and colleagues. Our results suggest that factors affecting CTC sexual and reproductive health workers' work motivation include both extrinsic and intrinsic factors. Extrinsic or hygiene factors include financial incentives, job security, community attitude, relationship with the stakeholders, supportive and regular supervision, monitoring, and physical safety and security. While, the intrinsic factors or motivators are the perceived quality of the services provided, witnessing the positive impact of the work in the community, the opportunity to serve vulnerable clients, professional development opportunities, recognition, and clients' compliance. In the context of a high unemployment rate, people might take a CTC health worker's job temporarily to earn a living or to use it as a pathway move to more secure employment. To maintain and improve the work motivation of the CTC sexual and reproductive health workers serving in low-income urban settlements, organizations should provide adequate financial incentives, job security, and professional development opportunities in addition to supportive and regular supervision.

Effective interventions for the promotion of breastfeeding and healthy complementary feeding in the context of Primary Health Care

Abstract Objective: To develop a rapid review on effective actions for the promotion of breastfeeding and healthy complementary feeding in primary health care and to summarize a list of actions and their elements for implementation. Data source: The review included systematic reviews on the effectiveness of interventions to promote breastfeeding and/or healthy complementary feeding for mothers and other caregivers, and/or professionals who work with this population, in comparison with any usual approach or none. Data synthesis: A total of 32 systematic reviews were included in the evidence synthesis. Ten types of interventions were evaluated in systematic reviews on promotion of breastfeeding and four types of interventions on promotion of healthy complementary feeding. The synthesis allowed six aspects to be discussed, and these must be considered to increase the chances of interventions’ impact: type of intervention, target audience, timing of intervention, actors that can implement it, strategies and methods of intervention, and intensity of intervention. Conclusions: It was possible to assemble a list of actions whose effectiveness has already been demonstrated, providing elements for local adaptations. Evidence is expected to support and strengthen the implementation of programs aimed at promoting breastfeeding and complementary feeding in primary health care.

Evaluation of a comprehensive maternal newborn health intervention in rural Tanzania: single-arm pre-post coverage survey results

Background

In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed.

Objective

Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania.

Methods

A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used ‘wedge sampling’ protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the ‘Real Accountability: Data Analysis for Results Coverage Survey to women 15–49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD.

Results

Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [−0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019.

Conclusions

Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved.

Assessing community health workers' time allocation for a cervical cancer screening and treatment intervention in Malawi: a time and motion study

BACKGROUND

Community health workers (CHWs) are essential field-based personnel and increasingly used to deliver priority interventions to achieve universal health coverage. Existing literature allude to the potential for detrimental effects of multi-tasking CHWs. This study objective was to assess the impact of integrating cervical cancer screening and prevention therapy (CCSPT) with family planning (FP) on time utilization among CHWs.

METHODS

A time and motion study was conducted in 7 health facilities in Malawi. Data was collected at baseline between October-July 2019, and 12 months after CCSPT implementation between July and August 2021. CHWs trained to deliver CCSPT were continuously observed in real time while their activities were timed by independent observers. We used paired sample t-test to assess pre-post differences in average hours CHWs spent on the following key activities, before and after CCSPT implementation: clinical and preventive care; administration; FP; and non-work-related tasks. Regression models were used to ascertain impact of CCSPT on average durations CHWs spent on key activities.

RESULTS

Thirty-seven (n = 37) CHWs were observed. Their mean age and years of experience were 42 and 17, respectively. Overall, CHWs were observed for 323 hours (inter quartile range: 2.8-5.5). Compared with the period before CCSPT, the proportion of hours CHWs spent on clinical and preventive care, administration and non-work-related activities were reduced by 13.7, 8.7 and 34.6%, respectively. CHWs spent 75% more time on FP services after CCSPT integration relative to the period before CCSPT. The provision of CCSPT resulted in less time that CHWs devoted towards clinical and preventive care but this reduction was not significant. Following CCPST, CHWs spent significantly few hours on non-work-related activities.

CONCLUSION

Introduction of CCSPT was not very detrimental to pre-existing community services. CHWs managed their time ensuring additional efforts required for CCSPT were not at the expense of essential activities. The programming and policy implications are that multi-tasking CHWs with CCSPT will not have substantial opportunity costs.

The role of community health worker-based care in post-conflict settings: a systematic review

Countries affected by conflict often experience the deterioration of health system infrastructure and weaken service delivery. Evidence suggests that healthcare services that leverage local community dynamics may ameliorate health system-related challenges; however, little is known about implementing these interventions in contexts where formal delivery of care is hampered subsequent to conflict. We reviewed the evidence on community health worker (CHW)-delivered healthcare in conflict-affected settings and synthesized reported information on the effectiveness of interventions and characteristics of care delivery. We conducted a systematic review of studies in OVID MedLine, Web of Science, Embase, Scopus, The Cumulative Index to Nursing and Allied Health Literature (CINHAL) and Google Scholar databases. Included studies (1) described a context that is post-conflict, conflict-affected or impacted by war or crisis; (2) examined the delivery of healthcare by CHWs in the community; (3) reported a specific outcome connected to CHWs or community-based healthcare; (4) were available in English, Spanish or French and (5) were published between 1 January 2000 and 6 May 2021. We identified 1976 articles, of which 55 met the inclusion criteria. Nineteen countries were represented, and five categories of disease were assessed. Evidence suggests that CHW interventions not only may be effective but also efficient in circumventing the barriers associated with access to care in conflict-affected areas. CHWs may leverage their physical proximity and social connection to the community they serve to improve care by facilitating access to care, strengthening disease detection and improving adherence to care. Specifically, case management (e.g. integrated community case management) was documented to be effective in improving a wide range of health outcomes and should be considered as a strategy to reduce barrier to access in hard-to-reach areas. Furthermore, task-sharing strategies have been emphasized as a common mechanism for incorporating CHWs into health systems.

Why maternal continuum of care remains low in Northwest Ethiopia? A multilevel logistic regression analysis

BACKGROUND

Non-adherence to the maternal continuum of care remains a significant challenge. Though early initiation and continuum of care are recommended for mothers' and newborns' well-being, there is a paucity of evidence that clarify this condition in resource-limited settings. This study aimed to assess the level of women's completion of the maternal continuum of care and factors affecting it in Northwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted from October to November, 2020. Data were collected from 811 women who had a recent history of birth within the past one year. The random and fixed effects were reported using an adjusted odds ratio with a 95% confidence interval. The p-value of 0.05 was used to declare significantly associated factors with women's completion of the maternal continuum of care.

RESULTS

The study revealed that 6.9% (95%CI: 5.3-8.9%) of women were retained fully on the continuum of maternal care, while 7.89% of women did not receive any care from the existing healthcare system. Attending secondary and above education (AOR = 3.15; 95%CI: 1.25,7.89), membership in the women's development army (AOR = 2.91; 95%CI: 1.56,5.44); being insured (AOR = 2.59; 95%CI: 1.33,5.01); getting health education (AOR = 2.44; 95%CI: 1.33,4.45); short distance to health facility (AOR = 4.81; 95%CI: 1.55,14.95); and mass-media exposure (AOR = 2.39; 95%CI: 1.11,5.15) were significantly associated with maternal continuum of care.

CONCLUSIONS

The maternal continuum of care is low in rural northwest Ethiopia compared to findings from most resource-limited settings. Therefore, the existing health system should consider multilevel intervention strategies that focus on providing maternal health education, facilitating insurance mechanisms, encouraging women's participation in health clubs, and ensuring physical accessibility to healthcare facilities to be more effective in improving maternal health services.

Demand-Side Factors in Maternal Health Outcomes: Evidence from a Community Health Worker Programme in Uganda

While community health workers (CHWs) are a core feature of many low-resource healthcare systems, evidence on both their health impacts and the mechanisms behind these impacts remains limited. Using a difference-in-differences design with a control and treatment group, this study evaluated a CHW programme in southwestern Uganda aimed at improving maternal health outcomes. We found relatively little evidence of an overall programme effect on health behaviours, including antenatal care attendance and delivery under skilled supervision. Analysis of heterogeneity by gestational age at first antenatal visit - which should have modulated exposure to the intervention - provided suggestive evidence that treatment effects varied predictably with gestational age. Altogether, the absence of strong programme effects may have been due to suboptimal performance by CHWs, thus highlighting the importance of studying and instituting appropriate monitoring and incentive schemes for such programmes. Additionally, in contrast to the weak treatment effect findings, analysis of the entire study sample between the pre- and post-intervention periods showed large improvements in healthcare-seeking behaviour across both the treatment and control groups. These changes may have arisen from concurrent supply-side health facility improvements affecting the entire study population, spillover effects from the CHWs, or background health trends.

A realist review protocol on communications for community engagement in maternal and newborn health programmes in low- and middle-income countries

BACKGROUND

Community engagement (CE) has been increasingly implemented across health interventions, including for maternal and newborn health (MNH). This may take various forms, from participatory women's groups and community health committees to public advocacy days. While research suggests a positive influence of CE on MNH outcomes, such as mortality or care-seeking behaviour, there is a need for further evidence on the processes of CE in different settings in order to inform the future development and implementation of CE across programmes. Communication is an integral component of CE serving as a link between the programme and community. The aim of the realist review described in this protocol is to understand how, why, to what extent, and for whom CE contributes to intended and unintended outcomes in MNH programming, focusing on the communication components of CE.

METHODS

Realist review methodology will be used to provide a causal understanding of what communication for CE interventions in MNH programming work, for whom, to what extent, why, and how. This will be done by developing and refining programme theories on communications for CE in MNH through a systematic review of the literature and engaging key experts for input and feedback. By extrapolating context-mechanism-outcome configurations, this review seeks to understand how certain contexts trigger or inhibit specific mechanisms and what outcomes this interaction generates when communication in CE interventions is used in MNH programming.

DISCUSSION

A realist philosophy is well-suited to address the aims of this study because of the complex nature of CE. The review findings will be used to inform a realist evaluation case study of CE for an MNH programme in order to ascertain transferable findings that can inform and guide engagement activities in various settings. Findings will also be shared with stakeholders and experts involved in the consultative processes of the review (through workshops or policy briefs) in order to ensure the relevance of these findings to policy and practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022293564.

Use of community engagement interventions to improve child immunisation in low- and middle-income countries: A systematic review and meta-analysis

Immunisation is one of the most cost-effective interventions to prevent and control life-threatening infectious diseases. Nonetheless, rates of routine vaccination of children in low- and middle-income countries (LMICs) are strikingly low or stagnant. In 2019, an estimated 19.7 million infants did not receive routine immunisations. Community engagement interventions are increasingly being emphasised in international and national policy frameworks as a means to improve immunisation coverage and reach marginalised communities. This systematic review examines the effectiveness and cost-effectiveness of community engagement interventions on outcomes related to childhood immunisation in LMICs and identifies contextual, design and implementation features that may be associated with effectiveness. We identified 61 quantitative and mixed methods impact evaluations and 47 associated qualitative studies related to community engagement interventions for inclusion in the reteview. For cost-effectiveness analysis 14 of the 61 studies had the needed combination of cost and effectiveness data. The 61 included impact evaluations were concentrated in South Asia and Sub-Saharan Africa and spread across 19 LMICs. The review found that community engagement interventions had a small but significant, positive effect on all primary immunisation outcomes related to coverage and their timeliness. The findings are robust to exclusion of studies assessed as high risk of bias. Qualitative evidence indicates appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints and practicalities on the ground are consistently cited as reasons for intervention success. Among the studies for which we were able to calculate cost-effectiveness, we find that the median non-vaccine cost per dose of intervention to increase immunisation coverage by 1% was US $3.68. Given the broad scope of the review in terms of interventions and outcomes, there is significant variation in findings. Among the various types of community engagement interventions, those that involve creation of community buy-in or development of new cadres of community-based structures were found to have consistent positive effect on more primary vaccination coverage outcomes than if the engagement is limited to the design or delivery of an intervention or is a combination of the various types. The evidence base for sub-group analysis for female children was sparse (only two studies) and the effect on coverage of both full immunisation and third dose of diphtheria pertussis tetanus for this group was insignificant.

Indicator-activities to apply primary health care principles in national or large-scale community health worker programs in low-and middle-income countries: a Delphi exercise

INTRODUCTION

Primary Health Care (PHC) gained considerable momentum in the past four decades and led to improved health outcomes across a wide variety of settings. In low-and middle-income countries (LMICs), national or large-scale Community Health Worker Programs (CHWPs) are considered as vehicles to incorporate PHC principles into healthcare provision and are an essential aspect of the PHC approach to achieve health for all and sustainable development goals. The success of CHWPs is rooted in the application of PHC principles. However, there is evidence that shows patchy implementation of PHC principles across national CHWPs in LMICs. This may reflect the lack of information on what activities would illustrate the application of these principles in CHWPs. This study aimed to identify a set of core/indicator-activities that reflect the application of PHC principles by CHWPs in LMICs.

METHODS

A two-round modified Delphi study was undertaken with participants who have extensive experience in planning, implementation and evaluation of CHWPs. Survey design and analysis was guided by the four PHC principles namely Universal Health Coverage, Community Participation, Intersectoral Coordination and Appropriateness. Responses were collected using a secure online survey program (survey monkey). In round one, participants were asked to list 'core activities' that would reflect the application of each PHC principle and its sub-attributes and challenges to apply these principles in CHWPs. In round two, participants were asked to select whether they agree or disagree with each of the activities and challenges. Consensus was set a priori at 70% agreement of participants for each question.

RESULTS

Seventeen participants from 15 countries participated in the study. Consensus was reached on 59 activities reflecting the application of PHC principles by CHWPs. Based on participants' responses, a set of 29 indicator-activities for the four PHC principles was developed with examples for each indicator-activity.

CONCLUSION

These indicator-activities may provide guidance on how PHC principles can be implemented in CHWPs. They can be used in the development and evaluation of CHWPs, particularly in their application of PHC principles. Future research may focus on testing the utility of indicator-activities on CHWPs in LMICs.

Retrospective evaluation of referral by community health workers on the uptake of intermittent preventive treatment of Malaria in pregnancy in Ohaukwu, Ebonyi State, Nigeria

Background

The World Health Organization recommends a minimum of three doses of quality-assured sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy (IPTp), in moderate to high malaria transmission areas in sub-Saharan Africa. Currently, coverage of IPTp lags behind coverage of antenatal care (ANC) visits; in Nigeria, 57% of women attended four or more ANC visits, whereas only 17% received the recommended three or more doses of IPTp. The innovative program aimed to close this gap by providing counseling on the benefits of comprehensive ANC, referral to ANC and community distribution of IPTp (C-IPTp), complementing IPTp at ANC. The study aimed to examine whether CHW referral to ANC improved the likelihood of receiving three or more doses of IPTp.

Methods

The data for this study were extracted from the maternity record books of 1437 pregnant women seen at 25 public health facilities in Ebonyi State, Nigeria. The outcome of interest was defined as the receipt of three or more doses of IPTp (IPTp3) and the independent variable was referral to ANC by a community health worker for any visit. Descriptive statistics were reported and the results from the multi-level regressions are reported as adjusted odds and prevalence ratios with corresponding 95% confidence intervals.

Results

Of the 936 women included in the analysis, 24.47% received the recommended three or more IPTp doses and 61.32% were referred by a community health worker (CHW) for at least one ANC visit. There was no difference in the mean number of ANC visits between women who received C-IPTp and those who received IPTp exclusively at a facility (2.40 vs 2.52; p = 0.374). There were no maternal characteristics associated with CHW referral. Women who were referred by a CHW had 60% greater odds (95% CI, 1.08–2.38) of receiving IPTp3 than those who were never referred.

Conclusion

The results indicate that CHW referrals conducted within a C-IPTp program are associated with higher IPTp uptake but not fewer ANC visits and that CHWs applied the referral process equally. This strengthens the evidence base for C-IPTp scale-up, which could have a large impact in sub-Saharan Africa in mitigating existing health systems issues.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04921-7.

Community health workers’ non-technical skills for delivering primary healthcare in low-income areas

BACKGROUND: To overcome the poor conditions of low-income areas in developing countries like Brazil, Community Health Workers (CHWs) are required to exceed the regular set of formal skills they are used to employ. OBJECTIVE: In this study, we aim at identifying the non-technical skills CHWs must develop to cope with the extraordinary situations that occur in vulnerable communities. METHODS: 41 CHWs based in two primary healthcare clinics in Brazil underwent two rounds of in-depth interviews. The analysis was carried out using the Analytical Hierarchy Process, resulting in the prioritization of social skills according to their calculated importance to house calls. RESULTS: Among the ten higher-scored skills, we find communication and advocacy skills being of high importance. Civility was found to be the most important attribute, confirming that community action relies strongly on the relationship between health professionals and the community. CONCLUSION: The results of our study contribute primarily to the improvement of community-based primary care programs as it helps to identify major skills required for community action.

Effect of integrated nutrition-sensitive and nutrition-specific intervention package on maternal malnutrition among pregnant women in Rwanda

Maternal undernutrition remains a major public health concern in Rwanda despite significant gains and progress. An integration of nutrition‐specific and nutrition‐sensitive interventions was implemented in five districts of Rwanda to improve maternal and child nutrition. The package included nutrition education and counselling, promotion of agricultural productivity, promotion of financial literacy/economic resilience and provision of Water, Hygiene and Sanitation services. However, there is limited evidence about the effect of such interventions in reducing maternal undernutrition. A postintervention quasi‐experimental study was conducted among pregnant women to determine the effect of the integrated intervention on their nutritional status. It was carried out in two intervention districts, namely Kicukiro and Kayonza, and two control districts, namely Gasabo and Gisagara between November 2020 and June 2021. Five hundred and fifty‐two women were recruited for the intervention arm, while 545 were recruited for the control arm. Maternal undernutrition was defined as either having low mid‐upper arm circumference (<23 cm) during delivery or low body mass index (<18.5 kg/m²) in the first trimester or both. A multivariable logistic regression model was used to assess the effect of the integrated interventions. The prevalence of maternal undernutrition was significantly lower in the intervention group compared with the control group (4.7% vs. 18.2%; p < 0.001). After controlling the potential confounders, the risk of maternal undernutrition was 77.0% lower in the intervention group than in the control group [adjusted odds ratio= 0.23; 95% confidence interval = 0.15–0.36; p < 0.001]. Further studies are therefore recommended to establish causation and inform the potential scale‐up of these interventions nationally in Rwanda.

Empirical evidence on the effect of integrated nutrition‐specific and nutrition‐sensitive interventions on maternal undernutrition is limited as existing studies are mainly directed at the effectiveness of nutritional interventions on improving child nutritional status.

The results indicated that the integrated nutrition‐specific and nutrition‐sensitive intervention package was significantly associated with low maternal undernutrition.

This study adds more evidence to the 2008, 2013 and 2021 Lancet Series regarding the proposed effectiveness of integrated nutrition‐sensitive and nutrition‐specific interventions.

Further research should focus on follow‐up randomized controlled trials and the cost‐effectiveness of these integrated nutrition‐specific and nutrition‐sensitive interventions.

"The Videos Gave Weight to Our Work": Animated mHealth Videos and Tablet Technology Boost Community Health Workers' Perceived Credibility in Khayelitsha, South Africa

Mobile health (mHealth) interventions are increasingly used to support community health workers (CHWs) in low-and middle-income countries. As near-peers within their communities, the credibility of CHWs is sometimes questioned-a recognized barrier to their efficacy. Nested within a large, randomized-controlled trial, this qualitative study captured the experiences of South African CHWs, called "Mentor-Mothers," using tablets and animated videos to promote exclusive breastfeeding. We conducted in-depth telephone interviews with 26 tablet-carrying Mentor-Mothers. We analyzed interview transcripts using a Grounded Theory approach, then developed a theoretical framework, based on an emerging theme, for understanding how tablet technology boosts the perceived credibility of CHWs. Tablet-carrying Mentor-Mothers described an increase in their perceived credibility, which they attributed to overt and signaling effects related to enhanced credibility of (1) their messages, (2) themselves as messengers, and (3) the program employing them. Mobile technology investments in CHWs could enhance their credibility, translating into meaningful investments in the health of under-served communities.

Telemedicine for Surgical Site Infection Diagnosis in Rural Rwanda: Concordance and Accuracy of Image Reviews

BACKGROUND

In rural Africa where access to medical personnel is limited, telemedicine can be leveraged to empower community health workers (CHWs) to support effective postpartum home-based care after cesarean section (c-section). As a first step toward telemedicine, we assessed the sensitivity, specificity, and interrater reliability of image-based diagnosis of surgical site infections (SSIs) among women delivering via c-section at a rural Rwandan Hospital.

METHODS

Women ≥18 years who underwent c-section from March to October 2017 at Kirehe District Hospital (KDH) were enrolled. On postoperative day 10 at KDH, participants underwent a physical examination by a general practitioner, who provided a diagnosis of SSI or no SSI. Trained CHWs photographed patients' incisions and the collected images were shown to six physicians, who upon review, assigned one of the following diagnoses to each image: definite SSI, suspected SSI, suspected no SSI, and definite no SSI, which were compared with the diagnoses based on physical exam. We report the sensitivity and specificity and assessed reviewer agreement using Gwet's AC1.

RESULTS

569 images were included, with 61 women (10.7%) diagnosed with an SSI. Of the 3414 image-reviews, 49 (1.4%) could not be assigned diagnoses due to image quality. The median sensitivity and specificity were 0.83 and 0.69, respectively. The Gwet's AC1 estimate for binary classification was 0.46.

CONCLUSIONS

We demonstrate decent accuracy but only moderate consistency for photograph-based SSI diagnosis. Strategies to improve overall agreement include providing clinical information to accompany photographs, providing a baseline photograph for comparison, and implementing photograph-taking processes aimed at improving image quality.

What are the mechanisms and contexts by which care groups achieve social and behavioural change in low- and middle-income countries? Group motivation findings from a realist synthesis

OBJECTIVE

Infant and under-five mortality rates in low- and middle-income countries (LMIC) can be reduced by encouraging behaviours such as sleeping under insecticide-treated bed nets, exclusive breast-feeding for the first 6 months, regular handwashing, etc. Community-based volunteer or peer-to-peer mechanisms are cost-effective ways of promoting these lifesaving practices. However, the sustainability and reach of community-based behaviour change promotion remains a challenge. Our inquiry focuses on the utilisation, by non-governmental organisations (NGO), of Care Groups, a peer-to-peer behaviour change intervention. We asked: What are the mechanisms and contexts by which Care Groups achieve social and behavioural change in nutrition, health and other sectors?

DESIGN

Realist synthesis reviewing forty-two texts that contained empirical evidence about Care Group interventions.

SETTING

LMIC.

PARTICIPANTS

We held consultations with a research reference group, which included Care Group and nutrition experts, and Care Group - implementing NGO staff in Malawi.

RESULTS

Different types of motivation drive the establishment and the sustainability of peer group interventions. A certain amount of motivation was derived from the resources provided by the NGO establishing the Care Groups. Subsequently, both volunteers and neighbourhood group members were motivated by the group dynamics and mutual support, as well as support from the wider community. Finally, volunteers and group members alike became self-motivated by their experience of being involved in group activities.

CONCLUSIONS

When designing and implementing community-based behaviour change interventions, awareness of the multi-directional nature of the motivating drivers that are experienced by peer- or community group members is important, to optimise these groups' reach and sustainability.

Are we listening to community health workers? Experiences of the community health worker journey in rural South Africa

Access to healthcare in developing countries remains a challenge. As a result, task-shifting to community health workers (CHWs) is increasingly used to mitigate healthcare worker shortages. Although there is solid evidence of CHW program effectiveness, less is known about CHWs' experiences of becoming and then working daily as CHWs-information that should play an important role in the design of CHW programs. We examined the experiences of a group of CHWs working in a government-run CHW program in South Africa's rural Eastern Cape Province. Semistructured qualitative interviews (N = 9) and focus groups (N = 2) focusing on motivations for becoming a CHW and experiences of working as CHWs were conducted and thematically analyzed. Three themes were identified: (1) becoming a CHW, (2) facing challenges in the field, and (3) gaining community acceptance through respect and legitimacy. In this study, CHWs were motivated by altruism and a desire to help their community. They faced a range of challenges such as limited training, lack of supervision, equipment shortages, logistical issues, and clinics with limited services. Respect and legitimacy through community acceptance and trust is crucial for effective CHW work. CHWs in this study described how confidentiality and their own persistence facilitated the process of gaining respect and legitimacy. CHWs have a unique knowledge of contexts and requirements for successful programs and greater efforts are needed to include their perspectives to improve and develop programs. Recognition is needed to acknowledge the significant personal input required by CHWs for programs to be successful.

Infection preparedness of community health workers: implications for maternal and neonatal health services in Pakistan

AIM

This study aimed to (i) identify community health workers' (CHWs) perceived satisfaction for maternal and neonatal health services, with respect to (1) socio-demographic characteristics; (2) coronavirus preparedness; (3) coronavirus responsiveness; and (4) employee satisfaction and (ii) investigate the interplay among study variables to identify the role of direct effects and mediation.

BACKGROUND

Women CHWs are salient providers for maternal and neonatal services at the primary level, especially in conservative regions. Service delivery is a valuable indicator for mother and newborn wellbeing. There is need for empirical evidence to understand how CHWs may be supported in delivering maternal and neonatal health services during pandemics.

METHODS

Bivariate regression was used to identify the lower odds for CHWs' perceived satisfaction for maternal and neonatal health services. In addition, structural equation modeling was used to investigate if coronavirus responsiveness and employee satisfaction as mediating variables influence the relationship between coronavirus preparedness and maternal and neonatal health services. Data were collected telephonically from 350 CHWs. The sample was representative of 35 districts of Punjab, which is the most populated province in the country.

FINDINGS

We found thirty predictors with respect to coronavirus preparedness, coronavirus responsiveness and employee satisfaction which contribute to lower odds of satisfaction for maternal and neonatal health services. We also found that coronavirus preparedness has a direct effect on maternal and neonatal health service satisfaction (β = .242, P < .001) and an indirect effect on maternal health satisfaction (β = .242, P < .001) via the mediation of employee satisfaction. We conclude with four critical recommendations to support CHWs in delivering optimal services, comprising of education and training, operational support, public acceptance, and employee support and benefits. The findings are important for the planning of primary health services and governance support for CHWs and poor women clients in Pakistan and other developing countries.

Maternal and child surveillance in peri-urban communities: Perceptions of women and community health workers from Pakistan

Community health workers (CHWs) in maternal, newborn, and child health (MNCH) programs play an important role in demographic surveillance activities; however, there is lack of literature regarding the community and CHWs' perceptions about these activities. The purpose of this study was to explore perceptions of married women of reproductive age (MWRA) regarding the role of CHWs involved in maternal and child surveillance and explore facilitators and barriers for CHWs involved in surveillance activities. A qualitative study was conducted in five peri-urban surveillance sites along the coastal belt of Bin Qasim Town, Karachi, Pakistan. In-depth interviews were conducted with 25 randomly selected MWRAs and 15 CHWs. A thematic analysis was performed to explore perceptions, barriers, and facilitators of the study participants about maternal and child surveillance activities. The results showed that MWRAs perceived surveillance CHWs as service providers with regards to standard counselling i.e. importance of antenatal care, nutrition, immunization, and distribution of iron and folic acid tablets to pregnant women, child growth assessment, and referral of sick children to the health facility. Trust in the CHWs was an enabler for MWRAs, whereas lack of incentives was cited as a barrier to share their health data. CHWs perceived themselves as a bridge in liaising community with the primary health care facility. They highlighted an enabling environment such as appreciation, supportive supervision, training, and utilization of digital data collection tools as facilitators for their work. Low health literacy of the communities, lack of provision of incentives by CHWs to the community, and facility-based experiences of the community were reported as barriers. Surveillance CHWs are an integral link between the health facility and MWRAs. Hence an enabling environment may lead to improved health service delivery, translating into meaningful impact for the mother and child.

Identifying Programmatic Factors that Increase Likelihood of Health Facility Delivery: Results from a Community Health Worker Program in Zanzibar

INTRODUCTION

Community health worker (CHW) interventions have been utilized to address barriers that prevent pregnant women from delivering in health facilities in low- and middle-income countries (LMICs). The objective of this research was to assess the programmatic factors that increase the likelihood of health facility delivery within a large digital health-supported CHW program in Zanzibar, Tanzania.

METHODS

This study included 36,693 women who were enrolled in the Safer Deliveries program with a live birth between January 1, 2017 and July 31, 2019. We assessed whether long-term enrollment, recency of CHW pregnancy visit prior to delivery, and number of routine home pregnancy visits were associated with an increased likelihood of health facility delivery compared to home delivery. We used Chi-squared tests to assess bivariate relationships and performed logistic regression analyses to assess the association between each programmatic variable and health facility delivery, adjusting for relevant confounders.

RESULTS

We found that long-term enrollment was significantly associated with increased likelihood of health facility delivery, with the strongest relationship among women with a previous home delivery (OR = 1.4, 95%CI [1.0,1.7]). Among first-time mothers, two or more pregnancy visits by a CHW was positively associated with health facility delivery (OR = 1.8, 95%CI [1.2, 2.7]). Recent pregnancy visit by a CHW was positively associated with health facility delivery, but was not significant at the α = 0.05 level.

DISCUSSION

In this program, we found evidence that at least two routine home pregnancy visits, longer length of enrollment in the program, and recency of home visit to the delivery date were strategies to increase health facility delivery rates among enrolled mothers. Maternal and child health programs should undertake similar evaluations to improve program delivery.

Approaches and outcomes of community health worker's interventions for hypertension management and control in low-income and middle-income countries: systematic review

OBJECTIVES

To critically appraise the scope, content and outcomes of community health worker (CHW) interventions designed to reduce blood pressure (BP) in low-income and middle-income countries (LMICs).

METHOD

We performed a database search (PUBMED, EMBASE, CINAHL, PsycINFO, OpenGrey, Cochrane Central Trials Register and Cochrane Database of Systematic Reviews) to identify studies in LMICs from 2000 to 2020. Eligible studies were interventional studies published in English and reporting CHW interventions for management of BP in LMICs. Two independent reviewers screened the titles, abstracts and full texts of publications for eligibility and inclusion. Relevant information was extracted from these studies using a tailored template. Risk of bias was assessed using the Cochrane collaboration risk of bias tool. Qualitative synthesis of results was done through general summary of the characteristics and findings of each study. We also analysed the patterns of interventions and their outcomes across the studies. Results were presented in form of narrative and tables.

RESULTS

Of the 1557 articles identified, 14 met the predefined criteria. Of these, 12 were cluster randomised trials whereas two were pretest/post-test studies. The CHW interventions were mainly community-based and focused on behaviour change for promoting BP control among hypertensive patients as well as healthy individuals. The interventions had positive effects in the BP reduction, linkage to care, treatment adherence and in reducing cardivascular-disease risk level.

DISCUSSION AND CONCLUSION

The current review is limited in that, a meta-analysis to show the overall effect of CHW interventions in the management of hypertension was not possible due to the diversity of the interventions, and outcomes of the studies included in the review. Summarised outcomes of individual studies showed CHW enhanced the control and management of hypertension. Further studies are needed to indicate the impact and cost-effectiveness of CHW-led interventions in the control and management of hypertension in LMICs.

Application of primary healthcare principles in national community health worker programmes in low-income and middle-income countries: a scoping review

OBJECTIVE

To identify which primary healthcare (PHC) principles are reflected in the implementation of national community health worker (CHW) programmes and how they may contribute to the outcomes of these programmes in the context of low-income and middle-income countries (LMICs).

DESIGN

Scoping review.

DATA SOURCES

A systematic search was conducted through PubMed, CINAHL, EMBASE and Scopus databases.

ELIGIBILITY CRITERIA

The review considered published primary studies on national programmes, projects or initiatives using the services of CHWs in LMICs focused on maternal and child health. We included only English language studies. Excluded were programmes operated by non-government organisations, study protocols, reviews, commentaries, opinion papers, editorials and conference proceedings.

DATA EXTRACTION AND SYNTHESIS

We reviewed the application of four PHC principles (universal health coverage, community participation, intersectoral coordination and appropriateness) in the CHW programme's objectives, implementation and stated outcomes. Data extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was not performed in this scoping review.

RESULTS

From 1280 papers published between 1983 and 2019, 26 met the inclusion criteria. These 26 papers included 14 CHW programmes from 13 LMICs. Universal health coverage and community participation were the two commonly reported PHC principles, while intersectoral coordination was generally missing. Similarly, the cultural acceptability aspect of the principle of appropriateness was present in all programmes as these programmes select CHWs from within the communities. Other aspects, particularly effectiveness, were not evident.

CONCLUSION

The implementation of PHC principles across national CHW programmes in LMICs is patchy. For comprehensiveness and improved health outcomes, programmes need to incorporate all attributes of PHC principles. Future research may focus on how to incorporate more attributes of PHC principles while implementing national CHW programmes in LMICs. Better documentation and publications of CHW programme implementation are also needed.

Is respectful care provided by community health workers associated with infant feeding practices? A cross sectional analysis from India

Objectives

Breastfeeding and complementary feeding practices in India do not meet recommendations. Community health care workers (CHWs) are often the primary source of information for pregnant and postpartum women about Infant and Young Child Feeding (IYCF) practices. While existing research has evaluated the effectiveness of content and delivery of information through CHWs, little is known about the quality of the interpersonal communication (respectful care). We analyzed the effect of respectful interactions on recommended IYCF practices.

Methods

We use data from evaluation of an at-scale mHealth intervention in India that serves as a job aid to the CHWs (n = 3266 mothers of children < 12 m from 841 villages in 2 Indian states). The binary indicator variable for respectful care is constructed using a set of 7 questions related to trust, respect, friendliness during these interactions. The binary outcomes variables are exclusive breastfeeding, timely introduction of complimentary feeding, and minimum diet diversity for infants. We also explore if most of the pathway from respectful care to improved behaviors is through better recall of messages (mediation analysis). All models controlled for socio-economic-demographic characteristics and number of interactions with the CHW.

Results

About half of women reported positive, respectful interactions with CHWs. Interactions that are more respectful were associated with better recall of appropriate health messages. Interactions that are more respectful were associated with a greater likelihood of adopting all child-feeding behaviors except timely initiation of breastfeeding. After including recall in the model, the effect of respectful interactions alone reduced.

Conclusions

Respectful care from CHWs appears to be significantly associated with some behaviors around infant feeding, with the primary pathway being through better recall of messages. Focusing on improving social and soft skills of CHWs that can translate into better CHW-beneficiary interactions can pay rich dividends.

Funding

This study is funded by Grant No. OPP1158231 from Bill and Melinda Gates Foundation. Trial registration number: 10.1186/ISRCTN83902145

Changing Behavior, Attitudes, and Beliefs About Food Safety: A Scoping Review of Interventions Across the World and Implications for Empowering Consumers

Foodborne illnesses are a global public health issue. Responsibility to prevent foodborne disease is shared by many actors along the food supply chain, including consumers. However, consumers often lack knowledge about food safety and behaviors that can reduce risk. Consumers are often targeted for interventions to address these gaps, but a current comprehensive analysis of such interventions globally by type, geography, and outcome is lacking in the literature. In addition, there is a need to understand how individual interventions could be broadened to include the relationships between consumers and other actors in the food system, and how targeted communication strategies can affect behavior. We conducted a rigorous scoping review to assess consumer-facing food safety interventions carried out globally over the past 20 years, and categorized and analyzed them by type of intervention, methods, and outcomes to understand which interventions might be effective in changing consumer behavior, knowledge, attitudes, beliefs, and perceptions on food safety. Ninety-two interventions were reviewed, the majority of which were published in the last 10 years in North America. Most target adults, and 25% are directed at women and mothers. Health or risk communication interventions are becoming increasingly common to move beyond skill-based education and address risk perceptions of food safety that might motivate consumers. Only two studies addressed risk perception in consumers to potentially change food handlers' behavior outside of the home. This review suggests that focusing on risk perception combined with strategies that leverage emotion and trusted sources, such as respected peers or family members, might be useful strategies for interventions.