Measuring client trust in community health workers: A multi-country validation study

Success in vaccination programming through community health workers: a qualitative analysis of interviews and focus group discussions from Nepal, Senegal and Zambia

OBJECTIVES

Community health workers are essential to front-line health outreach throughout low-income and middle-income countries, including programming for early childhood immunisation. Understanding how community health workers are engaged for successful early childhood vaccination among countries who showed success in immunisation coverage would support evidence-based policy guidance across contexts.

DESIGN

We employed a multiple case study design using qualitative research methods.

SETTING

We conducted research in Nepal, Senegal and Zambia.

PARTICIPANTS

We conducted 207 interviews and 71 focus group discussions with 678 participants at the national, regional, district, health facility and community levels of the health systems of Nepal, Senegal and Zambia, from October 2019 to April 2021. We used thematic analysis to investigate contributing factors of community health worker programming that supported early childhood immunisation within each country and across contexts.

RESULTS

Implementation of vaccination programming relied principally on the (1) organisation, (2) motivation and (3) trust of community health workers. Organisation was accomplished by expanding cadres of community health workers to carry out their roles and responsibilities related to vaccination. Motivation was supported by intrinsic and extrinsic incentives. Trust was expressed by communities due to community health worker respect and value placed on their work.

CONCLUSION

Improvements in immunisation coverage was facilitated by community health worker organisation, motivation and trust. With the continued projection of health worker shortages, especially in low-income countries, community health workers bridged the equity gap in access to vaccination services by enabling wider reach to underserved populations. Although improvements in vaccination programming were seen in all three countries-including government commitment to addressing human resource deficits, training and remuneration; workload, inconsistency in compensation, training duration and scope, and supervision remain major challenges to immunisation programming. Health decision-makers should consider organisation, motivation and trust of community health workers to improve the implementation of immunisation programming.

The use and potential impact of digital health tools at the community level: results from a multi-country survey of community health workers

BACKGROUND

Community health workers (CHWs) are increasingly viewed as a critical workforce to address health system strengthening and sustainable development goals. Optimizing and widening the capacity of this workforce through digital technology is currently underway, though there is skepticism regarding CHWs' willingness and optimism to engage in digital health. We sought to understand CHWs' perceptions on the use of digital health tools in their work.

METHODS

We obtained survey data from 1,141 CHWs from 28 countries with complete study information. We conducted regression analyses to explore the relationship between CHWs' training and perceived barriers to digital health access with current use of digital devices/tools and belief in digital impact while adjusting for demographic factors.

RESULTS

Most of the CHWs worked in Kenya (n = 502, 44%) followed by the Philippines (n = 308, 27%), Ghana (n = 107, 9.4%), and the United States (n = 70, 6.1%). There were significant, positive associations between digital tools training and digital device/tool use (Adjusted Odds Ratio (AOR) = 2.92, 95% CI = 2.09-4.13) and belief in digital impact (AORhigh impact = 3.03, 95% CI = 2.04-4.49). CHWs were significantly less likely to use digital devices for their work if they identified cost as a perceived barrier (AORmobile service cost = 0.68, 95% CI = 0.49-0.95; AORphone/device cost = 0.66, 95% CI = 0.47-0.92). CHWs who were optimistic about digital health, were early adopters of technology in their personal lives, and found great value in their work believed digital health helped them to have greater impact. Older age and greater tenure were associated with digital device/tool use and belief in digital impact, respectively.

CONCLUSIONS

CHWs are not an obstacle to digital health adoption or use. CHWs believe that digital tools can help them have more impact in their communities regardless of perceived barriers. However, cost is a barrier to digital device/tool use; potential solutions to cost constraints of technological access will benefit from further exploration of reimbursement models. Digital health tools have the potential to increase CHW capacity and shape the future of community health work.

Evaluating a peer-to-peer health education program in Australian public housing communities during the COVID-19 pandemic

BACKGROUND

The cohealth Health Concierge program operated in Melbourne, Australia from July 2020 to 30 June 2022. It provided peer-to-peer support to culturally and linguistically diverse residents of high-rise public housing. During this time, the COVID-19 public health response changed frequently and included movement restriction, testing and vaccination. We conducted a mixed-methods evaluation to determine the Health Concierge program's impact on residents' engagement with health services and public health activities.

METHODS

The evaluation, informed by a Project Reference Group, used the RE-AIM framework. We analysed data from 20,901 routinely collected forms describing interactions between Concierges and residents from August 2021 to May 2022. Additional evaluation-specific data were collected between March and May 2022 in four housing estates; we surveyed 301 residents and conducted 32 interviews with residents, Concierges and program stakeholders.

RESULTS

Concierges promoted COVID-safe behaviours; linked residents with support, testing and vaccination services; and disseminated up-to-date information. Of the 20,901 recorded interactions, 8,872 (42%) included Concierges providing support around COVID-19 vaccination. Most surveyed residents (191/301, 63%) reported speaking with a Concierge in the previous six months. The self-reported two-dose COVID-19 vaccine uptake was 94% (283/301). Some residents described having meaningful, appreciated conversations with Concierges, and some described superficial interactions. While residents initially welcomed the program, many felt it failed to evolve. Poorly defined management and hiring criteria led to variable program implementation. A need for bicultural workers to continue linking residents with services was discussed.

CONCLUSIONS

Concierges' impact on residents may have contributed to high community uptake of COVID-19 testing and vaccination, and had benefits beyond the COVID-19 remit. We recommend the program be revised and continued to inform further preparedness planning and support service access generally. Program models such as this have potential to inform and reassure high-risk communities during a pandemic. In addition, such programs can help overcome vaccine hesitancy and promote protective health behaviours, regardless of whether a pandemic is currently occurring. Ensuring these programs remain responsive to the changing needs of end-users needs over time is imperative.

Applying a Power and Gender Lens to Understanding Health Care Provider Experience and Behavior: A Multicountry Qualitative Study

A limited but growing body of literature shows that health care providers (HCPs) in reproductive, maternal, and newborn health face challenges that affect how they provide services. Our study investigates provider perspectives and behaviors using 4 interrelated power domains-beliefs and perceptions; practices and participation; access to assets; and structures-to explore how these constructs are differentially experienced based on one's gender, position, and function within the health system. We conducted a framework-based secondary analysis of qualitative in-depth interview data gathered with different cadres of HCPs across Kenya, Malawi, Madagascar, and Togo (n=123). We find across countries that power dynamics manifest in and are affected by all 4 domains, with some variation by HCP cadre and gender. At the service interface, HCPs' power derives from the nature and quality of their relationships with clients and the community. Providers' power within working relationships stems from unequal decision-making autonomy among HCP cadres. Limited and sometimes gendered access to remuneration, development opportunities, material resources, supervision quality, and emotional support affect HCPs' power to care for clients effectively. Power manifests variably among community and facility-based providers because of differences in prevailing hierarchical norms in routine and acute settings, community linkages, and type of collaboration required in their work. Our findings suggest that applying power-and secondarily, gender lenses-can elucidate consistencies in how providers perceive, internalize, and react to a range of relational and environmental stressors. The findings also have implications on how to improve the design of social behavior change interventions aimed at better supporting HCPs.

Advance planning for co-caring couples

This article explores joint advance planning for co-caring couples in the community, a group growing in number and need. A health crisis for one, exposes the vulnerability of the other. Lack of planning for this eventuality leaves health and social care struggling to provide an adequate safety net in a short timeframe. This inability to adequately support, can lead to harm to the couple. The authors conducted a formal reflective investigation to discover themes that impacted on their ability to meet the needs of such a couple in their care. The themes were: the need for advanced care planning in co-caring situations; capacity assessed through different lenses; using safeguarding systems appropriately to support questions of capacity; challenges when care is not accepted; and compassion fatigue. These themes were then used to develop an action plan to improve ways of working to reduce risk in these situations.

The role of community health workers in influencing social connectedness using the household model: a qualitative case study from Malawi

BACKGROUND

Community health workers (CHWs) play a vital role in facilitating social connectedness, building trust, decrease stigma, and link communities to essential healthcare and social support services. More studies are needed to understand the factors facilitating these interactions among CHWs, clients, and community members.

OBJECTIVE

This study examined the CHW role and relationships between CHWs, communities, and health facilities that promote trust, positive relationships, and social connectedness.

METHODS

In 2016, the CHW program in Neno District, Malawi, was transitioned to a household-level assignment of CHWs to provide screening, linkage to care, and psychosocial and chronic disease support from a disease-based program. We employed an exploratory qualitative study with thematic analysis linked to Fredrickson's broaden-and-build theory of positive emotions through focus group discussions (FGDs) and in-depth interviews (IDIs) to understand the impact of the household assignment. We purposively sampled community stakeholders, CHWs, health service providers, and clients (total N = 180) from October 2018 through March 2020. All interviews were audiotaped, transcribed verbatim, translated, coded, and analyzed.

RESULTS

Participants reported decreased stigma and discrimination with increased trust and confidence in CHWs with household-level assignment. Positive relationships between CHWs in their households, community members, and health facility staff fostered health knowledge, individual agency, and personal resources for the community members to access health services. Community members' personal resources of increased health knowledge, trust, gratitude, and social support improved social connectedness and subjective wellbeing. Areas to improve positive relationships include CHWs maintaining confidentiality and caring for pregnant women.

CONCLUSION

Our study findings demonstrate that by building solid relationships as a community chosen, well informed, and household-level workforce, CHWs can develop positive relationships with communities and the health-care facility staff through building knowledge, trust, gratitude, and hope. Further work is needed in maintaining CHW confidentiality and new ways to approach culturally sensitive health areas.

Improving the precision of maternal, newborn, and child health impact through geospatial analysis of the association of contextual and programmatic factors with health trends in Bihar, India

Background

There is a scarcity of research that comprehensively examines programme impact from a context-specific perspective. We aimed to determine the conditions under which the Bihar Technical Support Programme led to more favourable outcomes for maternal and child health in Bihar.

Methods

We obtained block-level data on maternal and child health indicators during the state-wide scale-up of the pilot Ananya programme and data on health facility readiness, along with geographical and sociodemographic variables. We examined the associations of these factors with increases in the levels of indicators using multilevel logistic regression, and the associations with rates of change in the indicators using Bayesian Hierarchical modelling.

Results

Frontline worker (FLW) visits between 2014-2017 were more likely to increase in blocks with better night lighting (odds ratio (OR) = 1.23, 95% confidence interval (CI) = 1.01-1.51). Birth preparedness increased in blocks with increasing FLW visits (OR = 3.43, 95% CI = 1.15-10.21), while dry cord care practice increased in blocks where satisfaction with FLW visits was increasing (OR = 1.52, 95% CI = 1.10-2.11). Age-appropriate frequency of complementary feeding increased in blocks with higher development index (OR = 1.55, 95% CI = 1.16-2.06) and a higher percentage of scheduled caste or tribe (OR = 3.21, 95% CI = 1.13-9.09). An increase in most outcomes was more likely in areas with lower baseline levels.

Conclusions

Contextual factors (eg, night lighting and development) not targeted by the programme and FLW visits were associated with favourable programme outcomes. Intervention design, including intervention selection for a particular geography, should be modified to fit the local context in the short term. Expanding collaborations beyond the health sector to influence modifiable contextual factors in the long term can result in a higher magnitude and more sustainable impact.

Registration

ClinicalTrials.gov: NCT02726230.

Factors Influencing Palliative Care Access and Delivery for Great Plains American Indians

CONTEXT

Despite the known importance of culturally tailored palliative care (PC), American Indian people (AIs) in the Great Plains lack access to such services. While clinicians caring for AIs in the Great Plains have long acknowledged major barriers to serious illness care, there is a paucity of literature describing specific factors influencing PC access and delivery for AI patients living on reservation land.

OBJECTIVES

This study aimed to explore factors influencing PC access and delivery on reservation land in the Great Plains to inform the development culturally tailored PC services for AIs.

METHODS

Three authors recorded and transcribed interviews with 21 specialty and 17 primary clinicians. A data analysis team of seven authors analyzed transcripts using conventional content analysis. The analysis team met over Zoom to engage in code negotiation, classify codes, and develop themes.

RESULTS

Qualitative analysis of interview data revealed four themes encompassing factors influencing palliative care delivery and access for Great Plains American Indians: health care system operations (e.g., hospice and home health availability, fragmented services), geography (e.g., weather, travel distances), workforce elements (e.g., care continuity, inadequate staffing, cultural familiarity), and historical trauma and racism.

CONCLUSION

Our findings emphasize the importance of addressing the time and cost of travel for seriously ill patients, increasing home health and hospice availability on reservations, and improving trust in the medical system. Strengthening the AI medical workforce, increasing funding for the Indian Health Service, and transitioning the governance of reservation health care to Tribal entities may improve the trustworthiness of the medical system.

Confirming-and testing-bonds of trust: A mixed methods study exploring community health workers' experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya

Amidst the COVID-19 pandemic and national responses, trust (one's belief that a system acts in one's best interest) is important to consider. In community health systems, trust is embedded in relationships between clients, CHWs, and health system stakeholders. This mixed-methods study explores trust through the evolving COVID-19 crisis in Bangladesh, Haiti, and Kenya, where multi-country community health research was underway. We investigate the extent and ways trust between communities, community health workers (CHWs), and health system actors shift, including its relation to community fear and hostility, through self-reported positive and negative experiences of CHWs and policy/program stakeholders on a phone-based survey with 2,025 CHWs and 72 key informant interviews, including CHWs, in late 2020. On surveys, CHWs reported high levels of community trust (8/10 in Bangladesh and Kenya; 6/10 in Haiti) with over 60% reporting client relief in seeing their CHWs. About one-third of CHWs across countries reported experiencing instances of hostility from community members during the pandemic in the form of refused home-entry, ignored advice, or being shouted at. Multivariate analyses revealed that CHWs reporting more positive and fewer negative experiences is consistently associated with continuing routine work, doing COVID-19-related work, and greater community trust. Qualitative interviews showed that existing pre-pandemic trusting relationships withstood the early phase of COVID-19, mitigating negative community reactions toward CHWs and stigma towards COVID-positive individuals, maintaining routine health services, and sustaining appreciation for CHW-provided prevention information and emotional support. CHW-community and CHW-health system actor trust is strengthened when CHWs are well-resourced; CHW-community trust is strained by public frustration at the pandemic, associated restrictions, and sociopolitical stressors. Our study suggests that with adequate institutional support, bonds of trust can promote resilient community health systems during extended public health crises, through CHWs' commitment to mitigating misinformation, reducing stigma, maintaining routine service provision, and promoting COVID-19 prevention.

Factors Related to COVID-19 Preventive Behaviors: A Structural Equation Model

Background: While COVID-19 has rapidly spread around the world, and vaccines are not widely available to the general population, the World Health Organization outlines preventive behavior as the most effective way to limit the rapid spread of the virus. Preventive behavior is associated with a number of factors that both encourage and discourage prevention. Aim: The aim of this research was to study COVID-19 threat appraisal, fear of COVID-19, trust in COVID-19 information sources, COVID-19 conspiracy beliefs and the relationship of socio-demographic variables (gender, age, level of education, place of residence, and employment status) to COVID-19 preventive behavior. Methods: The data originate from a national cross-sectional online survey (N = 2,608) undertaken in July 2020. The data were analyzed using structural equation modeling. Results: COVID-19 threat appraisal, trust in COVID-19 information sources, and fear of COVID-19 are all significant predictors of COVID-19 preventive behaviors. Together they explain 26.7% of the variance of this variable. COVID-19 conspiracy beliefs significantly negatively predict COVID-19 threat appraisal (R ² = 0.206) and trust in COVID-19 information sources (R ² = 0.190). COVID-19 threat appraisal contributes significantly and directly to the explanation of the fear of COVID-19 (R ² = 0.134). Directly, as well as mediated by COVID-19 conspiracy beliefs, threat appraisal predicts trust in COVID-19 information sources (R ² = 0.190). The relationship between COVID-19 threat appraisal and COVID-19 preventive behaviors is partially mediated by fear of COVID-19 (indirect effect 28.6%) and trust in information sources (15.8%). Socio-demographic variables add very little in prediction of COVID-19 preventive behavior. Conclusions: The study results demonstrate that COVID-19 threat appraisal is the most important factor associated with COVID-19 preventive behavior. Those Latvian residents with higher COVID-19 threat appraisal, experienced higher levels of fear of COVID-19, had more trust in COVID-19 information sources, and were more actively involved in following COVID-19 preventive behaviors. COVID-19 conspiracy beliefs negatively predict COVID-19 threat appraisal and trust in COVID-19 information sources, but not the COVID-19 preventive behaviors. Socio-demographic factors do not play an important role here.

Development and validation of a multi-dimensional scale to assess community health worker motivation

BACKGROUND

Ensuring that Community Health Workers (CHWs) are motivated is critical to their performance, retention and well-being - and ultimately to the effectiveness of community health systems worldwide. While CHW motivation is as multi-dimensional construct, there is no multi-dimensional measure available to guide programming. In this study, we developed and validated a pragmatic, multi-dimensional measure of CHW motivation.

METHODS

Scale validation entailed qualitative and survey research in Mali and Bangladesh. We developed a pool of work satisfaction items as well as several items assessing the importance of hypothesized sub-dimensions of motivation, based on the literature and expert consultations. Qualitative research helped finalize scale sub-dimensions and items. We tested the scale in surveys with CHWs in Mali (n = 152, 40% female, mean age 32) and Bangladesh (n = 76 women, mean age 46). We applied a split-sample exploratory/confirmatory factor analysis (EFA/CFA) in Mali, and EFA in Bangladesh, then assessed reliability. We also gauged convergent/predictive validity, assessing associations between scale scores with conceptually related variables.

RESULTS

The final 22-item scale has four sub-dimensions: Quality of supervision, Feeling valued and capacitated in your work, Peer respect and support, and Compensation and workload. Model fit in CFAs was good, as were reliabilities for the full scale (alpha: 0.84 in Mali, 0.93 in Bangladesh) and all sub-dimensions. To construct scores for the final scale, we weighted the scores for each sub-dimension by CHW-reported importance of that sub-dimension. Final possible range was -6 to +6 (sub-dimensions), -24 to +24 (full scale). Mean (standard deviation) of full-scale scores were 5.0 (3.3) in Mali and 14.5 (5.3) in Bangladesh. In both countries, higher motivation was significantly associated with higher overall interest in their work, feeling able to improve health/well-being in their community, as well as indicators of higher performance and retention.

CONCLUSIONS

We found that the Multi-dimensional Motivation (MM) scale for CHWs is a valid and reliable measure that comprehensively assesses motivation. We recommend the scale be employed in future research around CHW performance and community health systems strengthening worldwide. The scale should be further evaluated within longitudinal studies assessing CHW performance and retention outcomes over time.

The Client Empowerment in Community Health Systems Scale: Development and validation in three countries

BACKGROUND

Effectively measuring client empowerment is critical for monitoring and supporting empowerment through interventions, including via community health workers (CHWs) on the front line. Yet a comprehensive measure capturing the multidimensional aspects of client empowerment is not currently available. We aimed to develop and validate the Client Empowerment in Community Health Systems (CE-CHS) Scale in three countries.

METHODS

We used data from cross-sectional surveys from 2019-2020 with clients of CHWs in Bangladesh (n = 1384), Haiti (n = 616), and Kenya (n = 306). Nineteen candidate CE-CHS Scale items were adapted from existing health empowerment and sociopolitical control scales. Items spanned three hypothesized sub-domains: personal agency around health (eg, "I feel in control of my health"), agency in sharing health information with others (eg, "I feel confident sharing health information with my family/friends"), and empowerment in community health systems (eg, "Most facility/managers would listen to any concerns I raise"). Face and content validity of items were assessed via two focus group discussions in Haiti. For each country, we conducted split-sample exploratory/confirmatory factor analyses (EFA/CFA) and assessed internal consistency reliability. We assessed convergent validity by comparing final full-scale and sub-dimension scores to theoretically related variables.

RESULTS

All participants in Bangladesh and Kenya were female, as were 85% in Haiti. Mean age in Bangladesh and Kenya was around 25 years; 40 in Haiti. EFA/CFA resulted in a final 16-item CE-CHS Scale representing the three hypothesized sub-scales. Three items were dropped in EFA due to poor performance. CFA fit statistics were good for the full-scale and each sub-scale. The mean CE-CHS score (range 1 to 4) was 2.4 in in Bangladesh, 2.8 in Haiti, and 3.0 in Kenya. Cronbach's alpha and ordinal theta of the full and sub-scales were greater than 0.7. Increased empowerment was associated with increased trust in CHWs, influence of CHWs on empowerment, satisfaction with CHW services, number of CHW interactions, civic engagement, and education, with slight variations in magnitude and significance by country.

CONCLUSIONS

Findings suggest that the 16-item CE-CHS Scale is valid and reliable. This scale can be used to assess levels and determinants of, and changes in, client empowerment in future implementation research and monitoring of community health systems.

Measuring quality of care at the community level using the contraceptive method information index plus and client reported experience metrics in Bangladesh

BACKGROUND

Low rates of contraceptive continuation in Bangladesh are a symptom of poor quality family planning (FP) counseling. Improving family planning counseling by the country's community health care workers (CHWs) could improve contraceptive continuation. This study explores client experiences of care from CHWs, as measured by the method information index plus (MII+) and communication quality metric.

METHODS

Conducted in a peri-urban sub-district with low contraceptive use rates, this mixed methods study explores FP client experiences with community-based counseling and referrals by Family Welfare Assistants (FWAs), a CHW cadre providing FP services. Client- and patient-reported experience with community FP services was measured by the MII+ and communication quality metric. A quantitative post-service exit survey was coupled with observations of the interactions between 62 FWAs and 692 female clients to measure FWA and client FP knowledge, FWA capacities, attitudes, quality of FP communication, FP referrals, and contraceptive uptake.

RESULTS

Summary MII+ scores suggest that only 20% of clients reported adequate provision of information for informed decisions. Observations and self-reporting alike suggest moderate to high quality of communication during FWA and client interactions. Despite FWAs' theoretical knowledge of long-acting reversible and permanent FP methods, few clients were referred to facilities for them; 81% of clients who preferred a pill received it, while only 34% of clients seeking long-acting methods received needed referrals.

CONCLUSIONS

Quality community-based FP counseling could help address rising contraceptive discontinuation rates in Bangladesh. While MII and MII+ scores in this study were low, and FWA evinced numerous misconceptions, FWAs demonstrated strong communication skills that facilitate rapport and trust with their clients and communities. Bangladesh's policy and programs should capitalize upon these relationships and enhance CHWs' knowledge of all method types, and side effects management, with updated job aids, refresher training, and supervision.