Advancing social care integration in health systems with community health workers: an implementation evaluation based in Bronx, New York

BACKGROUND

In recent years, health systems have expanded the focus on health equity to include health-related social needs (HRSNs) screening. Community health workers (CHWs) are positioned to address HRSNs by serving as linkages between health systems, social services, and the community. This study describes a health system's 12-month experience integrating CHWs to navigate HRSNs among primary care patients in Bronx County, NY.

METHODS

We organized process and outcome measures using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation framework domains to evaluate a CHW intervention of the Community Health Worker Institute (CHWI). We used descriptive and inferential statistics to assess RE-AIM outcomes and socio-demographic characteristics of patients who self-reported at least 1 HRSN and were referred to and contacted by CHWs between October 2022 and September 2023.

RESULTS

There were 4,420 patients who self-reported HRSNs in the standardized screening tool between October 2022 and September 2023. Of these patients, 1,245 were referred to a CHW who completed the first outreach attempt during the study period. An additional 1,559 patients self-reported HRSNs directly to a clinician or CHW without being screened and were referred to and contacted by a CHW. Of the 2,804 total patients referred, 1,939 (69.2%) were successfully contacted and consented to work with a CHW for HRSN navigation. Overall, 78.1% (n = 1,515) of patients reported receiving social services. Adoption of the CHW clinician champion varied by clinical team (median 22.2%; IQR 13.3-39.0%); however, there was no difference in referral rates between those with and without a clinician champion (p = 0.50). Implementation of CHW referrals via an electronic referral order appeared successful (73.2%) and timely (median 11 days; IQR 2-26 days) compared to standard CHWI practices. Median annual cost per household per CHW for the intervention was determined to be $184.02 (IQR $134.72 - $202.12).

CONCLUSIONS

We observed a significant proportion of patients reporting successful receipt of social services following engagement with an integrated CHW model. There are additional implementation factors that require further inquiry and research to understand barriers and enabling factors to integrate CHWs within clinical teams.

Integrating Community Health Workers' Dual Clinic-Community Role in Safety-Net Primary Care: Implementation Lessons from a Pragmatic Diabetes-Prevention Trial

BACKGROUND

Over a third of US adults carry a diagnosis of prediabetes, 70% of whom may progress to type 2 diabetes mellitus ("diabetes"). Community health workers (CHWs) can help patients undertake healthy behavior to prevent diabetes. However, there is limited guidance to integrate CHWs in primary care, specifically to address CHWs' dual clinic-based and community-oriented role.

OBJECTIVE

Using evidence from CHWs' adaptations of a diabetes-prevention intervention in safety-net hospitals in New York City, we examine the nature, intent, and possible consequences of CHWs' actions on program fidelity. We propose strategies for integrating CHWs in primary care.

DESIGN

Case study drawing on the Model for Adaptation Design and Impact (MADI) to analyze CHWs' actions during implementation of CHORD (Community Health Outreach to Reduce Diabetes), a cluster-randomized pragmatic trial (2017-2022) at Manhattan VA and Bellevue Hospital.

PARTICIPANTS

CHWs and clinicians in the CHORD study, with a focus in this analysis on CHWs.

APPROACH

Semi-structured interviews and focus group discussion with CHWs (n=4); semi-structured interviews with clinicians (n=17). Interpretivist approach to explain CHWs' adaptations using a mix of inductive and deductive analysis.

KEY RESULTS

CHWs' adaptations extended the intervention in three ways: by extending social assistance, healthcare access, and operational tasks. The adaptations were intended to improve fit, reach, and retention, but likely had ripple effects on implementation outcomes. CHWs' focus on patients' complex social needs could divert them from judiciously managing their caseload.

CONCLUSIONS

CHWs' community knowledge can support patient engagement, but overextension of social assistance may detract from protocolized health-coaching goals. CHW programs in primary care should explicitly delineate CHWs' non-health support to patients, include multiprofessional teams or partnerships with community-based organizations, establish formal communication between CHWs and clinicians, and institute mechanisms to review and iterate CHWs' work to resolve challenges in their community-oriented role.

A Model of Community Health Worker Integration into Schools: Community-based Participatory Research in Action

BACKGROUND

Schools are rich sites for collaborations between health and educational sectors.

OBJECTIVES

To identify lessons learned from formation of a community-academic partnership and application of community-based participatory research (CBPR) to develop a model that integrates community health workers into schools.

METHODS

Individuals from an academic medical center, a large public school district, and a community-based research institute applied CBPR principles to reimagine schools as a place for improving the health of children.

LESSONS LEARNED

Three lessons emerged. Leveraging each team member's expertise centered the partnership on community strengths, co-learning, and stakeholder engagement. Adherence to CBPR's principles of power sharing and equity helped navigate the challenges of collaboration between large institutions. Early focus on sustainability helped address unexpected issues, build capacity, and boost advocacy.

CONCLUSIONS

This partnership demonstrates how CBPR fosters conditions in which equitable partnerships between research institutions and public schools can thrive to promote childhood health.

Community Health Workers Deliver Mental Health Intervention to Uninsured Latinx in Baltimore: Evaluation and Lessons Learned in a Pilot Program

BACKGROUND

Implementation of evidence-based interventions to reduce depression among uninsured Latinx patients who are at high risk of depression are rare.

OBJECTIVES

Our goal was to evaluate Strong Minds, a language and culturally tailored, evidence-based intervention adapted from cognitive behavioral therapy (CBT) for mild-moderate depression and anxiety, delivered by community health workers (CHWs) in Spanish to uninsured Latinx immigrants.

METHODS

As part of the pilot, 35 participants, recruited from a free community primary care clinic, completed Strong Minds. Assessments and poststudy interviews were conducted. Paired t-tests were used to assess change of depressive symptoms at 3 and 6 months.

LESSONS LEARNED

CHW delivery of depression care to this population was feasible and among those who completed the program, preliminary evidence of depression outcomes suggests potential benefit. CHWs had specific training and support needs related to mental health care delivery.

CONCLUSIONS

Further implementation studies of depression care interventions using CHWs for underserved Latinx is needed.

Vers une décolonisation des ressources de soins et services sociaux : les travailleurs communautaires locaux au Nunavik

OBJECTIVES

According to the World Health Organization, discrepancies in health statistics reflect unequal access to resources. The Truth and Reconciliation Commission of Canada calls for an increase in the number of Indigenous workers within health and social services. The involvement of local community workers is essential to ensure the cultural security of care and the decolonization of services. This article presents the role played by these workers in the expansion of mental health services and social interventions in Nunavik, the contextual considerations that influence their practice and their place within professional teams.

METHODS

A thematic analysis was conducted on semi-structured interviews done in 2016 with 60 Inuit and non-Inuit individuals working in the broad field of health and social services in Nunavik.

RESULTS

The integration of local community workers is perceived to bring several benefits, including the improvement of interventions and unique learning opportunities. However, several factors hinder this collaboration, such as clarity of mandates, access to pre-requisite training and diplomas, recognition of local knowledge, and staff turnover. More flexibility and support after hiring would allow for the service structure to be adapted to the complex reality of Nunavik.

CONCLUSION

This article adds to the body of literature highlighting the importance of collaboration with local community workers. The decolonization of services necessarily involves redesigning structures in order to recognize their contribution and to give a place to local knowledge.

Community Health Worker Asthma Interventions for Children: Results From a Clinically Integrated Randomized Comparative Effectiveness Trial (2016‒2019)

Objectives. To compare asthma control for children receiving either community health worker (CHW) or certified asthma educator (AE-C) services. Methods. The Asthma Action at Erie Trial is a comparative effectiveness trial that ran from 2016 to 2019 in Cook County, Illinois. Participants (aged 5‒16 years with uncontrolled asthma) were randomized to 10 home visits from clinically integrated asthma CHWs or 2 in-clinic sessions from an AE-C. Results. Participants (n = 223) were mainly Hispanic (85%) and low-income. Both intervention groups showed significant improvement in asthma control scores over time. Asthma control was maintained after interventions ended. The CHW group experienced a greater improvement in asthma control scores. One year after intervention cessation, the CHW group had a 42% reduction in days of activity limitation relative to the AE-C group (b = 0.58; 95% confidence interval = 0.35, 0.96). Conclusions. Both interventions were associated with meaningful improvements in asthma control. Improvements continued for 1 year after intervention cessation and were stronger with the CHW intervention. Public Health Implications. Clinically integrated asthma CHW and AE-C services that do not provide home environmental remediation equipment may improve and sustain asthma control.

Effect of Community Health Workers on 30-Day Hospital Readmissions in an Accountable Care Organization Population: A Randomized Clinical Trial

IMPORTANCE

Value-based care within accountable care organizations (ACOs) has magnified the importance of reducing preventable hospital readmissions. Community health worker (CHW) interventions may address patients' unmet psychosocial and clinical care needs but have been underused in inpatient and postdischarge care.

OBJECTIVE

To determine if pairing hospitalized patients with ACO insurance with CHWs would reduce 30-day readmission rates.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted in 6 general medicine hospital units within 1 academic medical center in Boston, Massachusetts. Participants included adults hospitalized from April 1, 2017, through March 31, 2019, who had ACO insurance and were at risk for 30-day readmission based on a hospital readmission algorithm. The main inclusion criterion was frequency of prior nonelective hospitalizations (≥2 in the past 3 months or ≥3 in the 12 months prior to enrollment). Data were analyzed from February 1, 2018, through March 3, 2021.

INTERVENTION

CHWs met with intervention participants prior to discharge and maintained contact for 30 days postdischarge to assist participants with clinical access and social resources via telephone calls, text messages, and field visits. CHWs additionally provided psychosocial support and health coaching, using motivational interviewing, goal-setting, and other behavioral strategies. The control group received usual care, which included routine care from primary care clinics and any outpatient referrals made by hospital case management or social work at the time of discharge.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day hospital readmissions. Secondary outcomes included 30-day missed primary care physician or specialty appointments.

RESULTS

A total of 573 participants were enrolled, and 550 participants (mean [SD] age, 70.1 [15.7] years; 266 [48.4%] women) were included in analysis, with 277 participants randomized to the intervention group and 273 participants randomized to the control group. At baseline, participants had a mean (SD) of 3 (0.8) hospitalizations in the prior 12 months. There were 432 participants (78.5%) discharged home and 127 participants (23.1%) discharged to a short rehabilitation stay prior to returning home. Compared with participants in the control group, participants in the intervention group were less likely to be readmitted within 30 days (odds ratio [OR], 0.44; 95% CI, 0.28-0.90) and to miss clinic appointments within 30 days (OR, 0.56; 95% CI, 0.38-0.81). A post hoc subgroup analysis showed that compared with control participants, intervention participants discharged to rehabilitation had a reduction in readmissions (OR, 0.09; 95% CI, 0.03-0.31), but there was no significant reduction for those discharged home (OR, 0.68; 95% CI, 0.41-1.12).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that pairing ACO-insured inpatient adults with CHWs reduced readmissions and missed outpatient visits 30 days postdischarge. The effect was significant for those discharged to short-term rehabilitation but not for those discharged home.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03085264.

Community surveillance of COVID-19 by village health volunteers, Thailand

PROBLEM

To control the increasing spread of coronavirus disease 2019 (COVID-19), the government of Thailand enforced the closure of public and business areas in Bangkok on 22 March 2020. As a result, large numbers of unemployed workers returned to their hometowns during April 2020, increasing the risk of spreading the virus across the entire country.

APPROACH

In anticipation of the large-scale movement of unemployed workers, the Thai government trained existing village health volunteers to recognize the symptoms of COVID-19 and educate members of their communities. Provincial health offices assembled COVID-19 surveillance teams of these volunteers to identify returnees from high-risk areas, encourage self-quarantine for 14 days, and monitor and report the development of any relevant symptoms.

LOCAL SETTING

Despite a significant and recent expansion of the health-care workforce to meet sustainable development goal targets, there still exists a shortage of professional health personnel in rural areas of Thailand. To compensate for this, the primary health-care system includes trained village health volunteers who provide basic health care to their communities.

RELEVANT CHANGES

Village health volunteers visited more than 14 million households during March and April 2020. Volunteers identified and monitored 809 911 returnees, and referred a total of 3346 symptomatic patients to hospitals by 13 July 2020.

LESSONS LEARNT

The timely mobilization of Thailand's trusted village health volunteers, educated and experienced in infectious disease surveillance, enabled the robust response of the country to the COVID-19 pandemic. The virus was initially contained without the use of a costly country-wide lockdown or widespread testing.

Integrated community case management of childhood illness in low- and middle-income countries

BACKGROUND

The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012).

OBJECTIVES

To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison.

AUTHORS' CONCLUSIONS

iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.

Assessing Iran's health system according to the COVID-19 strategic preparedness and response plan of the World Health Organization: health policy and historical implications

Background

The role of health systems in the management of disasters, including natural hazards like outbreaks and pandemics, is crucial and vital. Healthcare systems which are unprepared to properly deal with crises are much more likely to expose their public health workers and health personnel to harm and will not be able to deliver healthcare provisions in critical situations. This can lead to a drammatic toll of deaths, even in developed countries. The possible occurrence of global crises has prompted the World Health Organization (WHO) to devise instruments, guidelines and tools to assess the capacity of countries to deal with disasters. Iran's health system has been hit hardly by the COVID-19 pandemic. In this study, we aimed to assess its preparedness and response to the outbreak.

Methods

The present investigation was designed as a qualitative study. We utilized the "COVID-19 Strategic Preparedness and Response Plan" devised by WHO as a conceptual framework.

Results

The dimension/pillar which scored the highest was national laboratories, followed by surveillance, rapid response teams and case investigations. Risk communication and community engagement was another pillar receiving a high score, followed by infection prevention and control and by country-level coordination, planning and monitoring. The pillars/dimensions receiving the lowest scores were operational support and logistics; case management; and points of entry.

Discussion

The COVID-19 pandemic has represented an unprecedent event that has challenged healthcare systems and facilities worldwide, highlighting their weaknesses and the need for inter-sectoral cooperation and collaboration during the crisis. Analyzing these experiences and capitalizing on them, by strengthening them,will help countries to be more prepared to face possible future crises.

Community health workers for non-communicable diseases prevention and control in Bangladesh: a qualitative study

BACKGROUND

The increasing burden of Non-Communicable Diseases (NCDs) in Bangladesh underscores the importance of strengthening primary health care systems. In this study, we examined the barriers and facilitators to engaging Community Health Workers (CHWs) for NCDs prevention and control in Bangladesh.

METHODS

We used multipronged approaches, including a. Situation analyses using a literature review, key personnel and stakeholders' consultative meetings, and exploratory studies. A grounded theory approach was used for qualitative data collection from health facilities across three districts in Bangladesh. We conducted in-depth interviews with CHWs (Health Inspector; Community Health Care Provider; Health Assistant and Health Supervisor) (n = 4); key informant interviews with central level health policymakers/ managers (n = 15) and focus group discussions with CHWs (4 FGDs; total n = 29). Participants in a stakeholder consultative meeting included members from the government (n = 4), non-government organisations (n = 2), private sector (n = 1) and universities (n = 2). Coding of the qualitative data and identification of themes from the transcripts were carried out and thematic approach was used for data analyses.

RESULTS

The CHWs in Bangladesh deliver a wide range of public health programs. They also provide several NCDs specific services, including screening, provisional diagnosis, and health education and counselling for common NCDs, dispensing basic medications, and referral to relevant health facilities. These services are being delivered from the sub-district health facility, community clinics and urban health clinics. The participants identified key challenges and barriers, which include lack of NCD specific guidelines, inadequate training, excessive workload, inadequate systems-level support, and lack of logistics supplies and drugs. Yet, the facilitating factors to engaging CHWs included government commitment and program priority, development of NCD related policies and strategies, establishment of NCD corners, community support systems, social recognition of health care staff and their motivation.

CONCLUSION

Engaging CHWs has been a key driver to NCDs services delivery in Bangladesh. However, there is a need for building capacity of CHWs, maximizing CHWs engagement to NCD services delivery, facilitating systems-level support and strengthening partnerships with non-state sectors would be effective in prevention and control efforts of NCDs in Bangladesh.

Addressing Neurocognitive Disorders, Dementias, and Alzheimer's Disease in Colonias of the Lower Rio Grande Valley: Establishing a Research Foundation Using Promotores

Several Texas communities along the Mexican border, including the Lower Rio Grande Valley (LRGV), are home to low-income Hispanic populations, many of whom live in underserved communities known as colonias. These areas have high incidences of neurocognitive disorders, dementia, and Alzheimer's disease (AD); health care strategies that are culturally and linguistically appropriate for the area are needed. We aim to build capacity to reduce risk, facilitate treatment, and provide caregiver support for affected individuals. However, gaining trust of communities and presenting information about research studies in a way that is culturally appropriate is critical for engagement of underserved communities. This brief report examines our work with local community health workers.(CHWs), promotores in Spanish, to establish contact with, engage, mobilize, and educate the Hispanic communities of the LGRV. Lessons from the succesful experience of training promotores in autism spectrum disorder in the LRGV highlight the importance of specifically addressing outreach in health fairs, clinic vists and referral as well as adequate selection, training, management, and support of the promotores as critical aspects. To initiate and sustain recruitment of older adults and care partners in research studies of AD and other dementias in the RGV, we have incorporated these aspects as components of the promotores training and engagement model, which has been developed and implemented by researchers and their colleagues at the School of Medicine at the University of Texas Rio Grande Valley.

Community-Based Surveillance in Côte d'Ivoire

Community-based surveillance can be an important component of early warning systems. In 2016, the Côte d'Ivoire Ministry of Health launched a community-based surveillance project in 3 districts along the Guinea border. Community health workers were trained in detection and immediate reporting of diseases and events using a text-messaging platform. In December 2017, surveillance data from before and after implementation of community-based surveillance were analyzed in intervention and control districts. A total of 3,734 signals of priority diseases and 4,918 unusual health events were reported, of which 420 were investigated as suspect diseases and none were investigated as unusual health events. Of the 420 suspected cases reported, 23 (6%) were laboratory confirmed for a specific pathogen. Following implementation of community-based surveillance, 5-fold and 8-fold increases in reporting of suspected measles and yellow fever clusters, respectively, were documented. Reporting incidence rates in intervention districts for suspected measles, yellow fever, and acute flaccid paralysis were significantly higher after implementation, with a difference of 29.2, 19.0, and 2.5 cases per 100,000 person-years, respectively. All rate differences were significantly higher in intervention districts (p < 0.05); no significant increase in reporting was noted in control districts. These findings suggest that community-based surveillance strengthened detection and reporting capacity for several suspect priority diseases and events. However, the surveillance program was very sensitive, resulting in numerous false-positives. Learning from the community-based surveillance implementation experience, the ministry of health is revising signal definitions to reduce sensitivity and increase specificity, reviewing training materials, considering scaling up sustainable reporting platforms, and standardizing community health worker roles.

Promoting Hispanic Immigrant Health via Community Health Workers and Motivational Interviewing

Hispanic immigrant health disparities are among the highest in the nation, especially related to obesity and access to health services. Healthy Fit (En Forma Saludable) is a health promotion program that leverages public health department infrastructure to address these disparities through the use of three key innovations explored in this article: community health workers (CHWs), motivational interviewing (MI), and vouchers for free preventative health services. CHWs trained in MI conduct a health screening and then distribute preventive service vouchers and health resources as needed based on screening results. Vouchers cover breast, cervical, and colorectal cancer screening, and several vaccinations including flu and human papillomavirus. Resources to support exercise, to support a healthy diet, to quit smoking, and to reduce risky drinking are also distributed as needed. CHWs then use MI to address perceived barriers and strengthen intrinsic motivation to make use of the health resources. Integrating these strategies provides a low-cost approach to promote healthy behavior in an underserved immigrant population.

Programmatic determinants of successful referral to health and social services for orphans and vulnerable children: A longitudinal study in Tanzania

Background

Trained community workers (CWs) successfully deliver health and social services, especially due to greater community acceptance. Orphans and vulnerable children (OVC) and their caregivers (CG) often need support from several sectors. We identified CW, program and referral characteristics that were associated with success of referrals provided to OVC and their CG in Tanzania in a cross-sectoral bi-directional referral system.

Methods

Data for this secondary analysis come from the first two years (2017–2018) of the USAID funded Kizazi Kipya project. Referral success was defined as feedback and service received within 90 days post-referral provision. We analyzed factors that are associated with the referral success of HIV related, education, nutrition, parenting, household economic strengthening, and child protection services among OVC and CG, using generalized estimating equations.

Results

During the study period, 19,502 CWs in 68 councils provided 146,996 referrals to 132,640 beneficiaries. OVC had much lower referral success for HIV related services (48.1%) than CG (81.2%). Adjusted for other covariates, CW age (26–49 versus 18–25 years, for OVC aOR = 0.83, 95%CI (0.78, 0.87) and CW gender (males versus females, for OVC aOR = 1.12, 95%CI (1.08, 1.16); CG aOR = 0.84, 95%CI (0.78, 0.90)) were associated with referral success. CWs who had worked > 1 year in the project (aOR = 1.52, 95%CI 1.46, 1.58) and those with previous work experience as CW (aOR = 1.57, 95%CI (1.42, 1.74) more successfully referred OVC. Referrals provided to OVC for all other services were more successful compared to HIV referrals, with aORs ranging from 2.99 to 7.22. Longer project duration in the district council was associated with increased referral success for OVC (aOR = 1.16 per month 95%CI 1.15,1.17), but decreased for CG (aOR = 0.96, 95%CI 0.94, 0.97). Referral success was higher for OVC and CGs with multiple (versus single) referrals provided within the past 30 days (aOR = 1.28 95%CI 1.21, 1.36) and (aOR = 1.17, 95%CI (1.06, 1.30)) respectively.

Conclusion

CW characteristics, referral type and project maturity had different and often contrasting associations with referral success for OVC versus for CG. These findings could help policymakers decide on the recruitment and allocation of CWs in community based multi-sectoral intervention programs to improve referral successes especially for OVC.

How should community health workers in fragile contexts be supported: qualitative evidence from Sierra Leone, Liberia and Democratic Republic of Congo

BACKGROUND

Community health workers (CHWs) are critical players in fragile settings, where staff shortages are particularly acute, health indicators are poor and progress towards Universal Health Coverage is slow. Like other health workers, CHWs need support to contribute effectively to health programmes and promote health equity. Yet the evidence base of what kind of support works best is weak. We present evidence from three fragile settings-Sierra Leone, Liberia and Democratic Republic of Congo on managing CHWs, and synthesise recommendations for best approaches to support this critical cadre.

METHODS

We used a qualitative study design to explore how CHWs are managed, the challenges they face and potential solutions. We conducted interviews with decision makers and managers (n = 37), life history interviews with CHWs (n = 15) and reviewed policy documents.

RESULTS

Fragility disrupts education of community members so that they may not have the literacy levels required for the CHW role. This has implications for the selection, role, training and performance of CHWs. Policy preferences about selection need discussion at the community level, so that they reflect community realities. CHWs' scope of work is varied and may change over time, requiring ongoing training. The modular, local and mix of practical and classroom training approach worked well, helping to address gender and literacy challenges and developing a supportive cohort of CHWs. A package of supervision, community support, regular provision of supplies, performance rewards and regular remuneration is vital to retention and performance of CHWs. But there are challenges with supervision, scarcity of supplies, inadequate community recognition and unfulfilled promises about allowances. Clear communication about incentives with facility staff and communities is required as is their timely delivery.

CONCLUSIONS

This is the first study that has explored the management of CHWs in fragile settings. CHWs' interface role between communities and health systems is critical because of their embedded positionality and the trusting relationships they (often) have. Their challenges are aligned to those generally faced by CHWs but chronic fragility exacerbates them and requires innovative problem solving to ensure that countries and communities are not left behind in reforming the way that CHWs are supported.

Barriers to access and organization of primary health care services for rural riverside populations in the Amazon

BACKGROUND

The ways of life in the Amazon are diverse and not widely known. In addition, social inequities, large geographic distances and inadequate health care network noticeably limit access to health services in rural areas. Over the last decades, Brazilian health authorities have implemented fluvial mobile units (FMU) as an alternative to increase access and healthcare coverage. The aim of the study was to identify the strategies of access and utilization of primary health care (PHC) services by assessing the strengths and limitations of the healthcare model offered by the FMU to reduce barriers to services and ensure the right to healthcare.

METHODS

Qualitative and ethnographic research involving participant observation and semi-structured interviews. Data collection consisted of interviews with users and health professionals and the observation of service organization and healthcare delivered by the FMU, in addition to the therapeutic itineraries that determine demand, access and interaction of users with healthcare services.

RESULTS

Primary care is offered by the monthly locomotion of the FMU that serves approximately 20 rural riverside communities. The effectiveness of the actions of the FMU proved to be adequate for conditions such as antenatal care for low-risk pregnancy, which require periodic consultations. However, conditions that require continued attention are not adequately met through the organization of care established in the FMU. The underutilization of the workforce of community health workers and disarrangement between their tasks and those of the rest of the multi-professional team are some of the reasons pointed out, making the healthcare continuity unfeasible within the intervals between the trips of the FMU. From the users' perspective, although the presence of the FMU provides healthcare coverage, the financial burden generated by the pursuit for services persists, since the dispersed housing pattern requires the locomotion of users to reach the mobile unit services as well as for specialized care in the urban centers.

CONCLUSIONS

The implementation of the FMU represents an advance in terms of accessibility to PHC. However, the organization of their activity uncritically replicates the routines adopted in the daily routine of health services located in urban spaces, proving to be inadequate for providing healthcare strategies capable of mitigating social and health inequalities faced by the users.

Is Theory Guiding Our Work? A Scoping Review on the Use of Implementation Theories, Frameworks, and Models to Bring Community Health Workers into Health Care Settings

Community health workers (CHWs) are becoming a well-recognized workforce to help reduce health disparities and improve health equity. Although evidence demonstrates the value of engaging CHWs in health care teams, there is a need to describe best practices for integrating CHWs into US health care settings. The use of existing health promotion and implementation theories could guide the research and implementation of health interventions conducted by CHWs. We conducted a standard 5-step scoping review plus stakeholder engagement to provide insight into this topic. Using PubMed, EMBASE, and Web of Science, we identified CHW intervention studies in health care settings published between 2000 and 2017. Studies were abstracted by 2 researchers for characteristics and reported use of theory. Our final review included 50 articles published between January 2000 and April 2017. Few studies used implementation theories to understand the facilitators and barriers to CHW integration. Those studies that incorporated implementation theories used RE-AIM, intervention mapping, cultural tailoring, PRECEDE-PROCEED, and the diffusion of innovation. Although most studies did not report using implementation theories, some constructs of implementation such as fidelity or perceived benefits were assessed. In addition, studies that reported intervention development often cited specific theories, such as the transtheoretical or health belief model, that helped facilitate the development of their program. Our results are consistent with other literature describing poor uptake and use of implementation theory. Further translation of implementation theories for CHW integration is recommended.

Establishing voluntary certification of community health workers in Arizona: a policy case study of building a unified workforce

BACKGROUND

Community health workers (CHWs) are widely recognized as essential to addressing disparities in health care delivery and outcomes in US vulnerable populations. In the state of Arizona, the sustainability of the workforce is threatened by low wages, poor job security, and limited opportunities for training and advancement within the profession. CHW voluntary certification offers an avenue to increase the recognition, compensation, training, and standardization of the workforce. However, passing voluntary certification legislation in an anti-regulatory state such as Arizona posed a major challenge that required a robust advocacy effort.

CASE PRESENTATION

In this article, we describe the process of unifying the two major CHW workforces in Arizona, promotoras de salud in US-Mexico border communities and community health representatives (CHRs) serving American Indian communities. Differences in the origins, financing, and even language of the population-served contributed to historically divergent interests between CHRs and promotoras. In order to move forward as a collective workforce, it was imperative to integrate the perspectives of CHRs, who have a regular funding stream and work closely through the Indian Health Services, with those of promotoras, who are more likely to be grant-funded in community-based efforts. As a unified workforce, CHWs were better positioned to gain advocacy support from key health care providers and health insurance companies with policy influence. We seek to elucidate the lessons learned in our process that may be relevant to CHWs representing diverse communities across the US and internationally.

CONCLUSIONS

Legislated voluntary certification provides a pathway for further professionalization of the CHW workforce by establishing a standard definition and set of core competencies. Voluntary certification also provides guidance to organizations in developing appropriate training and job activities, as well as ongoing professional development opportunities. In developing certification with CHWs representing different populations, and in particular Tribal Nations, it is essential to assure that the CHW definition is in alignment with all groups and that the scope of practice reflects CHW roles in both clinic and community-based settings. The Arizona experience underscores the benefits of a flexible approach that leverages existing strengths in organizations and the population served.

Telephone or Visit-Based Community Health Worker Care Management for Uncontrolled Diabetes Mellitus: A Longitudinal Study

Community health workers (CHWs) can reduce health disparities for low income patients but type of contact and outcomes has had limited study. Low-income Hispanic primary care patients with hemoglobin A1c [HbA1c] ≥ 9% received care managment (CM) over 6 months classified as: (CM1) telephone only; (CM2) clinic visit but no calls; (CM3) clinic visit with calls; and (CM4) ≥ 2 visits ± calls. Type of CM delivery and time to DM control (HbA1c < 9%) examined in Cox proportional hazards model and more rapid control within 6 months using logistic regression. Models adjusted for demographics, clinical, and health care variables. At baseline, 523 patients had mean HbA1c 10.9% (SD = 1.7%), mean age 57.9 years (SD = 10), 58.5% women, 87.6% Hispanic, and 55.5% uninsured. CM types for patients: 51 (9.8%) CM1; 192 (36.7%) CM2; 44 (8.4%) CM3; and 236 (45.4%) CM4. Median time to HbA1c control was 197 days (95% CI [71, 548]) and 41.5% achieved control within 6 months. Compared with CM1, control was more rapid for CM2 (Hazard ratio [HR] 1.45, 95% CI [1.01, 2.09], p = 0.043) and CM4 but not significant (HR [95% CI] 1.29 [0.91, 1.83], p = 0.15). Adjusted odds of more rapid control within 6 months were twofold higher for CM2 (p = 0.04) and CM4 (p = 0.055), respectively, versus CM1. CM2 did not differ from CM1. DM control was less likely for CM by telephone only than face-to-face in clinic. To benefit vulnerable patients with uncontrolled DM, in-person engagement may be required.

Adapting a health video library for use in Afghanistan: provider-level acceptability and lessons for strengthening operational feasibility

BACKGROUND

Community health workers (CHWs) in Afghanistan are a critical care extender for primary health services, including reproductive, maternal, neonatal, and child health (RMNCH) care. However, volunteer CHWs face challenges including an ever-expanding number of tasks and insufficient time to conduct them. We piloted a health video library (HVL) intervention, a tablet-based tool to improve health promotion and counseling by CHWs. We qualitatively assessed provider-level acceptability and operational feasibility.

METHODS

CHWs implemented the HVL pilot in three rural districts of Balkh, Herat, and Kandahar provinces. We employed qualitative methods, conducting 47 in-depth interviews (IDIs) with male and female CHWs and six IDIs with community health supervisors. We used semi-structured interview guides to explore provider perceptions of program implementation processes and solicit feedback on how to improve the HVL intervention to inform scale-up. We conducted a thematic analysis.

RESULTS

CHWs reported that the HVL increased time efficiencies, reduced work burden, and enhanced professional credibility within their communities. CHWs felt video content and format were accessible for low literacy clients, but also identified challenges to operational feasibility. Although tablets were considered easy-to-use, certain technical issues required continued support from supervisors and family. Charging tablets was difficult due to inconsistent electricity access. Although some CHWs reported reaching most households in their catchment area for visits with the HVL, others were unable to visit all households due to sizeable populations and gender-related barriers, including women's limited mobility.

CONCLUSIONS

The HVL was acceptable and feasible for integration into existing CHW duties, indicating it may improve RMNCH counseling, contributing to increased care-seeking behaviors in Afghanistan. Short-term challenges with technology and hardware can be addressed through continued training and provision of solar chargers. Longer-term challenges, including tablet costs, community coverage, and gender issues, require further consideration with an emphasis on equitable distribution.

Design and sample characteristics of COordinated Oral health Promotion (CO-OP) Chicago: A cluster-randomized controlled trial

COordinated Oral health Promotion (CO-OP) Chicago is a two-arm cluster-randomized trial with a wait-list control. The primary aim is to evaluate the efficacy of an oral health community health worker (CHW) intervention to improve oral health behaviors in low-income, urban children under the age of three years. Exploratory aims will determine cost-effectiveness, and if any CHW intervention impact on child tooth brushing behaviors varies when CHWs are based out of a medical clinic compared to a community setting. This paper describes progress toward achieving these aims. Participating families were recruited from community social service centers and pediatric primary care medical clinics in Cook County, Illinois. Sites were cluster-randomized to CHW intervention or usual services (a wait-list control). The intervention is oral health support from CHWs delivered in four visits to individual families over one year. The trial sample consists of 420 child/caregiver dyads enrolled at the 20 participating sites over 11 months. Participant demographics varied across the sites, but primary outcomes values at baseline did not. Data on brushing frequency, plaque, and other oral health behaviors are collected at three timepoints: baseline, 6-, and 12-months. The primary analysis will assess differences in caregiver-reported child brushing frequency and observed plaque score between the two arms at 12-months. The trial is currently in the active intervention phase. The trial's cluster-randomized controlled design takes a real-world approach by integrating into existing health and social service agencies and collecting data in participant homes. Results will address an important child health disparity. ClinicalTrials.gov identifier: NCT03397589. CLINICAL TRIAL REGISTRATION: University of Illinois at Chicago Protocol Record 2017-1090. National Institutes of Dental & Craniofacial Research of the National Institutes of Health (NIDCR) Protocol Number: 17-074-E. NCT03397589.

Observational stepped-wedge analysis of a community health worker-led intervention for diabetes and hypertension in rural Mexico

OBJECTIVES

There is emerging interest and data supporting the effectiveness of community health workers (CHWs) in non-communicable diseases (NCDs) in low/middle-income countries (LMICs). This study aimed to determine whether a CHW-led intervention targeting diabetes and hypertension could improve markers of clinical disease control in rural Mexico.

DESIGN AND SETTING

A prospective observational stepped-wedge study was conducted across seven communities in rural Chiapas, Mexico from March 2014 to April 2018.

PARTICIPANTS

149 adults with hypertension and/or diabetes.

INTERVENTION

This study was conducted in the context of the programmatic roll-out of an accompaniment-based CHW-led intervention designed to complement comprehensive primary care for adults with diabetes and/or hypertension. Implementation occurred sequentially at 3-month intervals with point-of-care data collected at baseline and every 3 months thereafter for 12 months following roll-out in all communities.

OUTCOME MEASURES

Primary outcomes were glycated haemoglobin (HbA1c) and systolic blood pressure (SBP), overall and stratified by baseline disease control. We conducted an individual-level analysis using mixed effects regression, adjusting for time, cohort and clustering at the individual and community levels.

RESULTS

Among patients with diabetes, the CHW-led intervention was associated with a decrease in HbA1c of 0.35%; however, CIs were wide (95% CI -0.90% to 0.20%). In patients with hypertension, there was a 4.7 mm Hg decrease in SBP (95% CI -8.9 to -0.6). In diabetic patients with HbA1c ≥9%, HbA1c decreased by 0.96% (95% CI -1.69% to -0.23%), and in patients with uncontrolled hypertension, SBP decreased by 10.2 mm Hg (95% CI -17.7 to -2.8).

CONCLUSIONS

We found that a CHW-led intervention resulted in clinically meaningful improvement in disease markers for patients with diabetes and hypertension, most apparent among patients with hypertension and patients with uncontrolled disease at baseline. These findings suggest that CHWs can play a valuable role in supporting NCD management in LMICs.

TRIAL REGISTRATION NUMBER

NCT02549495.

A multistakeholder evaluation of Lazos Hispanos: An application of a community-based participatory research conceptual model

The goal of Lazos Hispanos is to enhance the health and well-being of the Latinx community through promotoras, who connect community members with service providers for multiple health and social needs. A community-based participatory research conceptual model framed the multimethod evaluation of promotoras, service providers, and community participants at baseline and at the 1-year follow up. The promotoras increased their self-efficacy and knowledge, felt a strong sense of commitment to the community, viewed themselves as a bridge between participants and providers, and felt empowered by their new role. Service providers valued the promotoras as their ambassadors in the community and Lazos Hispanos as central to connecting service providers, promotoras, and community members; they noted that this collaboration increased their accountability with the Latinx community. This multistakeholder evaluation highlights the depth of positive changes achieved during the first year and the challenges of a community-embedded project and the benefits and possibilities of calling upon theoretically informed evaluation models.

An Emerging Model for Community Health Worker-Based Chronic Care Management for Patients With High Health Care Costs in Rural Appalachia

Community health workers (CHWs) can improve patients' health by providing them with ongoing behavioral support during the health care experience, and they help decrease health care costs, especially among patients whose starting costs are high and among underserved and minority populations. We developed a CHW-based care model with the aim of improving outcomes and lowering costs for high-risk diabetes patients in rural Appalachia. Enrolled patients experienced a mean decrease in HbA1c of 2.4 percentage points, and 60% or more of patients with diabetes lowered their blood glucose between baseline and 6 to 12 months after enrollment. As health care providers and patients became familiar with this model of care management, enrollment in the program accelerated.

Decentralization in India's health sector: insights from a capacity building intervention in Karnataka

The Government of India has adopted decentralization/devolution as a vehicle for promoting greater equity and supporting people-centred, responsive health systems. This article reports on our year-long intervention project in Karnataka, South India, and articulates insights of both practical and theoretical significance. It explores the intersection of the political goal of enhanced local level autonomy and the programmatic goal of more responsive health service delivery. Focusing on the Village Health, Sanitation and Nutrition Committees (VHSNCs) set up under the National (Rural) Health Mission (NHM), the project set out to explore the extent to which political and programmatic decentralization are functional at the village level; the consonance between the design and objectives of decentralization under NHM; and whether sustained supportive capacity building can create the necessary conditions for more genuine decentralization and effective collaboration between village-level functionaries. Our methodology uses exploratory research with Panchayati Raj Institution (PRI) members and functionaries of the Health Department, followed by a year-long capacity building programme aimed at strengthening co-ordination and synergy between functionaries responsible for political and programmatic decentralization. We find that health sector decentralization at the village level in Karnataka is at risk due to lack of convergence between political and programmatic arms of government. This is compounded by problems inherent in the design of the decentralization mechanism at the district level and below. Sustained capacity building of the VHSNC can contribute to more effective decentralization, as part of a larger package of interventions that (1) provides for financial and other resources from the district (or higher) level to political and programme functionaries at the periphery; (2) helps the functionaries to develop a shared understanding of the salience of the VHSNC in addressing the health needs of their community; and (3) supports them to collaborate effectively to achieve clearly articulated outcomes.

Listening to the Voices of Community Health Workers: A Multilevel, Culture-Centered Approach to Overcoming Structural Barriers in U.S. Latinx Communities

Community Health Workers (CHWs) are often incorporated into efforts to reduce health disparities for vulnerable populations. However, their voices are rarely the focus of research when considering how to increase their job effectiveness and sustainability. The current study addresses this gap by privileging the voices of 28 CHWs who work with Latinx communities in Nebraska through in-depth, semistructured interviews. Using a multilevel, Culture-Centered Approach (CCA) to Health Communication, we identified two key structural communication issues: (a) increasing language accommodation and (b) increasing (and stabilizing) network integration across three ecological levels of health behavior (individual, microsystem, and exosystem). This study shows the uniquely valuable perspective that CHWs have as they navigate hierarchical health care structures and community cultures to meet the needs of their Latinx clients. Findings suggest that CHWs should be included in health care organization and policy discussions to reduce health disparities for Latinx populations.

Toward an institutional perspective on social capital health interventions: lay community health workers as social capital builders

This article argues that social capital health research should move beyond a mere focus on social cohesion and network perspectives to integrate an institutional approach into the development of social capital health interventions. An institutional perspective, which is unique in its emphasis on linking social capital in addition to the bonding and bridging forms, contextualises social capital, allowing researchers to confront the complexity of social relationships. This perspective allows for the construction of interventions that draw on the resources of diverse actors, particularly the state. One intervention strategy with the potential to create community linkages involves lay community health workers (LCHWs), individuals who are trained to perform a variety of health-related functions but lack a formal professional health education. This article begins with a review of the institutional social capital-building literature. It then goes on to briefly review the social capital and health literature and discuss the state of intervention research. Thereafter, it describes LCHWs and discusses studies that have utilised LCHWs to tackle community health problems. In doing so, this article presents an institutional-based systematic framework for how LCHWs can build social capital, including a discussion of the ways in which LCHWs can successfully promote bonding, bridging and linking social capital.

Rural-Urban Differences in Roles and Support for Community Health Workers in the Midwest

The Patient Protection and Affordable Care Act supports the integration of community health workers (CHWs) into the health care workforce, but little is known about integration and current roles of CHWs among employers in community settings. This analysis of 97 employers described the roles of CHWs in Nebraska and found significant differences between CHWs practicing in rural and urban areas in organization types employing CHWs, funding sources, and minority populations served. The findings suggest that the utility of CHWs is widely recognized among employers, but deliberate support will be needed to better define the roles of CHWs to meet the needs of the increasingly diverse demographic.

Physician and nurse practitioner perceptions of social worker and community health worker roles in primary care practices caring for frail elders: Insights for social work

Social workers (SW) and community health workers (CHW) have emerged as key workforce personnel in efforts to care for elders in the U.S. However, little is known about the presence and roles of SW and CHW in primary care practices. This paper presents findings from a nationally representative survey of geriatrics and primary care practices. Physician and nurse practitioner clinicians were randomly selected within practices, stratifying by practice staffing and presence/absence of geriatric clinicians; our final sample for this analysis included 341 practices. Key findings include: reported challenges in meeting the social service needs of elders, underutilization of SW, and fuller utilization of social work competencies in practices in which both SW and CHW were present. These findings offer a unique perspective of SW on interprofessional teams and have implications for the future of the profession.

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

OBJECTIVE

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Responding to the health needs of migrant farm workers in South Africa: Opportunities and challenges for sustainable community-based responses

Reflecting global trends, migrant farm workers in South Africa experience challenges in accessing healthcare. On the commercial farms in Musina, a sub-district bordering Zimbabwe, Medécins sans Frontières and the International Organization for Migration both implemented migration-aware community-based programmes that included the training of community-based healthcare workers, to address these challenges. Using qualitative data, this paper explores the experiences that migrant farm workers, specifically those involved in the programmes, had of these interventions. A total of 79 semi-structured interviews were completed with migrant farm workers, farm managers, NGO employees and civil servants between January 2017 and July 2018. These data were supplemented by a review of grey and published literature, as well as observation and field notes. Findings indicate that participants were primarily positive about the interventions. However, since the departure of both Medécins sans Frontières and the International Organization for Migration, community members have struggled to sustain the projects and the structural differences between the two programmes have created tensions. This paper highlights the ways in which local interventions that mobilise community members can improve the access that rural, migrant farming communities have to healthcare. However, it simultaneously points to the ways in which these interventions are unsustainable given the realities of non-state interventions and the fragmented state approach to community-based healthcare workers. The findings presented in this paper support global calls for the inclusion of migration and health in government policy making at all levels. However, findings also capture the limitations of community-based interventions that do not recognise community-based healthcare workers as social actors and fail to take into account their motivations, desires and need for continued supervision. As such, ensuring that the ways in which migration and health are included in policy making are sustainable emerges as a necessary element to be included in global calls.

Strengthening the community health worker programme for health improvement through enhancing training, supervision and motivation in Wakiso district, Uganda

OBJECTIVE

The objective of the project was to strengthen the community health worker (CHW) programme in Ssisa sub-county, Wakiso district, Uganda by providing a coherent, structured and standardized training, supervision and motivation package so as to enhance their performance.

RESULTS

The project trained all 301 CHWs who received non-financial incentives of t-shirts, gumboots and umbrellas, and 75 of them received solar equipment to support lighting their houses and charging phones. Twenty-four of the CHWs who had coordination roles received additional training. Three motorcycles were also provided to enhance transportation of CHW coordinators during their work including supervision. By end of the project, the CHWs had conducted 40,213 household visits, carried out health education sessions with 127,011 community members, and treated 19,387 children under 5 years of age. From the project evaluation, which used both quantitative and qualitative methods, 98% of the CHWs reported having improved competence in performance of their roles. In addition, the CHWs were highly motivated to do their work. The motorcycles were instrumental in supporting the work of CHW coordinators including monthly collection of reports and distribution of medicines. The project demonstrated that by improving training, supervision and motivation, performance of CHW programmes can be enhanced.

Using Evidence to Drive Impact: Developing the FP Goals Impact Matrix

When designing a family planning (FP) strategy, decision‐makers can choose from a wide range of interventions designed to expand access to and develop demand for FP. However, not all interventions will have the same impact on increasing modern contraceptive prevalence (mCP). Understanding the existing evidence is critical to planning successful and cost‐effective programs. The Impact Matrix is the first comprehensive summary of the impact of a full range of FP interventions on increasing mCP using a single comparable metric. It was developed through an extensive literature review with input from the wider FP community, and includes 138 impact factors highlighting the range of effectiveness observed across categories and subcategories of FP interventions. The Impact Matrix is central to the FP Goals model, used to project scenarios of mCP growth that help decision‐makers set realistic goals and prioritize investments. Development of the Impact Matrix, evidence gaps identified, and the contribution to FP Goals are discussed.

Effectiveness of a health belief model intervention using a lay health advisor strategy on mouth self-examination and cancer screening in remote aboriginal communities: A randomized controlled trial

OBJECTIVE

Oral cancers caused by chewing betel nuts have a poor prognosis. Using a lay health advisor (LHA) can increase access to health care among underprivileged populations. This study evaluated a health belief model (HBM) intervention using LHAs for oral cancer screening (OCS) and mouth self-examination (MSE) in remote aboriginal communities.

METHODS

The participants were randomly assigned to intervention (IG; n = 171) and control groups (CG; n = 176). In the IG, participants received a three-chapter one-on-one teaching course from LHAs, whereas those in the CG received only a leaflet.

RESULTS

The IG participants were 2.04 times more likely to conduct a monthly MSE than those in the CG (95% confidence interval: 1.31-3.17) and showed significantly higher self-efficacy levels toward OSC and MSE (β = 0.53 and 0.44, effect size = 0.33 and 0.25, respectively) and a lower barrier level for OSC (β = -1.81, effect size = -0.24).

CONCLUSION

The LHA intervention had a significantly positive effect on MSE, strengthening self-efficacy and reducing barriers to OCS among aboriginal populations.

PRACTICE IMPLICATIONS

The effectiveness of the clinical treatment of underprivileged group can be improved through early diagnosis, which can be achieved using LHAs to reduce barriers to OSC.

Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation

BACKGROUND

We studied the impact of Community Outreach and Patient Empowerment (COPE) intervention to support Community Health Representatives (CHR) on the clinical outcomes of patients living with diabetes in the Navajo Nation extending into the States of Arizona, Utah, and New Mexico. The COPE intervention integrated CHRs into healthcare teams by providing a structured approach to referrals and home visits.

METHODS

We abstracted routine clinical data from the Indian Health Service's information system on individuals with diabetes mellitus seen at participating clinical sites from 2010 to 2014. We matched 173 COPE participants to 2880 patients with similar demographic and clinical characteristics who had not participated in COPE. We compared the changes in clinical outcomes between the two groups using linear mixed models.

RESULTS

Over the four years of the study, COPE patients had greater improvements in glycosylated hemoglobin (- 0.56%) than non-COPE participants (+ 0.07%) for a difference in differences of 0.63% (95% confidence interval (CI): 0.50, 0.76). Low-density lipoprotein fell more steeply in the COPE group (- 10.58 mg/dl) compared to the non-COPE group (- 3.18 mg/dl) for a difference in differences of 7.40 mg/dl (95%CI: 2.00, 12.80). Systolic blood pressure increased slightly more among COPE (2.06 mmHg) than non-COPE patients (0.61 mmHg). We noted no significant change for body mass index in either group.

CONCLUSION

Structured outreach by Community Health Representatives as part of an integrated care team was associated with improved glycemic and lipid levels in the target Navajo population.

TRIAL REGISTRATION

Trial registration: NCT03326206. Registered 31 October 2017 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03326206.

mHealth tool to improve community health agent performance for child development: study protocol for a cluster-randomised controlled trial in Peru

INTRODUCTION

Cultivating child health and development creates long-term impact on the well-being of the individual and society. The Amazon of Peru has high levels of many risk factors that are associated with poor child development. The use of 'community health agents' (CHAs) has been shown to be a potential solution to improve child development outcomes. Additionally, mobile information and communication technology (ICT) can potentially increase the performance and impact of CHAs. However, there is a knowledge gap in how mobile ICT can be deployed to improve child development in low resource settings.

METHODS AND ANALYSIS

The current study will evaluate the implementation and impact of a tablet-based application that intends to improve the performance of CHAs, thus improving the child-rearing practices of caregivers and ultimately child health and development indicators. The CHAs will use the app during their home visits to record child health indicators and present information, images and videos to teach key health messages. The impact will be evaluated through an experimental cluster randomised controlled trial. The clusters will be assigned to the intervention or control group based on a covariate-constrained randomisation method. The impact on child development scores, anaemia and chronic malnutrition will be assessed with an analysis of covariance. The secondary outcomes include knowledge of healthy child-rearing practices by caregivers, performance of CHAs and use of health services. The process evaluation will report on implementation outcomes. The study will be implemented in the Amazon region of Peru with children under 4. The results of the study will provide evidence on the potential of a mHealth tool to improve child health and development indicators in the region.

ETHICS AND DISSEMINATION

The study received approval from National Hospital 'San Bartolome' Institutional Ethics Committee on 8 November 2018 (IRB Approval #15463-18) and will be disseminated via peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ISRCTN43591826.

The National Village Health Guide Scheme in India: lessons four decades later for community health worker programs today and tomorrow

BACKGROUND

Based in part on the success of India's early community health worker (CHW) programs, the Government of India launched in 1977 a national CHW scheme-the Village Health Guides (VHGs)-to provide preventive, promotive, and basic curative care to rural populations. Although this program had promising origins in smaller demonstration projects, it failed to deliver the hoped-for impact at scale and was abandoned. Based on extensive evidence and experience, the World Health Organization and the World Health Assembly have strongly endorsed the value of national CHW programs and their integration into national health systems. Surprisingly, given the scale and importance of the VHG program and its pioneering nature as a national CHW program, little has been published describing this experience. This article is the second in a series that focuses on critical issues that face the effectiveness of large-scale CHW programs.

CASE PRESENTATION

Several systemic factors emerge as main contributors to the failure of the VHG Scheme, namely, a lack of support from the formal health sector, an overly hasty implementation of the scheme, and poor communication between the government and health centers about the role of the VHGs. The remuneration structure and the VHG selection process were at the root of the program's shortcomings at the implementation level.

CONCLUSION

National CHW schemes are an increasingly important tool for achieving universal health coverage and ending maternal and child deaths by 2030. Although the VHG Scheme was initiated over 40 years ago, the lessons described in this case highlight important considerations to help both current and future large-scale CHW programs avoid the same pitfalls.

Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol

BACKGROUND

Over the past decade, prevalence of maternal and child morbidity and mortality in Togo, particularly in the northern regions, has remained high despite global progress. The causes of under-five child mortality in Togo are diseases with effective and low-cost prevention and/or treatment strategies, including malaria, acute lower respiratory infections, and diarrheal diseases. While Togo has a national strategy for implementing the integrated management of childhood illness (IMCI) guidelines, including a policy on integrated community case management (iCCM), challenges in implementation and low public sector health service utilization persist. There are critical gaps to access and quality of community health systems throughout the country. An integrated facility- and community-based initiative, the Integrated Community-Based Health Systems Strengthening (ICBHSS) initiative, seeks to address these gaps while strengthening the public sector health system in northern Togo. This study aims to evaluate the effect and implementation strategy of the ICBHSS initiative over 48 months in the catchment areas of 21 public sector health facilities.

METHODS

The ICBHSS model comprises a bundle of evidence-based interventions targeting children under five, women of reproductive age, and people living with HIV through (1) community engagement and feedback; (2) elimination of point-of-care costs; (3) proactive community-based IMCI using community health workers (CHWs) with additional services including family planning, HIV testing, and referrals; (4) clinical mentoring and enhanced supervision; and (5) improved supply chain management and facility structures. Using a pragmatic type II hybrid effectiveness-implementation study, we will evaluate the ICBHSS initiative with two primary aims: (1) determine effectiveness through changes in under-five mortality rates and (2) assess the implementation strategy through measures of reach, adoption, implementation, and maintenance. We will conduct a mixed-methods assessment using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. This assessment consists of four components: (1) a stepped-wedge cluster randomized control trial using a community-based household survey, (2) annual health facility assessments, (3) key informant interviews, and (4) costing and return-on-investment assessments for each randomized cluster.

DISCUSSION

Our research is expected to contribute to continuous quality improvement initiatives, optimize implementation factors, provide knowledge regarding health service delivery, and accelerate health systems improvements in Togo and more broadly.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03694366 , registered 3 October 2018.

Does task delegation to non-physician health professionals improve quality of diabetes care? Results of a scoping review

Objective

As a result of unhealthy lifestyles, reduced numbers of healthcare providers are having to deal with an increasing number of diabetes patients. In light of this shortage of physicians and nursing staff, new concepts of care are needed. The aim of this scoping review is to review the literature and examine the effects of task delegation to non-physician health professionals, with a further emphasis on inter-professional care.

Research design and methods

Systematic searches were performed using the PubMed, Embase and Google Scholar databases to retrieve papers published between January 1994 and December 2017. Randomised/non-randomised controlled trials and studies with a before/after design that described the delegation of tasks from physicians to non-physicians in diabetes care were included in the search. This review is a subgroup analysis that further assesses all the studies conducted using a team-based approach.

Results

A total of 45 studies with 12,092 patients met the inclusion criteria. Most of the interventions were performed in an outpatient setting with type-2 diabetes mellitus patients. The non-physician healthcare professionals involved in the team were nurses, pharmacists, community health workers and dietitians. Most studies showed significant improvements in glycaemic control and high patient satisfaction, while there were no indications that the task delegation affected quality of life scores.

Conclusions

The findings of the review suggest that task delegation can provide equivalent glycaemic control and potentially lead to an improvement in the quality of care. However, this review revealed a lack of clinical endpoints, as well as an inconsistency between the biochemical outcome parameters and the patient-centred outcome parameters. Given the vast differences between the individual healthcare systems used around the world, further high-quality research with an emphasis on long-term outcome effects and the expertise of non-physicians is needed.

Development of a gender-relevant tobacco cessation intervention for women in Brazil-an intervention mapping approach to planning

The purpose of this article is to describe the development of a theory-based, culturally and gender-relevant Community Health Worker (CWH)-led tobacco cessation intervention for low-income Brazilian women who augments the tobacco cessation program offered through the public health system using Intervention Mapping (IM). We began with the establishment of a network of representatives from different segments of society followed by comprehensive needs assessments. We then established a logical planning process that was guided by a theoretical framework (Social Cognitive Theory) and existing evidence-based tobacco cessation programs, taking into account socio-political context of a universal health care system. Given the gender-relevance of our intervention and the importance of social support in tobacco cessation among women, we chose an intervention that would be delivered within the public health system but augmented by CHWs that would be trained in behavior change by researchers. One of major advantages of utilizing IM was that decisions were made in a transparent and supportive manner with involvement of all stakeholders throughout the process. Despite the fact that this process is very taxing on researchers and the health care system as it takes time, resources and negotiation skills, it builds trust and promotes ownership which can assure sustainability.

Cardiovascular risk factor reduction by community health workers in rural India: A cluster randomized trial

BACKGROUND

There is a need to identify and test low-cost approaches for cardiovascular disease (CVD) risk reduction that can enable health systems to achieve such a strategy.

OBJECTIVE

Community health workers (CHWs) are an integral part of health-care delivery system in lower income countries. Our aim was to assess impact of CHW based interventions in reducing CVD risk factors in rural households in India.

METHODS

We performed an open-label cluster-randomized trial in 28 villages in 3 states of India with the household as a unit of randomization. Households with individuals at intermediate to high CVD risk were randomized to intervention and control groups. In the intervention group, trained CHWs delivered risk-reduction advice and monitored risk factors during 6 household visits over 12 months. Households in the non-intervention group received usual care. Primary outcomes were a reduction in systolic BP (SBP) and adherence to prescribed BP lowering drugs.

RESULTS

We randomized 2312 households (3261 participants at intermediate or high risk) to intervention (1172 households) and control (1140 households). At baseline prevalence of tobacco use (48.5%) and hypertension (34.7%) were high. At 12 months, there was significant decline in SBP (mmHg) from baseline in both groups- controls 130.3 ± 21 to 128.3 ± 15; intervention 130.3 ± 21 to 127.6 ± 15 (P < .01 for before and after comparison) but there was no difference between the 2 groups at 12 months (P = .18). Adherence to antihypertensive drugs was greater in intervention vs control households (74.9% vs 61.4%, P = .001).

CONCLUSION

A 12-month CHW-led intervention at household level improved adherence to prescribed drugs, but did not impact SBP. To be more impactful, a more comprehensive solution that addresses escalation and access to useful therapies is needed.

Effectiveness of a behavioural intervention involving regular weighing and feedback by community midwives within routine antenatal care to prevent excessive gestational weight gain: POPS2 randomised controlled trial

OBJECTIVES

To assess the effectiveness of a brief behavioural intervention based on routine antenatal weighing to prevent excessive gestational weight gain (defined by US Institute of Medicine).

DESIGN

Randomised controlled trial.

SETTING

Antenatal clinic in England.

PARTICIPANTS

Women between 10⁺⁰ and 14⁺⁶ weeks gestation, not requiring specialist obstetric care.

INTERVENTIONS

Participants were randomised to usual antenatal care or usual care (UC) plus the intervention. The intervention involved community midwives weighing women at antenatal appointments, setting maximum weight gain limits between appointments and providing brief feedback. Women were encouraged to monitor and record their own weight weekly to assess their progress against the maximum limits set by their midwife. The comparator was usual maternity care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Excessive gestational weight gain, depression, anxiety and physical activity.

RESULTS

Six hundred and fifty-six women from four maternity centres were recruited: 329 women were randomised to the intervention group and 327 to UC. We found no evidence that the intervention decreased excessive gestational weight gain. At 38 weeks gestation, the proportions gaining excessive gestational weight were 27.6% (81/305) versus 28.9% (90/311) (adjusted OR 0.84, 95% CI: 0.53 to 1.33) in the intervention and UC group, respectively. There were no significant difference between the groups in anxiety or depression scores (anxiety: adjusted mean -0.58, 95% CI:-1.25 to -0.8; depression: adjusted mean -0.60, 95% CI:-1.24 to -0.05). There were no significant differences in physical activity scores between the groups.

CONCLUSIONS

A behavioural intervention delivered by community midwives involving routine weighing throughout pregnancy, setting maximum weight gain targets and encouraging women to weigh themselves each week to check progress did not prevent excessive gestational weight gain. There was no evidence of psychological harm.

TRIAL REGISTRATION NUMBER

ISRCTN67427351.

A Collaborative Family Planning Program in Rural Uganda Utilizing Community Health Workers

In 2015, a household survey was conducted in rural eastern Ugandan villages to determine fertility rate, prevalence of childbirth in the hospital setting, use of and unmet need for modern contraception. There remains a high fertility rate as well as high unmet need for contraception in the surveyed villages. However, Uganda Village Project's community health worker-based family planning program has shown promise to address these concerns.

Performance of community health workers and associated factors in a rural community in Wakiso district, Uganda

Background

Community health workers (CHWs) continue to play a crucial role in supporting health service delivery globally. Several CHW programmes around the world face vast challenges which affect their performance.

Objectives

This study assessed the performance of CHWs and associated factors in a rural community in Wakiso district, Uganda.

Methods

This was a cross-sectional study that employed a structured questionnaire to collect quantitative data from 201 CHWs in Wakiso district. The main study variable was CHW performance based on various roles carried out by CHWs. Multivariable logistic regression in STATA was used to establish the predictors of CHW performance.

Results

Only 40 (19.9%) of the CHWs had a high performance which was associated with having attended additional / refresher trainings [AOR=12.79 (95% CI: 1.02–159.26)], and having attained secondary level education and above [AOR=3.93 (95% CI: 1.17–13.24)]. CHWs who were married [AOR=0.29 (95% CI: 0.09–0.94)] were less likely to perform highly. Among CHWs who had received essential medicines for treatment of childhood illnesses, the majority 90.3% (112/124) had experienced stock-outs in the 6 months preceding the study. Despite the majority of CHWs, 198 (98.5%), stating that being motivated was very important in their work, only 91 (45%) said that they were motivated.

Conclusion

Additional / refresher trainings are necessary to enhance performance of CHWs. In addition, level of education should be considered while selecting CHWs. The health system challenges of low motivation of CHWs as well as stock-out of medicines need to be addressed to support their work.