Project ECHO Brain Health: Assessing the Impact of a Pilot Program to Promote Self-Efficacy Among Community Health Workers

This mixed-methods study sought to examine the impact of the Project ECHO Brain Health program on participating community health workers' (CHWs') self-efficacy to address dementia, promote brain health, and advocate for research among Latinx South Texas communities. Using an explanatory sequential design, quantitative data collected from pre- and post-program surveys were analyzed to inform the collection of qualitative data, followed by an interpretation of all findings to better understand the impact of the program on self-efficacy. Pre- and post-surveys were collected from 25 CHWs, 13 of whom later participated in individual interviews. There was a statistically significant increase in mean self-efficacy scores between the pre- and post-surveys among participants. Three categories reflecting the experiences of participants were identified from the qualitative data: addressing training needs; impact on CHWs and their practice; and community of learning. The findings suggest that Project ECHO Brain Health program is a timely intervention that may facilitate increased self-efficacy among CHWs as they navigate the impacts of dementia in their communities.

Exploring the learning preferences of farmworker-serving community health workers

Community health workers are responsible for finding, processing, and transferring health information to communities with limited access to health-related resources, including farmworkers. This paper is the culmination of an undergraduate student research project to explore the learning processes and preferences of farmworker-serving community health workers in the USA. The project was designed for students from farmworker or agricultural backgrounds at two North Carolina universities and was supported by a North Carolina Department of Health and Human Services workforce development grant. Semi-structured interviews were conducted, in person and virtually, with a convenience sample of 17 current and former community health workers. The interview data were analysed thematically and identified a preference for a combination of learning styles, with visual and hands-on learning being the most preferred. Community health workers also identified the importance of learning preferences in relation to their responsibilities as health educators. This study provides librarians, along with public health and medical professionals, with useful information about learning preferences to inform the creation of new and varied learning materials for community health workers.

Factors associated with Community Health Agents' knowledge about tuberculosis

OBJECTIVE

To analyze the factors associated with the knowledge of Community Health Agents (ACS) about tuberculosis.

METHODS

A cross-sectional study was conducted with 110 ACS. A questionnaire was used to assess knowledge about pulmonary tuberculosis (component 1) and the work functions of ACS in the National Tuberculosis Control Program (component 2). The level of knowledge, according to the scores converted into a scale of 0 to 100, was classified as: 0-50% (low), 51-75% (medium), and over 75% (high). Multiple regression was used in the analysis of associated factors.

RESULTS

The global score (average of the scores of components 1 and 2) median knowledge was 68.6%. Overall knowledge about tuberculosis was positively associated with the length of professional experience, having received training on tuberculosis, and access to the tuberculosis guide/handbook.

CONCLUSIONS

Investments in training and capacity-building strategies for ACS will contribute to increasing these professionals' knowledge, resulting in greater success in tuberculosis control.

A qualitative study on the adaptation of community programmes for the promotion of early detection and health-seeking of perinatal depression in Nepal

BACKGROUND

Despite the high burden of perinatal depression in Nepal, the detection rate is low. Community-based strategies such as sensitization programmes and the Community Informant Detection Tool (CIDT) have been found to be effective in raising awareness and thus promoting the identification of mental health problems. This study aims to adapt these community strategies for perinatal depression in the Nepalese context.

METHODS

We followed a four-step process to adapt the existing community sensitization program manual and CIDT. Step 1 included in-depth interviews with women identified with perinatal depression (n=36), and focus group discussions were conducted with health workers trained in community mental health (n=13), female community health volunteers (FCHVs), cadre of Nepal government for the prevention and promotion of community maternal and child health (n=16), and psychosocial counsellors (n=5). We explored idioms and understanding of depression, perceived causes, and possible intervention. Step 2 included draft preparation based on the qualitative study. Step 3 included a one-day workshop with the psychosocial counsellors (n=2) and health workers (n=12) to assess the understandability and comprehensiveness of the draft and to refine the content. A review of the CIDT and community sensitization program manual by a psychiatrist was performed in Step 4.

RESULTS

The first step led to the content development for the CIDT and community sensitization manual. Multiple stakeholders and experts reviewed and refined the content from the second to fourth steps. Idioms of depression and commonly cited risk factors were incorporated in the CIDT. Additionally, myths of perinatal depression and the importance of the role of family were added to the community sensitization manual.

CONCLUSION

Both the CIDT and community sensitization manual are grounded in the local context and are simple, clear, and easy to understand.

Being both a grandmother and a health worker: experiences of community-based health workers in addressing adolescents' sexual and reproductive health needs in rural Zambia

INTRODUCTION

Community-based health workers (CBHWs) possess great potential to be the missing link between the community and the formal health system for improving adolescents' access to sexual and reproductive health and rights (SRHR) information and services. Yet, their role in addressing adolescents' SRHR within the context of the community-based health system has received very little attention. This paper analyses how CBHWs experience and perceive their role in addressing adolescents' SRHR needs in rural Zambia, including the possible barriers, dilemmas, and opportunities that emerge as CBHWs work with adolescents.

METHODS

Between July and September 2019, we conducted 14 in-depth interviews with 14 community-based health workers recruited across 14 different communities in the central province of Zambia. The interviews were focused on eliciting their experiences and perceptions of providing sexual and reproductive health services to adolescents. Charmaz's grounded theory approach was used for the analysis.

RESULTS

We present the core category "being both a grandmother and a CBHW", which builds upon four categories: being educators about sexual and reproductive health; being service providers and a link to SRHR services; being advocates for adolescents' SRHR; and reporting sexual violence. These categories show that CBHWs adopt a dual role of being part of the community (as a grandmother) and part of the health system (as a professional CBHW), in order to create/maximise opportunities and navigate challenges.

CONCLUSION

Community-based health workers could be key actors providing context-specific comprehensive SRHR information and services that could span all the boundaries in the community-based health system. When addressing adolescents SRHR, playing dual roles of being both a grandmother and a professional CBHW were sometimes complimentary and at other times conflicting. Additional research is required to understand how to improve the role of CBHWs in addressing adolescents and young people's sexual and reproductive health.

Examining global Indigenous community wellness worker models: a rapid review

BACKGROUND

There is a growing interest in employing community wellness worker models in Indigenous populations to address inequities in healthcare access and outcomes, concerns about shortage in health and mental health human resources, and escalating burden of chronic and complex diseases driving significant increase in health services demand and costs. A thorough review of Indigenous community wellness worker models has yet to be conducted. This rapid review sought to outline the characteristics of a community wellness worker model in Indigenous contexts across the globe, detailing factors shaping implementation challenges and success.

METHODS

A rapid review of the international peer-reviewed and grey literature of OVID Medline, Global Index Medicus, Google, and Google Scholar was conducted from January to June 2022 for Indigenous community wellness/mental health worker models and comparative models. Articles were screened and assessed for eligibility. From eligible articles, data pertaining to study design and sample; description of the program, service, or intervention; model development and implementation; terminology used to describe workers; training features; job roles; funding considerations; facilitators and barriers to success; key findings; outcomes measured; and models or frameworks utilized were extracted. Data were synthesized by descriptive and pattern coding.

RESULTS

Twenty academic and eight grey literature articles were examined. Our findings resulted in four overarching and interconnected themes: (1) worker roles and responsibilities; (2) worker training, education, and experience; (3) decolonized approaches; and (4) structural supports.

CONCLUSION

Community wellness worker models present a promising means to begin to address the disproportionately elevated demand for mental wellness support in Indigenous communities worldwide. This model of care acts as a critical link between Indigenous communities and mainstream health and social service providers and workers fulfill distinctive roles in delivering heightened mental wellness supports to community members by leveraging strong ties to community and knowledge of Indigenous culture. They employ innovative structural solutions to bolster their efficacy and cultivate positive outcomes for service delivery and mental wellness. Barriers to the success of community wellness worker models endure, including power imbalances, lack of role clarity, lack of recognition, mental wellness needs of workers and Indigenous communities, and more.

Motivational interviewing experiences from a community health worker-led HIV prevention and care intervention in rural Uganda: a qualitative study

Motivational Interviewing (MI) and Community Health Workers (CHWs) are increasingly utilized in global settings to improve HIV outcomes, yet research exploring implementation strategies using MI and CHWs is lacking. We examined the experiences of CHWs and their clients in a counseling intervention which used MI-informed counseling to increase engagement in HIV prevention and treatment. This study was nested within the mLAKE cluster-randomized trial in a high HIV prevalence fishing community in rural Rakai District, Uganda. We conducted in-depth interviews with purposively-sampled CHWs (n = 8) and clients (n = 51). Transcripts were analyzed thematically to characterize CHWs' implementation of the intervention. Main themes identified included use of specific MI strategies (including evocation, guidance towards positive behavior change, active listening, and open-ended questions), and MI spirit (including collaboration, power-sharing, trust, and non-judgmental relationship building). Through these specific MI mechanisms, CHWs supported client behavior change to facilitate engagement with HIV services. This study provides evidence from a low-resource setting that CHWs with no previous experience in MI can successfully implement MI-informed counseling that is well-received by clients. CHW-led MI-informed counseling appears to be a feasible and effective approach to increase uptake of HIV prevention and care services in low-resource, HIV endemic regions.

"I pray to God that greed never sets in": Community health workers' reflections on "care" during the Covid-19 pandemic

BACKGROUND

Care provision received renewed attention during the Covid-19 pandemic as several healthcare providers vied for the coveted title of "frontline warrior" while they struggled to provide care efficiently under varying health system constraints. While several studies on the health workforce during the pandemic highlighted their difficulties, there is little reflection on what "care" or "caring" itself meant specifically for community health workers (CHWs) as they navigated different community and health systems settings. The aim of the study was to examine CHWs' care-giving experiences during the pandemic.

METHODS

Twenty narrative interviews with CHWs including ASHAs (Accredited Social Health Activists) and ANMs (Auxiliary Nurse Midwives) were conducted in different states between July and December 2020.

RESULTS

Our findings highlight the moral, affectual, and relational dimensions of care in the CHWs' engagement with their routine and Covid-19 related services, as well as the "technical" aspects of it. In this article, we argue that these two aspects are, in fact, enmeshed in complex ways. CHWs extend this moral understanding not just to their work, but also to their relationship with the health system and the government, as they express a deep sense of neglect and the lack of "being cared for" by the health system.

CONCLUSION

CHWs' experiences demand a more nuanced understanding of the ethics of care or caring that challenges the binaries between the "technical" and moral aspects of care.

Opening up the 'black-box': what strategies do community mental health workers use to address the social dimensions of mental health?

PURPOSE

Community-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India.

METHODS

We interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically.

RESULTS

CHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD.

CONCLUSION

Community health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.

Community Health Worker Interventions for Men: A Scoping Review Using the RE-AIM Framework

INTRODUCTION

Community health workers (CHWs) are health promotion specialists who are trusted members of the community served and have a close understanding of the community's needs and values. CHWs are a cost-effective and scalable workforce to promote health among men through tailored approaches. The purpose of the present review was to use the RE-AIM Framework to assess design, implementation, and outcomes of CHW-implemented health promotion efforts tailored for men to provide recommendations for future efforts.

METHODS

The protocol was pre-registered with PROSPERO. The primary inclusion criteria were that the interventions were (a) implemented at least partially by CHWs, (b) conducted only among men, and (c) designed to improve a health-related outcome. PubMed, EMBASE, PsycINFO, CINAHL, Web of Science, and Global Index Medicus were searched using a librarian-generated search strategy. In all, 1,437 articles were uploaded to Rayyan and two reviewers blindly reviewed each article for inclusion. A total of 24 articles met the inclusion criteria.

RESULTS

Most interventions (a) targeted men under 50 years, (b) were conducted among a subset of underserved men, (c) improved health outcomes, (d) community-based and informed, (e) atheoretical, and (f) had satisfactory retention rates. The roles and responsibilities of CHWs were varied. Attention was given to training of CHWs, but limited attention was given to how/if the CHWs were supervised.

DISCUSSION

CHW-implemented interventions can improve health outcomes among men. Opportunities exist to build on past interventions, such as addressing mental health and incorporating prosocial aspects of masculinity. The results have implications for designing similar interventions.

Understanding the Public Health Role, Motivations, and Perceptions of Community Health Workers Deployed to Low-Income Housing in Richmond, Virginia

BACKGROUND

For the US health indicators to improve to the level of other developed countries, the use of Community Health Workers (CHWs) in vulnerable populations has been indicated as a possible long-term intervention. There are few models of long-term deployment of CHWs as part of the district level public health system in the US.

METHOD

In this study we interviewed CHWs who served as neighborhood-integrated health district staff assigned to low-income housing in Richmond, Virginia for 10 years. Qualitative analyses of their taped and transcribed interviews resulted in 5 themes from the interviews. The themes were Activities, Satisfaction, Strengths, Facilitation/Resources and Challenges. We highlighted quotes from the CHWs interviews for themes and summarized the findings from each theme.

RESULTS

CHWs carried out a variety of activities daily and these were described. The CHWs were generally satisfied with their job because it enabled them to assist others. The strength of their communities was resilience, and the resources they needed more included physical resources, human resources, political support, and more comprehensive programming. Their client's challenges include transportation, mental health, and physical safety and the CHWs challenge to effectively carrying out their work with clients was trust by community members.

CONCLUSION

The information garnered from the CHWs would be useful in designing CHW programs at other health districts.

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.

From policy to practice: a qualitive study exploring the role of community health workers during the COVID-19 response in Sierra Leone

BACKGROUND

During the COVID-19 pandemic, community health workers (CHWs) were required to help their communities respond to the outbreak in Sierra Leone. The Government of Sierra Leone released a policy that provided an interim guidance on the specific role of CHWs during the pandemic including support required to maintain continuity of routine and essential services during the COVID-19 response. This study explores how CHWs adapted their roles during the COVID-19 pandemic in Sierra Leone and the support they received from families, communities, and the health system.

METHODS

A qualitative exploratory study was conducted in two districts in Sierra Leone. We conducted eight key informant interviews with district and community level managers and leaders and four focus group discussions with CHWs. Thematic data analysis and synthesis were guided by the interim guidance released by the Government of Sierra Leone at the onset of the COVID-19 pandemic and supported by NVivo 11.

RESULTS

CHWs quickly took on COVID-19 frontline roles which included surveillance, contact tracing, social mobilization, and provision of psychosocial support. CHWs were trusted with these responsibilities as they were recognized as being knowledgeable about the community, were able to communicate effectively with community members and had experience of dealing with other outbreaks. Despite the release of the interim guidance aimed to optimize CHW contribution, motivate CHWs, ensure continuity of core and essential community-based services alongside COVID-19 services, CHWs faced many challenges in their work during the pandemic including heavy workload, low financial remuneration, lack of mental health support, and shortages of protective equipment, communication and transportation allowances. However, they were generally satisfied with the quality of the training and supervision they received. Support from families and communities was mixed, with some CHWs experiencing stigma and discrimination.

CONCLUSION

During the COVID-19 pandemic, CHWs played a critical role in Sierra Leone. Although, a policy was released by the government to guide their role during the crisis, it was not fully implemented. This resulted in CHWs being overworked and under supported. It is important that CHWs are provided with the necessary training, tools and support to take on their vital roles in managing health crises at the community level. Strengthening the capacity of CHWs will not only enhance pandemic response, but also lay the foundation for improved primary health care delivery and community resilience in the face of future health emergencies.

Mixed Methods, Implementation Science Evaluation of a Community Health Worker Strategy for HIV Service Engagement in Uganda

BACKGROUND

A trial found that a community health worker (CHW) strategy using "Health Scouts" improved HIV care uptake and ART coverage. To better understand outcomes and areas for improvement, we conducted an implementation science evaluation.

METHODS

Using the RE-AIM framework, quantitative methods included analyses of a community-wide survey (n = 1903), CHW log books, and phone application data. Qualitative methods included in-depth interviews (n = 72) with CHWs, clients, staff, and community leaders.

RESULTS

Thirteen Health Scouts logged 11,221 counseling sessions; 2532 unique clients were counseled. 95.7% (1789 of 1891) of residents reported awareness of the Health Scouts. Overall, reach (self-reported receipt of counseling) was 30.7% (580 of 1891). Unreached residents were more likely to be male and HIV seronegative ( P < 0.05). Qualitative themes included the following: (1) reach was promoted by perceived usefulness but deterred by busy client lifestyles and stigma, (2) effectiveness was enabled through good acceptability and consistency with the conceptual framework, (3) adoption was facilitated by positive impacts on HIV service engagement, and (4) implementation fidelity was initially promoted by the CHW phone application but deterred by mobility. Maintenance showed consistent counseling sessions over time. The findings suggested the strategy was fundamentally sound but had suboptimal reach. Future iterations could consider adaptations to improve reach to priority populations, testing the need for mobile health support, and additional community sensitization to reduce stigma.

CONCLUSIONS

A CHW strategy to promote HIV services was implemented with moderate success in an HIV hyperendemic setting and should be considered for adoption and scale-up in other communities as part of comprehensive HIV epidemic control efforts.

TRIAL REGISTRATION

ClinicalTrials.gov Trial Number NCT02556957.

Understanding How Community Health Workers Build Trust with Low-Income Women of Color At-Risk for Maternal Child Health Disparities: A Grounded Theory Study

This article examines how Community Health Workers (CHWs) build trust with low-income women of color who have a historical distrust of the healthcare system, and are at risk for maternal-child health disparities. This qualitative study used a grounded theory methodology guided by Charmaz's inductive social constructivist approach. Data were collected using open-ended semi-structured interviews and focus groups with CHWs who worked in community-based and hospital-based programs in California, Oregon, Illinois, Texas, South Carolina, New York, and Maine. Thirty-two CHWs participated, with 95% of participants being of Latinx and African American ethnicity. They served women from Latinx, African American, and Migrant communities. The CHW communication strategies represent aspects of respect and client-centered care and are applied in the development of a theoretical framework. CHWs were able to build and sustain trust at the initial encounter through these specific strategies: 1) addressing immediate needs related to social determinants of health; 2) embodying mannerisms and dress; 3) speaking appropriately to the client's age, culture, and knowledge; 4) easing client's fears through locus of control, and 5) allowing for time flexibility. These findings have implications for practice through interventions to train healthcare providers to build trust with low-income women of color who have a historical distrust of the healthcare system and who are at risk for maternal-child health disparities. Future research is recommended to explore how the communication trust-building constructs also benefit all other groups at similar risk, including those with mental health disorders and infectious diseases. The findings indicate specific communication strategies through which trust can be built, beginning at the initial encounter with low-income women at risk for maternal-child health disparities and who have a historical distrust of the healthcare system.

Health managers and community representatives' views of a system-wide intervention to strengthen public healthcare in the Free State, South Africa

Background

A system-wide health system strengthening (HSS) initiative, the Health Systems Governance and Accountability (HSGA) intervention, was developed, translated to policy, and implemented in the Free State province. This study assessed health managers (HMs) and community representatives' (CRs) views of the intervention and whether it improved integration and performance.

Method

A questionnaire survey among 147 HMs and 78 CRs and 14 focus group discussions (FGDs) with a mean of 10.3 participants and a total of 102 HMs and 42 CRs, were conducted. The questionnaire and FGD data were descriptively and thematically analysed to triangulate findings.

Results

Many HMs (44%) mostly positioned at the operational levels indicated that implementation of the HSGA intervention did contribute to integration of health services. Most CRs (54%) believed that communities were actively involved in the intervention. However, both the self-administered questionnaire and the FGD data evidenced lack of policy awareness among, especially, operational-level HMs.

Conclusion

From the perspectives of HMs and CRs, the implementation of the intervention was viewed as a step forward in strengthening public healthcare to respond to system deficiencies in the Free State province. Earlier engagement of especially operational-level HMs during reforms may be beneficial in successfully implementing HSS interventions.

The Role of Community Health Workers in the Health and Well-Being of Vulnerable Older Adults during the COVID Pandemic

The COVID-19 pandemic disrupted social support networks as well as resource access for participants. The purpose of this study was to: analyze the experiences of older adults enrolled in a geriatric-focused community health worker (CHW) support program, to gain a better understanding of how CHWs might enhance care delivery, and to further understand how COVID-19 affected the social and emotional needs and well-being of older adults during the first 18 months of the pandemic. Qualitative analysis was performed on notes entered by CHWs based on 793 telephone encounters with 358 participants between March 2020 and August 2021. Analysis was performed by two reviewers independently coding the data. Weighing the benefits of seeing family against the risks of COVID exposure was a source of emotional distress for participants. Our qualitative analysis suggests that CHWs were effective in providing emotional support and connecting participants to resources. CHWs are capable of bolstering the support networks of older adults and carrying out some of the responsibilities conventionally fulfilled by family supports. CHWs addressed participant needs that are frequently unmet by healthcare team members and provided emotional support to participants contributing to health and well-being. CHW assistance can fill gaps in support left by the healthcare system and family support structures.

Research interests, experience, and training of Community Health Workers: a mixed Method Approach

The Affordable Care Act includes a call for community health care workers (CHWs) to be integrated into health care delivery systems to improve health care quality. In recent years, there have been increasing calls for community-based participatory research (CBPR) and patient-centered outcomes research (PCOR), as such types of research hold much potential for identifying interventions to reduce health and health care disparities. Yet, little is known about the research training, knowledge, experience, and even interest of CHWs in these types of research or in health research in general (HR). Thus, the purposes of this study include determining if there are differences between participating CHWs (N = 202) in their levels of training, knowledge, experience, and interest in relation to CBPR, PCOR and HR. Findings suggest that certified CHWs, as compared to non-certified CHWs, have significantly higher knowledge levels across all three types of research (β = 1.3, p = .007). Additionally, participants had significantly higher knowledge of HR compared to CBPR (β = 0.5, p = .015), but not higher than their knowledge of PCOR (p > .5). Qualitative data analyses performed to determine research areas of interest among the participating CHWs resulted in eighteen major research interest themes. Examples of these major themes are chronic illness (n = 95), health promotion (n = 39), healthcare services and administration (n = 30), mental health (n = 29), and research evaluation and methodology (n = 26). Together, the findings suggest that though CHWs have an interest in a wide range of health research areas, they could benefit from research trainings tailored to their responsibilities and interests.

Interprofessional collaboration between social workers and community health workers to address health and mental health in the United States: A systematised review

Collaboration between social workers (SW) and community health workers (CHW) plays an essential role in addressing health inequities in the United States (US). However, little is known about the current state of CHW/SW collaboration. The objectives of this review were to identify (a) the nature, goals and setting of CHWs and SW collaboration; (b) the patient outcomes utilised to measure intervention efficacy. The literature search was conducted in December 2020 using six databases. The inclusion criteria were (1) interventions that included CHWs and SWs; (2) US-based; (3) published between 2000-2020; (4) peer-reviewed journal articles; (5) examining health or mental health outcomes. Search results identified 281 articles, and 15 were included in the final analysis. Settings that utilised SW/CHW collaboration included outpatient clinics (n = 10); community organisations (n = 4) or hospital (n = 1). CHW and SW interventions focused on disease prevention (n = 8), chronic care (n = 4) and mental health (n = 3). Health outcomes were the most evaluated (n = 13), and significant improvement of at least one health outcome was reported in those studies. Mental health outcomes (n = 3) were also significantly improved, while social determinants of health (n = 2) were least common and descriptive only. This is the first review of SW and CHW collaboration. Clarity regarding SW and CHW roles and scopes of practice are needed to understand better SW/CHW collaboration and its impacts on community health outcomes and improve the process of collaboration. SW and CHW collaboration may increase clients' access to preventive care, mental health and address health inequities.

Impact of community health worker intervention on PrEP knowledge and use in Rakai, Uganda: A mixed methods, implementation science evaluation

BACKGROUND

Effective models of support for HIV pre-exposure prophylaxis (PrEP) are needed for populations at elevated risk. In a hyperendemic Ugandan fishing community, PrEP counseling was provided through a situated Information, Motivation, and Behavioral Skills (sIMB)-based community health worker (CHW) intervention. We evaluated the intervention using a mixed-methods, implementation science design.

METHODS

We surveyed all community members aged 15-49 through the Rakai Community Cohort Study. We used multivariable logistic regressions with generalized estimating equations to estimate the intervention's effect on PrEP knowledge and utilization. To understand intervention experiences and mechanisms, we conducted 74 qualitative interviews with 5 informant types (clients, CHWs, program staff, community leaders, health clinic staff) and analyzed data using an iterative, deductive approach. A mobile phone application provided intervention process implementation data.

RESULTS

Individuals self-reporting receipt of the CHW intervention showed significantly higher PrEP knowledge (N = 1848, PRR: 1.10, 95% CI: 1.06-1.14, p = <.0001), PrEP ever use (N = 1176, PRR: 1.77, 95% CI: 1.33-2.36, p = <.0001), and PrEP current use (N = 1176, PRR: 1.86, 95% CI: 1.22-2.82, p = 0.0039) compared to those who did not. Qualitative findings attributed positive PrEP outcomes to CHW counseling and effective use of motivational interviewing skills by CHWs. Salient themes across the RE-AIM framework included support for the CHW intervention and PrEP across clients, community, and implementers. Mobile application data demonstrated consistent delivery of the PrEP module throughout implementation.

CONCLUSIONS

CHWs improved PrEP knowledge and use among clients in an HIV hyperendemic fishing community. Mixed-methods, implementation science evaluations can inform adaptation of similar PrEP implementation strategies.

An intervention package for supporting the mental well-being of community health workers in low, and middle-income countries during the COVID-19 pandemic

BACKGROUND

As the COVID-19 pandemic continues, there is an increasing reliance on community health workers (CHWs) to achieve its control especially in low, and middle-income countries (LMICs). An increase in the demand for their services and the challenges they already face make them prone to mental health illness. Therefore, there is a need to further support the mental health and well-being of CHWs during the COVID-19 pandemic.

METHODS

We organised a workshop on Zoom to deliberate on relevant components of an intervention package for supporting the mental health of CHWs in LMICs during the COVID-19 pandemic. We used a thematic analysis approach to summarise deliberations from this workshop.

OUTCOMES

Participants identified the need for a hub for coordinating CHW activities, a care coordination team to manage their health, training programs aimed at improving their work performance and taking control of their health, a communication system that keeps them in touch with colleagues, family, and the communities they serve. They cautioned against confidentiality breaches while handling personal health information and favoured tailoring interventions to the unique needs of CHWs. Participants also advised on the need to ensure job security for CHWs and draw on available resources in the community. To measure the impact of such an intervention package, participants encouraged the use of mixed methods and a co-designed approach.

INTERPRETATION

As CHWs contribute to the pandemic response in LMICs, their mental health and well-being need to be protected. Such protection can be provided by using an intervention package that harnesses inputs from members of the broader health system, their families, and communities.

Community health workers experiences and perceptions of working during the COVID-19 pandemic in Lagos, Nigeria-A qualitative study

BACKGROUND

Community Health Workers are globally recognised as crucial members of healthcare systems in low and middle-income countries, but their role and experience during COVID-19 is not well-understood. This study aimed to explore factors that influence CHWs' ability and willingness to work in the COVID-19 pandemic in Lagos.

DESIGN

A generic qualitative study exploring Community Health Workers experiences and perceptions of working during the COVID-19 pandemic in Lagos, Nigeria.

METHODS

15 semi-structured, in-depth, video interviews were conducted with Community Health Workers purposively sampled across seven of Lagos' Local Government Areas with the highest COVID-19 burden. Interviews explored Community Health Workers' attitudes towards COVID-19, its management, and their experiences working in Lagos. Data was analysed thematically using the framework method.

RESULTS

Three main themes were identified. 1. Influences on ability to undertake COVID-19 Role: Trust and COVID-19 knowledge were found to aid Community Health Workers in their work. However, challenges included exhaustion due to an increased workload, public misconceptions about COVID-19, stigmatisation of COVID-19 patients, delayed access to care and lack of transportation. 2. Influences on willingness to work in COVID-19 Role: Community Health Workers' perceptions of COVID-19, attitudes towards responsibility for COVID-19 risk at work, commitment and faith appeared to increase willingness to work. 3. Suggested Improvements: Financial incentives, provision of adequate personal protective equipment, transportation, and increasing staff numbers were seen as potential strategies to address many of the challenges faced.

CONCLUSION

Despite Community Health Workers being committed to their role, they have faced many challenges during the COVID-19 pandemic in Nigeria. Changes to their working environment may make their role during disease outbreaks more fulfilling and sustainable. International input is required to enhance Nigeria's policies and infrastructure to better support Community Health Workers during both current and future outbreaks.

Knowledge and attitude of health extension workers regarding mental health problems in Jimma Zone, Ethiopia: a cross-sectional study

OBJECTIVE

Health extension workers' (HEWs') knowledge and attitude regarding mental health problems are vital for integrating mental healthcare into primary healthcare services. However, information in this context is scarce in Ethiopia. So, this study aimed to assess HEWs' knowledge and attitude towards mental health problems in Jimma, Ethiopia.

DESIGN

A cross-sectional study.

SETTING

Five districts in Jimma Zone, Ethiopia, 2020.

PARTICIPANTS

A total of 259 HEWs working in selected five districts were included in the study.

OUTCOME

The knowledge and attitude status of HEWs towards mental health problems.

RESULTS

Nearly half of the respondents had inadequate knowledge (122,47.1%) and an unfavourable attitude (125, 48.3%). Most (139, 53.7%) described mental illness as due to evil spirits' possession. Almost all (240, 92.7%) of the respondents reported talking or laughing alone as a manifestation of mental illness. Almost two-thirds (157, 60.6%) of the respondents reported people with mental illness are dangerous. About a quarter (63, 24.3%) of the participants stated witch doctors should manage mental illnesses.

CONCLUSIONS

A significant proportion of the study respondents had poor knowledge and attitude towards mental health problems. Short-term and long-term mental health training is needed to improve their perception level and to provide effective community mental health services.

Effect of a Nurse-Led Community Health Worker Intervention on Latent Tuberculosis Medication Completion Among Homeless Adults

BACKGROUND

Tuberculosis (TB) disproportionately affects marginalized and impoverished homeless adults. Although active TB can be prevented by treating latent TB infection (LTBI), individual factors, such as high prevalence of depression and anxiety, drug and alcohol use, and unstable housing, lead to poor LTBI treatment adherence and completion among homeless adults.

OBJECTIVES

We hypothesized that the delivery of a tailored nurse-led, community health worker (RN/CHW) program across the LTBI continuum of care (e.g., screening, diagnosis, and treatment) that delivers 3HP treatment (3HP: rifapentine plus isoniazid) for homeless adults (e.g., sheltered and unsheltered) and is tailored to their health and social service needs will overcome existing treatment completion barriers. We also hypothesized that mental health symptoms (e.g., depression and anxiety), drug use score, and problematic alcohol use will decline over time among clients receiving this treatment.

METHODS

We assessed the effect of delivering a theoretically guided, RN/CHW-based, single-arm study among eligible LTBI-positive homeless adults (N = 50) on completion of a weekly, directly observed, 12-dose 3HP LTBI treatment in Central City East (Skid Row). Completing 3HP treatment was compared to the only known historical, clinic-based control that obtained 65% completion among homeless adults. Secondary outcomes included drug and alcohol use, depression, and anxiety.

RESULTS

The RN/CHW program achieved a 91.8% 3HP treatment completion rate among homeless adults. Younger homeless adults (<50 years old) were less likely to complete 3HP treatment compared to those who were older. Neither drug use, depression, nor anxiety was associated with 3HP treatment completion. Decrease in anxiety was observed at 3 months, but not at 6 months, compared to baseline.

DISCUSSION

To our knowledge, the pilot study is the first to evaluate an effective RN/CHW-delivered, community-based intervention, which can reduce the burden of active TB for homeless adults.

Association between Japanese community health workers' willingness to continue service and two categories of motives: Altruistic and self-oriented

BACKGROUND

As population aging progresses, volunteers in health field are expected to play a key role in health promotion and disease prevention, which may improve community residents' health and well-being and at the same time help slow the growth of healthcare cost. The objective of this study is to examine the effects of self-oriented motives and altruistic motives as explanatory factors for Japanese Community Health Workers (CHWs)' desire to continue their service. Unraveling the relative effects of these two types of motivation on CHW retention may lead to policy and practical implications for recruiting, training, and supporting CHWs in Japan. Haddad (2007) observed that citizens in Japan generally have a sense of governmental and individual responsibility for dealing with social problems. Applying these insights to CHWs, we hypothesize that altruistic motives have more potent influence on volunteers' willingness to continue to serve than self-oriented motives.

METHODS

Three cities in Shiga prefecture, Japan agreed to participate in the study. Anonymous, self-administered questionnaire was mailed to all CHWs who work in the three communities. The survey data were collected in March and April, 2013. A total of 417 questionnaires were mailed to CHWs, of which 346 were completed and returned (response rate 83.0%). Nine questionnaires missing response to the question concerning willingness to continue serving were removed from the analysis. The final analysis used 337 questionnaires (effective response rate 80.8%).

RESULTS

One hundred ninety-nine (59.1%) of the respondents answered the question about willingness to continue CHW affirmatively, and 138 (40.9%) negatively. Controlling for other relevant factors, those with self-oriented motives in serving as CHWs were more likely to state they are willing to continue to serve (OR:1.54, confidence interval 1.00-2.37) than those without such motives. Those with altruistic motives were also more likely to say they want to continue their service (OR 1.56, confidence interval 1.08-2.27) than those without such motives. Contrary to our hypothesis, the two motives, altruistic and self-oriented, were shown to have nearly equal degree of influence on respondents' willingness to continue serving as CHWs.

CONCLUSION

One practical implication of the research is that learning more about the twin motives, self-oriented and altruistic, of volunteers and tailoring the content of CHW training by municipal health professionals to address those motives may be beneficial.

Chronic disease stigma, skepticism of the health system, and socio-economic fragility: Qualitative assessment of factors impacting receptiveness to group medical visits and microfinance for non-communicable disease care in rural Kenya

BACKGROUND

Non-communicable diseases (NCDs) are the leading cause of mortality in the world, and innovative approaches to NCD care delivery are being actively developed and evaluated. Combining the group-based experience of microfinance and group medical visits is a novel approach to NCD care delivery. However, the contextual factors, facilitators, and barriers impacting wide-scale implementation of these approaches within a low- and middle-income country setting are not well known.

METHODS

Two types of qualitative group discussion were conducted: 1) mabaraza (singular, baraza), a traditional East African community gathering used to discuss and exchange information in large group settings; and 2) focus group discussions (FGDs) among rural clinicians, community health workers, microfinance group members, and patients with NCDs. Trained research staff members led the discussions using structured question guides. Content analysis was performed with NVivo using deductive and inductive codes that were then grouped into themes.

RESULTS

We conducted 5 mabaraza and 16 FGDs. A total of 205 individuals (113 men and 92 women) participated in the mabaraza, while 162 individuals (57 men and 105 women) participated in the FGDs. In the context of poverty and previous experiences with the health system, participants described challenges to NCD care across three themes: 1) stigma of chronic disease, 2) earned skepticism of the health system, and 3) socio-economic fragility. However, they also outlined windows of opportunity and facilitators of group medical visits and microfinance to address those challenges.

DISCUSSION

Our qualitative study revealed actionable factors that could impact the success of implementation of group medical visits and microfinance initiatives for NCD care. While several challenges were highlighted, participants also described opportunities to address and mitigate the impact of these factors. We anticipate that our approach and analysis provides new insights and methodological techniques that will be relevant to other low-resource settings worldwide.

Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

BACKGROUND

During childbirth, complications may arise which necessitate an expedited delivery of the fetus. One option is instrumental assistance (forceps or a vacuum-cup), which, if used with skill and sensitivity, can improve maternal/neonatal outcomes. This review aimed to understand the core competencies and expertise required for skilled use in AVD in conjunction with reviewing potential barriers and facilitators to gaining competency and expertise, from the point of view of maternity care practitioners, funders and policy makers.

METHODS

A mixed methods systematic review was undertaken in five databases. Inclusion criteria were primary studies reporting views, opinions, perspectives and experiences of the target group in relation to the expertise, training, behaviours and competencies required for optimal AVD, barriers and facilitators to achieving practitioner competencies, and to the implementation of appropriate training. Quality appraisal was carried out on included studies. A mixed-methods convergent synthesis was carried out, and the findings were subjected to GRADE-CERQual assessment of confidence.

RESULTS

31 papers, reporting on 27 studies and published 1985-2020 were included. Studies included qualitative designs (3), mixed methods (3), and quantitative surveys (21). The majority (23) were from high-income countries, two from upper-middle income countries, one from a lower-income country: one survey included 111 low-middle countries. Confidence in the 10 statements of findings was mostly low, with one exception (moderate confidence). The review found that AVD competency comprises of inter-related skill sets including non-technical skills (e.g. behaviours), general clinical skills; and specific technical skills associated with particular instrument use. We found that practitioners needed and welcomed additional specific training, where a combination of teaching methods were used, to gain skills and confidence in this field. Clinical mentorship, and observing others confidently using the full range of instruments, was also required, and valued, to develop competency and expertise in AVD. However, concerns regarding poor outcomes and litigation were also raised.

CONCLUSION

Access to specific AVD training, using a combination of teaching methods. Complements, but does not replace, close clinical mentorship from experts who are positive about AVD, and opportunities to practice emerging AVD skills with supportive supervision. Further research is required to ascertain effective modalities for wider training, education, and supportive supervision for optimal AVD use.

Knowledge, attitudes, and perceptions of Kenyan healthcare workers regarding pediatric discharge from hospital

OBJECTIVE

To assess attitudes, perceptions, and practices of healthcare workers regarding hospital discharge and follow-up care for children under age five in Migori and Homa Bay, Kenya.

METHODS

This mixed-methods study included surveys and semi-structured telephone interviews with healthcare workers delivering inpatient pediatric care at eight hospitals between November 2017 and December 2018.

RESULTS

The survey was completed by 111 (85%) eligible HCWs. Ninety-seven of the surveyed HCWs were invited for interviews and 39 (40%) participated. Discharge tasks were reported to be "very important" to patient outcomes by over 80% of respondents, but only 37 (33%) perceived their hospital to deliver this care "very well" and 23 (21%) believed their facility provides sufficient resources for its provision. The vast majority (97%) of participants underestimated the risk of pediatric post-discharge mortality. Inadequate training, understaffing, stock-outs of take-home therapeutics, and user fees were commonly reported health systems barriers to adequate discharge care while poverty was seen as limiting caregiver adherence to discharge and follow-up care. Respondents endorsed the importance of follow-up care, but reported supportive mechanisms to be lacking. They requested enhanced guidelines on discharge and follow-up care.

CONCLUSION

Kenyan healthcare workers substantially underestimated the risk of pediatric post-discharge mortality. Pre- and in-service training should incorporate instruction on discharge and follow-up care. Improved post-discharge deaths tracking-e.g., through vital registry systems, child mortality surveillance studies, and community health worker feedback loops-is needed, alongside dissemination which could leverage platforms such as routine hospital-based mortality reports. Finally, further interventional trials are needed to assess the efficacy and cost-effectiveness of novel packages to improve discharge and follow-up care.

Gender intentional approaches to enhance health social enterprises in Africa: a qualitative study of constraints and strategies

BACKGROUND

Health social enterprises are experimenting with community health worker (CHW) models that allow for various income-generating opportunities to motivate and incentivize CHWs. Although evidence shows that improving gender equality contributes to the achievement of health outcomes, gender-based constraints faced by CHWs working with social enterprises in Africa have not yet been empirically studied. This study is the first of its kind to address this important gap in knowledge.

METHODS

We conducted 36 key informant interviews and 21 focus group discussions between 2016 and 2019 (for a total of 175 individuals: 106 women and 69 men) with four health social enterprises in Uganda and Kenya and other related key stakeholders and domain experts. Interview and focus group transcripts were coded according to gender-based constraints and strategies for enhanced performance as well as key sites for intervention.

RESULTS

We found that CHW programs can be more gender responsive. We introduce the Gender Integration Continuum for Health Social Enterprises as a tool that can help guide gender equality efforts. Data revealed female CHWs face seven unique gender-based constraints (compared to male CHWs): 1) higher time burden and lack of economic empowerment; 2) risks to personal safety; 3) lack of career advancement and leadership opportunities; 4) lack of access to needed equipment, medicines and transport; 5) lack of access to capital; 6) lack of access to social support and networking opportunities; and 7) insufficient financial and non-financial incentives. Data also revealed four key areas of intervention: 1) the health social enterprise; 2) the CHW; 3) the CHW's partner; and 4) the CHW's patients. In each of the four areas, gender responsive strategies were identified to overcome constraints and contribute to improved gender equality and community health outcomes.

CONCLUSIONS

This is the first study of its kind to identify the key gender-based constraints and gender responsive strategies for health social enterprises in Africa using CHWs. Findings can assist organizations working with CHWs in Africa (social enterprises, governments or non-governmental organizations) to develop gender responsive strategies that increase the gender and health outcomes while improving gender equality for CHWs, their families, and their communities.

"Even when people live just across the road…they won't go": Community health worker perspectives on incentivized delays to under-five care-seeking in urban slums of Kampala, Uganda

Background

Although under-five (U5) mortality in Uganda has dropped over the past two decades, rates in urban slum neighborhoods remain high. As part of a broader verbal and social autopsy study of U5 deaths, this study explored the perspectives of volunteer community health workers, called Village Health Teams (VHTs), on why children under five in Kampala’s informal settlements are still dying despite living in close proximity to nearby health facilities.

Methods

This exploratory, qualitative study took place between January and March 2020 in the Rubaga division of Kampala, Uganda. VHTs from the slums of Kawaala and Nankulabye parishes, both located near a large government health center, were interviewed by a trained local interviewer to determine their perceptions of barriers to care-seeking and attribution for U5 childhood deaths. All interviews were audiotaped, transcribed into English, imported into NVivo V 12.0 and thematically analyzed using the Attride-Stirling framework.

Results

20 VHTs were interviewed, yielding two global themes, the first focusing on VHTs perceptions of their role in the community to promote positive health outcomes, and the second focusing on VHTs’ perceptions of how prompt care-seeking is disincentivized. Within the latter theme, three inter-related sub-themes emerged: disincentives for care-seeking at the health system level, which can drive negative beliefs held by families about the health system, and in turn, drive incentives for alternative health behaviors, which manifest as “incentivized delays” to care-seeking.

Discussion

This study illustrates VHT perspectives on the complex interactions between health system disincentives and the attitudes and behaviors of families with a sick child, as well as the reinforcing nature of these factors. Findings suggest a need for multi-pronged approaches that sensitize community members, engage community and health system leadership, and hold providers accountable for providing high-quality care. VHTs have enormous potential to foster improvement if given adequate resources, training, and support.

Health beliefs and health seeking behavior towards lymphatic filariasis morbidity management and disability prevention services in Luangwa District, Zambia: Community and provider perspectives

Background

Morbidity management and disability prevention (MMDP) services are essential for the management of chronic stages of lymphatic filariasis (LF) infection. However, there is limited information on health beliefs and health seeking behavior towards MMDP services for LF in endemic regions of Zambia. This study sought to document health beliefs and health seeking behavior towards MMDP services for LF in Luangwa District, Zambia.

Methods

This was an exploratory qualitative study conducted with community members including LF patients, community health workers and healthcare providers. Data was collected through a series of four focus group discussions stratified by sex and 26 in-depth interviews. Data was analyzed by thematic analysis using NVivo software.

Results

The perceived causes of the chronic manifestations of LF included; contact with animal faeces, use of traditional herbal aphrodisiacs (mutoto), witchcraft and sexual contact with women who were menstruating or had miscarried. LF patients opted to visit traditional healers before going to health facilities. Hydrocele patients were afraid of hydrocelectomies as they were thought to cause infertility or death. Very few community members were able to identify any home and facility-based care strategies for lymphoedema. Health system and cultural barriers to seeking healthcare included; long distances to the health facilities, lack of awareness of existing MMDP services, perceived costs of accessing MMDP services, gender and social norms, and fear of stigmatization.

Conclusion

Health seeking behavior for LF in the district is mainly driven by negative beliefs about the causes of the disease and lack of awareness of available MMDP services and homecare strategies. Lymphatic filariasis programs should promote strategies that seek to empower patients and community members with the required information to access and use the MMDP services at the health facilities, as well as adhere to self-care practices in their households.

Lymphatic filariasis (LF) infection if untreated results in fluid accumulation in the limbs or breasts (lymphedema) or genitalia (hydrocele) that is painful and causes great discomfort. Morbidity management and disability prevention (MMDP) strategies such as surgery for hydrocele, treatment of acute attacks and management of lymphedema are necessary for the management of the advanced stages of LF. However, very few countries including Zambia, have adequate information on the health beliefs and health seeking behavior of communities living in endemic areas towards MMDP services for LF. This study sought to explore community and health provider perspectives towards MMDP services for LF in a highly endemic region, Luangwa District, Zambia, between February and April 2019. Some of the perceived causes of lymphedema and hydrocele were; contact with animal faeces, use of traditional herbal aphrodisiacs (mutoto), witchcraft and sexual contact with women who were menstruating or had miscarried. There was limited knowledge of home-based and facility-based care strategies for lymphoedema. Nevertheless, patients would often go to health facilities after visiting traditional healers and observing no improvement. Barriers to accessing healthcare included; long distances to the health facilities, lack of awareness of existing MMDP services, perceived costs of accessing healthcare services, gender and social norms and fear of stigmatization.

Viewpoints of pregnant mothers and community health workers on antenatal care in Lweza village, Uganda

BACKGROUND

Uganda is a low-income country with high fertility, adolescent birth, and maternal mortality rates. How Ugandan Ministry of Health antenatal education guidelines have been implemented into standardized health education and how pregnant women utilize health facilities remains unclear.

OBJECTIVE

We aimed to determine how women obtain education during pregnancy, what guidelines health educators follow, and what barriers exist to receiving antenatal care in Lweza Village, Uganda.

METHODS

Household surveys were conducted with women in Lweza who were or had previously been pregnant. Focus group discussions were conducted with community members and Lweza Primary School teachers. Interviews were conducted with key informants, including midwives, a traditional birth attendant, a community leader, and a Village Health Team member. Data collection was done in English along with a Luganda translator.

RESULTS

Of the 100 household surveys conducted, 86% of women did not meet the WHO recommendation of 8 antenatal appointments during their pregnancies. Reasons cited for inadequate visits included facing long wait times (>7 h) at health facilities, getting education from family or traditional healers, or being told to delay antenatal care until 6 months pregnant. Informant interviews revealed that no standardized antenatal education program exists. Respondents felt least educated on family planning and postpartum depression, despite 37% of them reporting symptoms consistent with postpartum depression. Education was also lacking on the use of traditional herbs, although most women (60%) reported using them during pregnancy.

CONCLUSIONS

Most women in Lweza do not receive 8 antenatal appointments during their pregnancies or any standardized antenatal education. Educational opportunities on family planning, postpartum depression, and the safety of traditional herbs during pregnancy exist. Future studies should focus on ways to overcome barriers to antenatal care, which could include implementing community-based education programs to improve health outcomes for women in Lweza Village.

Evaluation of the mental health status of community healthcare workers during the COVID-19 outbreak

ABSTRACT

Coronavirus disease 2019 (COVID-19) has rapidly spread across China and many countries worldwide, and community healthcare workers at the front lines of disease control are under high physical and mental pressure. This study investigated the mental health status of community healthcare workers during the COVID-19 outbreak in Sichuan Province, China. This cross-sectional study, which was conducted from February 8 to 18, 2020, involved 450 healthcare workers in 18 community hospitals who had worked for more than 1 year. A self-designed demographic data questionnaire and Symptom Checklist 90 (SCL-90) were provided to the participants through links and quick response codes. The respondents completed and submitted the questionnaires online. Binary logistic regression was used to analyze multiple factors related to the SCL-90 scores of these community healthcare workers in China. For the 450 community healthcare workers who completed the study, the median scores in each SCL-90 factor were lower than the Chinese norms, and 119 (26.4%) participants were SCL-90 positive. Among them, 178 participants were doctors and had the highest scores on most SCL-90 factors except for obsessive compulsiveness, hostility, phobic anxiety, and psychoticism (P < 0.05). The top 3 positive items for doctors working in the community were obsessive compulsiveness, others, and somatization, and those among nurses were obsessive compulsiveness, others, and hostility. Sex, type of workers, and occupational exposure risk to COVID-19 were independent risk factors for the mental health status of the community healthcare workers. Overall, the community healthcare workers experienced psychological problems during the COVID-19 outbreak in Sichuan Province, China. More attention should be paid to the mental health of these workers, and their mental status should be regularly assessed. Psychological interventions should be provided to those with serious mental problems through networks or telephone visits.

The self-psychological safety maintenance and its influencing factors of community frontline staff during COVID-19 pandemic

The present study was designed to determine the self-psychological safety maintenance and its influencing factors of community staff on the front-line during Coronavirus Disease 2019 (COVID-19) pandemic.A total of 126 frontline staff in community were involved in the current cross-section study. Online questionnaires including the anxiety sensitivity index-3 (ASI-3), patient health questionnaire (PHQ-9), simple coping style questionnaire (SCSQ) and general self-efficacy scale (GSES) were utilized to analyze psychological state, coping style and self-efficacy of the surveyed staff.The ASI-3 standard score of 126 community frontline staff was 10.01 ± 2.82, of which 21 community frontline staff scored > 16, and the detection rate of anxiety was 16.67%. The anxiety state of doctors and nursing staff was significantly lower than that of administrative staff, logistics staff and other staff, and the rate of anxiety of having colleagues with suspected symptoms was significantly higher than that without colleagues with suspected symptoms (P < .05). The PHQ-9 standard score was 2.03 ± 0.16, of which 19 frontline staff in the community scored more than 5, and the detection rate of depression was 15.08%. Among them, the depression state of those with bachelor degree or above was significantly lower than that of those with junior college education, and the rate of depressive symptoms of community frontline staff with colleagues harboring suspected symptoms were significantly higher than those without colleagues with suspected symptoms (P < .05). The aggregated results showed that most of the community frontline staff in anxiety state group and depression group adopted negative coping style while most of the community frontline staff in the non-anxiety group and the non-depression group adopted positive coping style (P < .05). Additionally, lower score of self-efficacy of the community frontline staff was observed in the anxiety state group and the depression state group (P < .05).During the outbreak of COVID-19, several community frontline staff showed negative psychology of anxiety and depression, which could affect their coping style and self-efficacy. Early and effective psychological safety maintenance was required to alleviate the negative psychology of community frontline staff.

Community demand for comprehensive primary health care from malaria volunteers in South-East Myanmar: a qualitative study

BACKGROUND

Malaria volunteers have contributed significantly to malaria control achieving a reduction of annual parasite incidence to pre-elimination levels in several townships across Myanmar. However, the volunteers' role is changing as Myanmar transitions from a malaria control to elimination programme and towards the goal of universal health coverage. The aim of the study is to explore the perspectives of community leaders, members and malaria volunteers in South-East Myanmar on community-delivered models to inform an optimal design that targets malaria elimination in the context of primary health care in Myanmar.

METHODS

Qualitative methods including focus group discussions (FGDs) with community members and current or ex-malaria volunteers, and participatory workshops with community leaders were conducted. All data collection tools were pilot tested with similar participants. The FGDs were stratified into male and female participants in consideration of diverse gender roles among the ethnic groups of Myanmar. Data saturation was the key cut-off point to cease recruitment of participants. Inductive thematic analysis was used.

RESULTS

Community members were willing to be tested for malaria because they were concerned about the consequences of malaria although they were aware that malaria prevalence is low in their villages. Malaria volunteers were the main service providers for malaria and other infectious diseases in the community. Apart from malaria, the community identified common health problems such as the flu (fever, sneezing and coughing), diarrhoea, skin infections and tuberculosis as priority diseases in this order. Incorporating preventive, and whenever possible curative, services for those diseases into the current malaria volunteer model was recommended.

DISCUSSION AND CONCLUSION

There was a gap between the communities' expectations of health services and the health services currently being delivered by volunteers in the community that highlights the need for reassessment and reform of the volunteer model in the changing context. An evidence-based, community preferred, pragmatic community-delivered integrated model should be constructed based on the context of malaria elimination and progressing towards universal health coverage in Myanmar.

Examining Associations between Community Health Worker-Rated Health and Mental Health among Latino Adults with Chronic Disease

Latinos with chronic disease often experience comorbid depression, but confront barriers to mental health treatment. Community health workers (CHWs) develop trusting relationships with the communities they serve, and may be uniquely positioned to identify Latinos with mental health care needs. Research has not examined whether their rating of clients' health is indicative of their mental health. This mixed-methods study examines CHWs' appraisals of Latino adults' health and their relation to mental health outcomes, and explores factors informing CHWs' rating of health status. The current study utilized baseline data from the Linking Individual Needs to Community and Clinical Services (LINKS) study. We assessed associations between CHW-rated health (CHWRH), or rating of health status as poor-excellent, and mental health outcomes with multilevel linear regression modelling. We qualitatively analyzed CHWs' written perceptions of participants' health status to understand what influenced their health rating. The quantitative results showed that CWHRH was significantly related to depressive symptoms and emotional problems severity. The qualitative results showed that CHWs took a holistic and ecological approach in rating health. The findings suggest that CHWRH could be indicative of mental health among Latino adults. Further studies investigating CHWRH as an independent indicator of mental health are warranted.

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.

Myths, misconceptions, othering and stigmatizing responses to Covid-19 in South Africa: A rapid qualitative assessment

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a new strain of virus in the Coronavirus family that has not been previously identified. Since SARS-CoV-2 is a new virus, everyone is at risk of catching the Coronavirus disease 2019 (Covid-19). No one has immunity to the virus. Despite this, misconceptions about specific groups of people who are immune to Covid-19 emerged with the onset of the pandemic. This paper explores South African communities' misconceptions about who is most vulnerable to Covid-19. A rapid qualitative assessment was conducted remotely in Gauteng, KwaZulu-Natal and the Western Cape provinces of South Africa. Recruitment of study participants took place through established relationships with civil society organizations and contacts made by researchers. In total, 60 key informant interviews and one focus group discussion was conducted. Atlas.ti.8 Windows was used to facilitate qualitative data analysis. The qualitative data was coded, and thematic analysis used to identify themes. The results show a high level of awareness and knowledge of the transmission and prevention of SARS-CoV-2. Qualitative data revealed that there is awareness of elderly people and those with immunocompromised conditions being more vulnerable to catching Covid-19. However, misconceptions of being protected against the virus or having low or no risk were also evident in the data. We found that false information circulated on social media not only instigated confusion, fear and panic, but also contributed to the construction of misconceptions, othering and stigmatizing responses to Covid-19. The study findings bring attention to the importance of developing communication materials adapted to specific communities to help reduce misconceptions, othering and stigmatization around Covid-19.

Factors influencing the performance of community health workers: A qualitative study of Anganwadi Workers from Bihar, India

Globally, there remain significant knowledge and evidence gaps around how to support Community Health Worker (CHW) programmes to achieve high coverage and quality of interventions. India's Integrated Child Development Services scheme employs the largest CHW cadre in the world-Anganwadi Workers (AWWs). However, factors influencing the performance of these workers remain under researched. Lessons from it have potential to impact on other large scale global CHW programmes. A qualitative study of AWWs in the Indian state of Bihar was conducted to identify key drivers of performance in 2015. In-depth interviews were conducted with 30 AWWs; data was analysed using both inductive and deductive thematic analysis. The study adapted and contextualised existing frameworks on CHW performance, finding that factors affecting performance occur at the individual, community, programme and organisational levels, including factors not previously identified in the literature. Individual factors include initial financial motives and family support; programme factors include beneficiaries' and AWWs' service preferences and work environment; community factors include caste dynamics and community and seasonal migration; and organisational factors include corruption. The initial motives of the worker (the need to retain a job for family financial needs) and community expectations (for product-oriented services) ensure continued efforts even when her motivation is low. The main constraints to performance remain factors outside of her control, including limited availability of programme resources and challenging relationships shaped by caste dynamics, seasonal migration, and corruption. Programme efforts to improve performance (such as incentives, working conditions and supportive management) need to consider these complex, inter-related multiple determinants of performance. Our findings, including new factors, contribute to the global literature on factors affecting the performance of CHWs and have wide application.

Influencing factors for prevention of postpartum hemorrhage and early detection of childbearing women at risk in Northern Province of Rwanda: beneficiary and health worker perspectives

BACKGROUND

Reduction of maternal mortality and morbidity is a major global health priority. However, much remains unknown regarding factors associated with postpartum hemorrhage (PPH) among childbearing women in the Rwandan context. The aim of this study is to explore the influencing factors for prevention of PPH and early detection of childbearing women at risk as perceived by beneficiaries and health workers in the Northern Province of Rwanda.

METHODS

A qualitative descriptive exploratory study was drawn from a larger sequential exploratory-mixed methods study. Semi-structured interviews were conducted with 11 women who experienced PPH within the 6 months prior to interview. In addition, focus group discussions were conducted with: women's partners or close relatives (2 focus groups), community health workers (CHWs) in charge of maternal health (2 focus groups) and health care providers (3 focus groups). A socio ecological model was used to develop interview guides describing factors related to early detection and prevention of PPH in consideration of individual attributes, interpersonal, family and peer influences, intermediary determinants of health and structural determinants. The research protocol was approved by the University of Rwanda, College of Medicine and Health Sciences Institutional Ethics Review Board.

RESULTS

We generated four interrelated themes: (1) Meaning of PPH: beliefs, knowledge and understanding of PPH: (2) Organizational factors; (3) Caring and family involvement and (4) Perceived risk factors and barriers to PPH prevention. The findings from this study indicate that PPH was poorly understood by women and their partners. Family members and CHWs feel that their role for the prevention of PPH is to get the woman to the health facility on time. The main factors associated with PPH as described by participants were multiparty and retained placenta. Low socioeconomic status and delays to access health care were identified as the main barriers for the prevention of PPH.

CONCLUSIONS

Addressing the identified factors could enhance early prevention of PPH among childbearing women. Placing emphasis on developing strategies for early detection of women at higher risk of developing PPH, continuous professional development of health care providers, developing educational materials for CHWs and family members could improve the prevention of PPH. Involvement of all levels of the health system was recommended for a proactive prevention of PPH. Further quantitative research, using case control design is warranted to develop a screening tool for early detection of PPH risk factors for a proactive prevention.

HPV-associated oropharyngeal cancer: Knowledge and attitude/beliefs among non-clinical staff at community-based HIV/AIDS Service Organizations (ASO) in the south United States (U.S.) census region

This study describes knowledge and attitude/beliefs about HPV-associated oropharyngeal cancer among non-clinical staff, at community-based HIV/AIDS Service Organizations (ASOs) located in the Southern U.S. states of South Carolina and Texas. It also explores the difference in knowledge and attitude/beliefs between Texas-based (n = 21) and South Carolina-based (n = 30) ASO staff. The ASOs in our study provide comprehensive HIV prevention, supportive and care services to individuals living with HIV/AIDS or at risk for HIV/AIDS, through partnerships and collaborations. We collected data from the two Texas-based ASOs in 2018 and the three South Carolina-based ASOs in 2016 via a 118-item, self-administered needs assessment survey. Data were analysed using Stata/SE 15.1. Over half the study participants were females (59%), black (78%), heterosexual (61%) and mean age (years) 44.2 ± 12.8 SD. Most participants (73%) believed that quitting smoking positively impacts health. Alarmingly though, only 32% were aware about HPV as a risk factor for oropharyngeal cancer, and over half (53%) were unsure about the success of the HPV vaccine in preventing oropharyngeal cancer. In addition, there were no statistically significant differences observed in the oropharyngeal cancer-related knowledge and attitudes/beliefs, between ASOs in Texas and South Carolina. ASO staff work closely with people living with HIV (PLWH), who are disproportionately affected by HPV-associated cancers. The low/poor knowledge and attitudes/beliefs regarding the role of HPV in causing oropharyngeal cancer ascertain the need for equipping community health workers with adequate education/training that improves their knowledge and attitudes/beliefs about the role of HPV in causing various forms of cancer.

Community health worker motivation to perform systematic household contact tuberculosis investigation in a high burden metropolitan district in South Africa

BACKGROUND

South Africa faces a chronic shortage of professional health workers. Accordingly, community health workers (CHWs) are being employed to mitigate the ongoing health workforce deficiencies. As increased access to quality service delivery hinges upon their motivation, this study explored CHWs' motivation to deliver systematic household contact tuberculosis (TB) investigation (SHCI).

METHODS

In 2017, a cross-sectional survey was conducted among CHWs in the Mangaung Metropolitan District, Free State Province. Exploratory factor analysis was performed on a 30-item scale to determine the dimensions underlying CHW motivation. Items with factor loadings of 0.4 and above were retained. Descriptive and inferential analyses were used to determine CHW motivation levels. Multiple linear regression analysis was used to investigate the determinants of CHW motivation.

RESULTS

Out of 235 participants, 89.2% were female. Participants' median age was 39 (inter-quartile range: 33-45) years. CHW motivation was defined by 16 items across three dimensions - intrinsic job satisfaction, burnout and team commitment, together explaining 56.04% of the total variance. The derived scale showed satisfactory internal consistency (Cronbach's alpha: 0.81), with a mean motivation score of 52.26 (standard deviation [sd]: 5.86) out of 64. Statistically significant differences were observed between formal CHWs - those with at least phase 1 standardised accredited training, and informal CHWs - those without such accredited training regarding team commitment scores (17.82 [sd: 2.48] vs. 17.07 [sd: 2.82]; t(233) = 2.157; p = 0.013). CHW age (β = 0.118, p = 0.029), location (β = 1.737, p = 0.041), length of service (β = - 0.495, p < 0.001), attendance of TB SHCI training (β = 1.809, p = 0.036), and TB SHCI competence (β = 0.706, p < 0.001), contributed statistically significantly to CHW motivation.

CONCLUSION

CHW motivation to perform TB SHCI was both intrinsic and extrinsic. The high overall mean score implies that the CHWs were well-motivated to perform TB SHCI. To ensure sustained improved access to quality TB SHCI service provision, programme managers in the Free State and similar settings could potentially use the tool derived from this study to monitor and inform CHW motivation interventions. Interventions should pay close attention to the CHWs' formalisation, competence and training.

Insights on COVID-19 From Community Health Worker State Leaders

Community health workers (CHWs) leverage their trusting relationships with underresourced populations to promote health equity and social justice in their communities. Little is known about CHWs roles in addressing COVID-19 or how the pandemic may have affected CHWs' ability to interact with and support communities experiencing disparities. A focus group with CHW leaders from 7 states revealed 8 major themes: CHW identity, CHW resiliency, self-care, unintended positives outcomes of COVID-19, technology, resources, stressors, and consequences of COVID-19. Understanding the pandemic's impact on CHWs has implications for workforce development, training, and health policies.

Equity for health delivery: Opportunity costs and benefits among Community Health Workers in Rwanda

Community Health Workers (CHWs) play a vital role delivering health services to vulnerable populations in low resource settings. In Rwanda, CHWs provide village-level care focused on maternal/child health, control of infectious diseases, and health education, but do not receive salaries for these services. CHWs make up the largest single group involved in health delivery in the country; however, limited information is available regarding the socio-economic circumstances and satisfaction levels of this workforce. Such information can support governments aiming to control infectious diseases and alleviate poverty through enhanced healthcare delivery. The objectives of this study were to (1) evaluate CHW opportunity costs, (2) identify drivers for CHW motivation, job satisfaction and care provision, and (3) report CHW ideas for improving retention and service delivery. In this mixed-methods study, our team conducted in-depth interviews with 145 CHWs from three districts (Kirehe, Kayonza, Burera) to collect information on household economics and experiences in delivering healthcare. Across the three districts, CHWs contributed approximately four hours of volunteer work per day (range: 0-12 hrs/day), which translated to 127 684 RWF per year (range: 2 359-2 247 807 RWF/yr) in lost personal income. CHW out-of-pocket expenditures (e.g. patient transportation) were estimated at 36 228 RWF per year (range: 3 600-364 800 RWF/yr). Participants identified many benefits to being CHWs, including free healthcare training, improved social status, and the satisfaction of helping others. They also identified challenges, such as aging equipment, discrepancies in financial reimbursements, poverty, and lack of formal workspaces or working hours. Lastly, CHWs provided perspectives on reasonable and feasible improvements to village-level health programming that could improve conditions and equity for those providing and using the CHW system.

Psychiatric Sequelae Among Community Social Service Agency Staff 1 Year After a Mass Shooting

This cross-sectional study examines the prevalence of mental health disorders and substance use among professional staff members at community social service agencies 1 year after a mass shooting in Pittsburgh, Pennsylvania.

Measuring motivation among close-to-community health workers: developing the CTC Provider Motivational Indicator Scale across six countries

BACKGROUND

Close-to-community (CTC) health service providers are a cost-effective and important resource in the promotion of and increasing access to health services. However, many CTC provider programmes suffer from high rates of de-motivation and attrition due to inadequate support systems. Recent literature has identified the lack of rigorous approaches towards measuring and monitoring motivation among CTC providers as an important gap. Building on scales used in previous studies, we set out to develop a short, simple-to-administer scale to monitor and measure indicators of CTC provider motivation across CTC programmes implemented in six countries: Ethiopia, Kenya, Malawi, Mozambique, Indonesia, and Bangladesh.

METHODS

We used focus group discussions (n = 18) and interviews (n = 106) conducted with CTC providers across all six countries, applying thematic analysis techniques to identify key determinants of motivation across these contexts. These themes were then used to carry out a systematic search of the literature, to identify existing scales or questionnaires developed for the measurement of these themes. A composite 24-item scale was then administered to CTC providers (n = 695) across the six countries. Survey responses were subsequently randomly assigned to one of two datasets: the first for scale refinement, using exploratory techniques, and the second for factorial validation. Confirmatory factor analysis was applied to both datasets.

RESULTS

Results suggest a 12-item, four-factor structure, measuring community commitment, organisational commitment, job satisfaction, and work conscientiousness as common indicators of motivation among CTC providers across the six countries.

CONCLUSIONS

Consistent with previous studies, findings support the inclusion of job satisfaction, organisational commitment, and work conscientiousness within the CTC Provider Motivation Indicator Scale. In addition, findings further supported the addition of a fourth, community commitment, sub-scale. Practical applications of the revised scale, including how it can be applied to monitor motivation levels within CTC provider programming, are discussed.

Novel Service Delivery Approach to Address Reproductive Health Disparities within Immigrant Latino Communities in Geographic Hot Spots: An Implementation Study

Latinx youths continue to have the highest rates of teenage births in the United States and are at increased risk of acquiring sexually transmitted infections, including HIV/AIDS. A community-based research partnership piloted Families Talking Together, a brief, parent-based sexual risk reduction program using a novel and culturally relevant approach. This mixed-methods study examined the feasibility and acceptability of Spanish-speaking promotoras de salud (that is, community health workers) as implementers of an evidence-based intervention (EBI) to reach underserved immigrant communities. Findings suggest that promotoras are capable of implementing the EBI with positive organizational, client, and implementation outcomes. Furthermore, promotoras hold particular promise for addressing reproductive health disparities as they are indigenous and trusted members of the community who can reach members of marginalized Latino populations.

Using qualitative evaluation components to help understand context: case study of a family planning intervention with female community health volunteers (FCHVs) in Nepal

BACKGROUND

Evaluations of health interventions are increasingly concerned with measuring or accounting for 'context'. How to do this is still subject to debate and testing, and is particularly important in the case of family planning where outcomes will inevitably be influenced by contextual factors as well as any intervention effects. We conducted an evaluation of an intervention where female community health volunteers (FCHVs) in Nepal were trained to provide better interpersonal communication on family planning. We included a context-orientated qualitative component to the evaluation. Here, we discuss the evaluation findings, specifically focusing on what was added by attending to the context. We explore and illustrate important dimensions of context that may also be relevant in future evaluation work.

METHODS

The evaluation used a mixed methods approach, with a qualitative component which included in-depth interviews with women of reproductive age, FCHVs, and family planning service providers. We conducted iterative, thematic analysis.

RESULTS

The life-history fertility and contraception narratives generated from the in-depth interviews contextualised the intervention, yielding nuanced data on contraceptive choices, needs, and areas for future action. For instance, it highlighted how women generally knew about effective contraceptive methods and were willing to use them: information was not a major barrier. Barriers instead included reports of providers refusing service when women were not in the fifth day of their menstrual cycle when this was unnecessary. Privacy and secrecy were important to some women, and risked being undermined by information sharing between FCHVs and health services. The qualitative component also revealed unanticipated positive effects of our own evaluation strategies: using referral slips seemed to make it easier for women to access contraception.

CONCLUSIONS

Life history narratives collected via in-depth interviews helped us understand pathways from intervention to effect from the user point of view without narrowly focusing only on the intervention, highlighting possible areas for action that would otherwise have been missed. By attending to context in a nuanced way in evaluations, we can build a body of evidence that not only informs future interventions within that context, but also builds better knowledge of contextual factors likely to be important elsewhere.

Job burnout and correlated factors of three-tiered public health workers: A cross-sectional study in China

This study aimed to reveal burnout levels and its potential influencing factors among three-tiered public health workers in China. A total of 1,328 public health workers from cities, counties and townships in Henan and Hubei provinces participated. Cumulative logistic regressions were used to determine job burnout predictors. Township workers (β = 0.276, p = .046) showed higher levels of emotional exhaustion (EE) than city workers. Municipal workers showed higher levels of depersonalisation (DP) (β = -0.439, p = .004) and lack of personal accomplishment (LPA) (β = -0.343, p = .005) than township workers. Compared with those who had better results, township workers with average levels of interpersonal relationships (β = 0.703, p = .014) exhibited higher EE degrees. Municipal (β = 1.050, p < .001) and county (β = 1.359, p < .001) workers with moderate training satisfaction had higher levels of burnout than those with a high degree of training satisfaction. Municipal (β = 3.933, p < .001) and county (β = 1.218, p = .018) workers earning 2,000 RMB and below every month were more likely to have higher burnout levels than those earning 4,001 RMB and above. Township respondents exhibited high EE levels, given the low-level education of their services' target audience. Similarly affected by interpersonal relationships, township workers require interpersonal and emotional intervention programmes. City respondents showed a high level of DP and LPA, which was attributed to considerable differences between public health workers and medical workers in cities. Hence, apart from narrowing the reward gap between clinicians and public health workers, improving public health workers' social cognition and status by various channels was found necessary. The burnout of municipal and county respondents were influenced by income and training. Improving the role of income as incentive and reforming trainings programmes would be necessary.