Community health workers at the dawn of a new era

A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low- and middle-income countries

BACKGROUND

Global concerns regarding effective response strategies to the COVID-19 pandemic arose amid the swift spread of the virus to low- and middle-income country (LMIC) settings. Although LMICs instituted several measures to mitigate spread of the virus in low resource settings, including task shifting certain demand and supply functions to community actors such as community health workers (CHWs), there remains a lack of synthesized evidence on these experiences and lessons. This scoping review sought to synthesize evidence regarding the roles and challenges faced by CHWs during the fight against COVID-19, along with strategies to address these challenges.

METHODOLOGY

We systematically searched several major electronic databases including PubMed, HINARI, Cochrane Library (Reviews and Trials), Science Direct and Google Scholar for relevant literature. The search strategy was designed to capture literature published in LMICs on CHWs roles during COVID-19 period spanning 2019-2023. Two researchers were responsible for retrieving these studies, and critically reviewed them in accordance with Arksey and O'Malley scoping review approach. In total, 22 articles were included and analysed using Clarke and Braun thematic analysis in NVivo 12 Pro Software.

RESULTS

Community health workers (CHWs) played a vital role during the COVID-19 pandemic. They engaged in health promotion and education, conducted surveillance and contact tracing, supported quarantine efforts, and maintained essential primary health services. They also facilitated referrals, advocated for clients and communities, and contributed to vaccination planning and coordination, including tracking and follow-up. However, CHWs faced significant challenges, including a lack of supplies, inadequate infection prevention and control measures, and stigma from community members. Additionally, they encountered limited supportive policies, insufficient remuneration and incentives. To enhance CHWs' performance, regular training on preventive measures is essential. Utilizing digital technology, such as mobile health, can be beneficial. Establishing collaborative groups through messaging platforms and prioritizing access to COVID-19 vaccines are important steps. Additionally, delivering wellness programs and providing quality protective equipment for CHWs are crucial for their effectiveness.

CONCLUSION

The study found that CHWs are vital actors within the health system during global pandemics like COVID-19. This entails the need for increased support and investment to better integrate CHWs into health systems during such crises, which could ultimately contribute to sustaining the credibility of CHWs programs and foster more inclusive community health systems (CHSs).

Strengthening the role of community health assistants in delivering primary health care: the case of maternal health services in Zambia

INTRODUCTION

Many low-and middle-income countries, including Zambia experience a huge deficit of human resource for health, which affects the delivery of primary health care services such as maternal and child health (MCH), nutrition, HIV and gender-based services. The Clinton Health Access Initiative in collaboration with the Zambian Ministry of Health implemented a community health systems (CHS) strengthening project to enhance the capacity of community health assistants (CHA) to provide MCH services from 2019 to 2021. The project activities included capacity building in supervision, provision of financial incentives and logistics. This study explores how these interventions strengthened the role of the CHAs in delivering MCH services.

METHODOLOGY

This was a qualitative study consisting of 189 KIIs and IDIs as well as 20 FGDs conducted in all the 10 provinces of Zambia with the CHAs, and their supervisors, health workers, neighbourhood health committees and community members. Data were analysed using thematic analysis.

RESULTS

The CHS strengthening interventions including provision of training manuals, streamlined recruitment and deployment policies, capacity building of CHA supervisors, provision of transport and monthly remuneration contributed to improved delivery and acceptability of MCH services. Further, the leveraging of community networks, linkages and partnerships when delivering these services, including the traditional and religious leaders contributed to improved coverage and acceptability of MCH services. Meanwhile, health systems barriers such as limited supplies in some health facilities, shortage of health workers, persistent transportation challenges and failure to fully abide by the CHA recruitment and selection criteria affected delivery and acceptability of MCH services.

CONCLUSION

This study builds on existing evidence on the importance of building a stronger community-based primary health care to effectively address maternal and child health related issues. We emphasize the need to integrate strategies such as provision of training manuals, enhanced recruitment and deployment policies, capacity building of supervisors, provision of transport and remuneration within the CHA program to enhance the provision and acceptability of health services.

Relationship of perinatal outcomes to the competence and quantity of contact with community health workers

Background

The effectiveness of perinatal home visits by community health workers (CHWs) often diminishes when large regional or national programmes are implemented. To address this gap, we aimed to identify which CHW behaviours influence maternal and child outcomes.

Methods

We randomised all government-funded CHWs at eight deeply rural clinics (n = 43) by clinic to usual care, which consisted of home visits (control group; four clinics, 23 CHWs, 392 mothers), or to home visiting, which included improved monitoring and supervision (intervention group; four clinics, 20 CHWs, 423 mothers). Since fewer than 7% of CHWs in the control group ever implemented home visits and no data was available on the frequency of visits, we focussed on the CHWs in the intervention group. We monitored the number and timing of home visits over time and documented it by paper and mobile phone records. Supervisors who conducted at-home observations of visits completed competency ratings on each CHW. We evaluated the associations between the competency of the CHW and the number and timing of CHWs' visits with 13 maternal/child outcomes using multiple regression analyses.

Results

Consistent home visits by CHWs reached the threshold at about 9-12 months, with the frequency reducing because of COVID-19. There were two significant outcomes (antiretroviral therapy adherence and securing the child grant) associated with the number of home visits in the intervention group, but insufficient to demonstrate efficacy. The CHW competency was unrelated to any maternal/child outcome. Moreover, CHWs visited 7% of mothers during the first two days of their infants' lives, 26% during the first week, 57% within the first month, and 90% by the first three months of life.

Conclusions

Current standards for training and monitoring of paraprofessional home visitors are highly unrealistic. Substantial and ongoing investments are needed for visits to occur consistently over time. However, hiring and selection criteria are likely as important as training and monitoring. CHW programmes must be embedded in organisational contexts that are well functioning and have management and support structures that are operational to ensure their success.Keywords.

How community-based health workers fulfil their roles in epidemic disease surveillance: a case study from Burkina Faso

BACKGROUND

In 2016, Burkina Faso adopted a new community-based model for disease surveillance, appointing two community-based health workers (CBHWs) per village. The CBHWs play a crucial yet under-researched role in Burkina Faso's health system. This study aimed to analyze the factors influencing their practices in relation to their official roles in epidemic disease surveillance.

METHODS

Conducted in the Dandé Health District in southwestern Burkina Faso, this qualitative study collected data through semi-structured interviews with 15 CBHWs and 25 health professionals, supplemented by observations of the CBHWs' working conditions. Data analysis employed a qualitative content analysis.

RESULTS

Analysis showed major challenges in the current community health strategy, particularly in capacity building and the working conditions of CBHWs (e.g., lack of monthly report sheets and financial incentives). Recognition from the community was the key motivation for volunteering as a CBHW in Dandé Health District where rural populations are under great financial pressure. Consequently, financial incentives (monthly remuneration and extra incentives) and non-financial rewards in terms of status and prestige, play a crucial role in sustaining volunteer enegagment and effectiveness.

CONCLUSIONS

This study underscores the necessity of establishing a clear policy on compensation and protection for CBHWs to motivate and optimize their work. Such policies are essential for enhancing their contribution to a robust national community surveillance system, ultimately improving public health outcomes in Burkina Faso.

Insights and inspirations: A qualitative exploration of community health workers' motivations in Myanmar and Bangladesh

Community Health Workers (CHWs) play significant roles in various settings, with their motivations and retention strategies widely studied. Yet, literature is sparse on CHWs from Myanmar, who are key to primary health care in marginalized and conflict-affected areas. This study explores the unique challenges these CHWs face, using firsthand accounts. Life story interviews, enhanced with a lifeline tool, were conducted with 34 CHWs from conflict-affected regions in Myanmar and in Rohingya camps in Bangladesh. Additionally, eight key informant interviews were held with leaders from organizations that work with CHWs. Data analysis was facilitated by NVivo 14 software and four layers of influence adapted from Urie Bronfenbrenner's ecological systems theory of human development. The findings reveal that, CHWs primarily joined organizations to acquire skills and knowledge. In Bangladesh, the focus was on job-related skills, whereas in Myanmar, healthcare skills were prioritized. Despite remuneration being inadequate, it remained crucial for retention, as did the sense of being valued by the community in Myanmar. Mental health support emerged as a potential need for CHWs. Funding deficits and fragmented support presented organizational challenges, thereby impacting both program implementation and retention of CHWs. To address these challenges, effective, sustainable CHW programs in conflict-affected regions require a shift towards long-term support for organizations and health systems. This includes focusing on CHWs' mental health and stakeholder engagement. Short-term, fragmented solutions may revert to pre-existing situations once removed. Sustainability planning is key to break the CHW turnover cycle and maximize investments in these contexts.

Responding to fluctuations in public and community trust and health seeking behaviour during the COVID-19 pandemic: a qualitative study of national decision-makers' perspectives in Guinea and Sierra Leone

BACKGROUND

The level of trust in health systems is often in flux during public health emergencies and presents challenges in providing adequate health services and preventing the spread of disease. Experiences during previous epidemics has shown that lack of trust can impact the continuity of essential health services and response efforts. Guinea and Sierra Leone were greatly challenged by a lack of trust in the system during the Ebola epidemic. We thus sought to investigate what was perceived to influence public and community trust in the health system during the COVID-19 pandemic, and what strategies were employed by national level stakeholders in order to maintain or restore trust in the health system in Guinea and Sierra Leone.

METHODS

This qualitative study was conducted through a document review and key informant interviews with actors involved in COVID-19 and/or in malaria control efforts in Guinea and Sierra Leone. Key informants were selected based on their role and level of engagement in the national level response. Thirty Six semi-structured interviews (16 in Guinea, 20 in Sierra Leone) were recorded, transcribed, and analyzed using an inductive and deductive framework approach to thematic analysis.

RESULTS

Key informants described three overarching themes related to changes in trust and health seeking behavior due to COVID-19: (1) reignited fear and uncertainty among the population, (2) adaptations to sensitization and community engagement efforts, and (3) building on the legacy of Ebola as a continuous process. Communication, community engagement, and on-going support to health workers were reiterated as crucial factors for maintaining trust in the health system.

CONCLUSION

Lessons from the Ebola epidemic enabled response actors to consider maintaining and rebuilding trust as a core aim of the pandemic response which helped to ensure continuity of care and mitigate secondary impacts of the pandemic. Monitoring and maintaining trust in health systems is a key consideration for health systems resilience during public health emergencies.

Strengthening the effectiveness of community health system: Assessing the factors that enhance or constrain the delivery of health services within communities in Nigeria

INTRODUCTION

Sub-optimal community health service delivery (CHSD) has been a challenge constraining community health systems (CHS) globally, especially in developing countries such as Nigeria. This paper examined the key factors that either enhance or constrain CHSD in Nigeria at the individual, community/facility and governmental levels while recommending evidence-based solutions for sustaining and improving CHSD within the framework of CHS.

METHODS

Data were collected through a qualitative study undertaken in three states (Anambra, Akwa-Ibom and Kano) in Nigeria. Respondents were formal/informal health providers, community leaders and representatives of civil society organizations all purposively sampled. There were 90 in-depth interviews and 12 focus group discussions, which were audio-recorded, transcribed verbatim and analysed thematically using codes to identify key themes.

RESULTS

Factors constraining community health service delivery at the individual level were poor health-seeking behaviour, preference for quacks and male dominance of service delivery; at the community/facility level were superstitious/cultural beliefs and poor attitude of facility workers; at the governmental level were inadequate financial support, embezzlement of funds and inadequate social amenities. Conversely, the enabling factors at the individual level were community members' participation and the compassionate attitude of informal providers. At the community and facility levels, the factors that enhanced service delivery were synergy between formal and informal providers and support from community-based organizations and structures. At the governmental level, the enhancing factors were the government's support of community-based formal/informal providers and a clear line of communication.

CONCLUSIONS

Community health service delivery through a functional community-health system can improve overall health systems strengthening and lead to improved community health. Policy-makers should integrate community health service delivery in all program implementation and ultimately work with the community health system as a veritable platform for effective community health service delivery.

Expanded roles of community health workers to sustain malaria services in the Asia-Pacific: A landscaping survey

Malaria Community Health Workers (CHWs) in the Greater Mekong Subregion (GMS) are an important component of malaria elimination efforts. As malaria declines with intensified efforts to eliminate by 2030, expanding their roles beyond malaria could help to sustain funding and provision of malaria services at the community level. Evidence of how programmes have implemented and managed CHWs performing both malaria and non-malaria roles across the Asia-Pacific region can provide insight into the viability of this strategy. A short survey was distributed to national malaria programmes and implementing organizations in the Asia-Pacific region in 2021-2022. The survey identified CHW programmes in the region, and collected information on malaria and non-malarial services provided by CHWs, characteristics of each identified programme, and the impact of COVID-19 on these programmes. 35 survey responses identified 28 programmes in 14 countries. The most frequently reported services provided by malaria CHWs were health promotion and education for malaria (13/14 countries) and other diseases (11/14); and COVID-19 related activities (10/14). Most programmes were financed wholly through donor funding (18/28 programmes), or donor plus government funding (6/28). Of 21 programmes which performed programme evaluation, only 2 evaluated their impacts on diseases beyond malaria. Declining donor funding, and COVID-19 related travel and activity restrictions were identified as implementation challenges. CHWs across the Asia Pacific provide a range of health services with malaria and are resilient under changing public health landscapes such as the COVID-19 pandemic. Further investigation into the impact of additional roles on malaria CHW performance and targeted health outcomes is needed to verify the benefits and feasibility of role expansion. As the GMS approaches elimination, and funding declines, verifying the cost effectiveness of malaria CHW programmes will be vital to persuade donors and countries to invest in malaria CHWs to sustain malaria services, and strengthen community-based health care.

Expanding community case management of malaria to all ages can improve universal access to malaria diagnosis and treatment: results from a cluster randomized trial in Madagascar

BACKGROUND

Global progress on malaria control has stalled recently, partly due to challenges in universal access to malaria diagnosis and treatment. Community health workers (CHWs) can play a key role in improving access to malaria care for children under 5 years (CU5), but national policies rarely permit them to treat older individuals. We conducted a two-arm cluster randomized trial in rural Madagascar to assess the impact of expanding malaria community case management (mCCM) to all ages on health care access and use.

METHODS

Thirty health centers and their associated CHWs in Farafangana District were randomized 1:1 to mCCM for all ages (intervention) or mCCM for CU5 only (control). Both arms were supported with CHW trainings on malaria case management, community sensitization on free malaria care, monthly supervision of CHWs, and reinforcement of the malaria supply chain. Cross-sectional household surveys in approximately 1600 households were conducted at baseline (Nov-Dec 2019) and endline (Nov-Dec 2021). Monthly data were collected from health center and CHW registers for 36 months (2019-2021). Intervention impact was assessed via difference-in-differences analyses for survey data and interrupted time-series analyses for health system data.

RESULTS

Rates of care-seeking for fever and malaria diagnosis nearly tripled in both arms (from less than 25% to over 60%), driven mostly by increases in CHW care. Age-expanded mCCM yielded additional improvements for individuals over 5 years in the intervention arm (rate ratio for RDTs done in 6-13-year-olds, RRRDT6-13 years = 1.65; 95% CIs 1.45-1.87), but increases were significant only in health system data analyses. Age-expanded mCCM was associated with larger increases for populations living further from health centers (RRRDT6-13 years = 1.21 per km; 95% CIs 1.19-1.23).

CONCLUSIONS

Expanding mCCM to all ages can improve universal access to malaria diagnosis and treatment. In addition, strengthening supply chain systems can achieve significant improvements even in the absence of age-expanded mCCM.

TRIAL REGISTRATION

The trial was registered at the Pan-African Clinical Trials Registry (#PACTR202001907367187).

Community health workers' dissemination of COVID-19 information and services in the early pandemic response: a systematic review

BACKGROUND

Community health workers (CHWs) had important roles mitigating the impact of the COVID-19 pandemic in vulnerable communities. We described how CHWs supported the dissemination of COVID-19 information and services during the early pandemic response.

METHODS

Online article searches were conducted across five scientific databases, with review article reference lists hand searched to identify grey/unpublished literature. Articles were included if they reported on a program that engaged CHWs and aimed to prevent/control COVID-19.

RESULTS

Nineteen relevant programs were identified from 18 included articles. CHWs were widely engaged in the pandemic response, especially in low- and middle-income countries and in vulnerable communities. CHWs' ability to effectively disseminate COVID-19 information/services was enabled by community trust and understanding community needs. CHWs were often underfunded and required to work in difficult conditions. Pre-existing services incorporating CHWs rapidly adapted to the new challenges brought by the pandemic.

CONCLUSIONS

We recommend establishing programs that employ CHWs to disseminate health information and services in communities at-risk of misinformation and poor health outcomes during non-pandemic times. CHWs are well-placed to deliver interventions should an infectious disease outbreak arise. Having pre-existing trusted relationships between CHWs and community members may help protect vulnerable groups, including when outbreaks occur.

Building consensus on common features and interoperability use cases for community health information systems: a Delphi study

INTRODUCTION

Information systems for community health have become increasingly sophisticated and evidence-based in the last decade and they are now the most widely used health information systems in many low-income and middle-income countries. This study aimed to establish consensus regarding key features and interoperability priorities for community health information systems (CHISs).

METHODS

A Delphi study was conducted among a systematically selected panel of CHIS experts. This impressive pool of experts represented a range of leading global health institutions, with gender and regional balance as well as diversity in their areas of expertise. Through five rounds of iterative surveys and follow-up interviews, the experts established a high degree of consensus. We supplemented the Delphi study findings with a series of focus group discussions with 10 community health worker (CHW) leaders.

RESULTS

CHISs today are expected to adapt to a wide range of local contextual requirements and to support and improve care delivery. While once associated with a single role type (CHWs), these systems are now expected to engage other end users, including patients, supervisors, clinicians and data managers. Of 30 WHO-classified digital health interventions for care providers, experts identified 23 (77%) as being important for CHISs. Case management and care coordination features accounted for more than one-third (14 of 37, 38%) of the core features expected of CHISs today, a higher proportion than any other category. The highest priority use cases for interoperability include CHIS to health management information system monthly reporting and CHIS to electronic medical record referrals.

CONCLUSION

CHISs today are expected to be feature-rich, to support a range of user roles in community health systems, and to be highly adaptable to local contextual requirements. Future interoperability efforts, such as CHISs in general, are expected not only to move data efficiently but to strengthen community health systems in ways that measurably improve care.

An anthropological history of Nepal's Female Community Health Volunteer program: gender, policy, and social change

BACKGROUND

Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history-even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs).

METHODS

We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources.

RESULTS

Looking across four decades of the program's history illuminates that issues of gender, workload, and pay-hotly debated in the CHW literature now-have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system.

CONCLUSIONS

Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment.

On-demand mobile hypertension training for primary health care workers in Nigeria: a pilot study

BACKGROUND

Only one out of every ten Nigerian adults with hypertension has their blood pressure controlled. Health worker training is essential to improve hypertension diagnosis and treatment. In-person training has limitations that mobile, on-demand training might address. This pilot study evaluated a self-paced, case-based, mobile-optimized online training to diagnose and manage hypertension for Nigerian health workers.

METHODS

Twelve hypertension training modules were developed, based on World Health Organization and Nigerian guidelines. After review by local academic and government partners, the course was piloted by Nigerian health workers at government-owned primary health centers. Primary care physician, nurse, and community health worker participants completed the course on their own smartphones. Before and after the course, hypertension knowledge was evaluated with multiple-choice questions. Learners provided feedback by responding to questions on a Likert scale.

RESULTS

Out of 748 users who sampled the course, 574 enrolled, of whom 431 (75%) completed the course. The average pre-test score of completers was 65.4%, which increased to 78.2% on the post-test (P < 0.001, paired t-test). Health workers who were not part of existing hypertension control programs had lower pre-test scores and larger score gains. Most participants (96.1%) agreed that the training was applicable to their work, and nearly all (99.8%) agreed that they enjoyed the training.

CONCLUSIONS

An on-demand mobile digital hypertension training increases knowledge of hypertension management among Nigerian health workers. If offered at scale, such courses can be a tool to build health workforce capacity through initial and refresher training on current clinical guidelines in hypertension and other chronic diseases in Nigeria as well as other countries.

Community health workers for health systems resilience during COVID-19: protocol for qualitative evidence synthesis

INTRODUCTION

COVID-19 exposed the fragility of health systems, where even the most basic health services in high-income and low-income and middle-income nations could not withstand the health systems shock due to the pandemic. Community health workers (CHWs) can contribute to improving the resilience of health systems, specifically to withstand shocks and emergencies and to avoid disruptions of routine service delivery. We aim to explore and understand the 'individual' and 'systems-level' resilience factors that shaped the involvement of CHWs in the COVID-19 response.

METHODS AND ANALYSIS

We will search five electronic databases (PubMed, Cochrane Library, EMBASE, CINAHL and SciELO (Spanish)) and conduct citation screening to identify studies on CHWs' response during the COVID-19 pandemic. Two review authors will independently screen the studies for inclusion and to extract data. The software Rayyan will be used to assist in screening the relevant literature. A thematic analysis approach will be followed to analyse and synthesise the qualitative evidence. The quality of the included studies will be critically assessed using the Critical Skills Appraisal Programme Tool. We will use the GRADE CERQual(Grading of Recommendations, Assessment, Development, and Evaluations - Confidence in the Evidence from Reviews of Qualitative Research) approach to assess certainty in the synthesised findings of the qualitative evidence.

ETHICS AND DISSEMINATION

This study will be conducted on published evidence, with no living participants; thus, no ethical approval is required. The final review will be submitted and published in a peer-reviewed journal. We will also develop a policy brief to communicate the review findings to the stakeholders.

Prospects for the development of community-based care in remote rural areas: a stakeholder analysis in Laos

BACKGROUND

Community-based health programmes have been a cornerstone of primary care in Laos for decades. The study presented here aimed to document prospects for the development of current programmes, considering perceptions about health and health care priorities in the communities, implementation challenges, the policy landscape and opportunities associated with the availability of new technologies.

METHODS

The research design primarily involved qualitative in-depth interviews with stakeholders (n = 35) responsible for the planning, management, or implementation of community-based care in Laos at different levels of the health system. These included health managers at central departments or institutes of the Ministry of Health, provincial health departments, district health offices, heads of health centres, village health volunteers, community representatives, and international stakeholders.

RESULTS

There was consensus that service delivery is still a challenge in many areas, due to geographic inaccessibility of health facilities, communication barriers, health-seeking behaviour, trust, and gender discrimination, particularly among ethnic minorities. In these settings, community health workers have the potential to extend the reach of the formal health system, acting as cultural brokers across sectors of society, ethnicities, and worldviews. To maximise impact, planners need to carefully consider the implementation model, financing arrangements, health system integration, and changing health priorities in the communities.

CONCLUSIONS

This study examined challenges to, and opportunities for, the expansion and health system integration of community-based care in Laos. Further development and horizontal integration of community-based care remains a complex financing and governance challenge, although the renewed emphasis on primary care and the ongoing process of decentralisation provide a favourable policy environment in the country to sustain and potentially expand existing programmes.

Experiences of community health workers on adopting mHealth in rural Malawi: A qualitative study

Background

The use of mobile health technology (mHealth) by community health workers (CHWs) can strengthen community-based service delivery and improve access to and quality of healthcare.

Objective

This qualitative study sought to explore experiences and identify factors influencing the use of an integrated smartphone-based mHealth called YendaNafe by CHWs in rural Malawi.

Methods

Using pre-tested interview guides, between August and October 2022, we conducted eight focus group discussions with CHWs (n = 69), four in-depth interviews with CHW supervisors, and eight key informant interviews in Neno District, Malawi. We audio-recorded and transcribed the interviews verbatim and organized them for analysis in Dedoose V9.0.62. We used an inductive analysis technique to analyze the data. We further applied the six domains of the socio-technical system (STS) framework to map factors influencing the use of YendaNafe.

Results

User experiences and facilitators and barriers were the two main themes that emerged. mHealth was reported to improve the task efficiency, competence, trust, and perceived professionalism of CHWs. CHWs less frequently referred to cultural factors influencing app uptake. However, for other social systems, they identified relationships and trust with stakeholders, availability of training and programmatic support, and performance monitoring and feedback as influencing the use of YendaNafe. From the STS technical domain, the availability and adequacy of hardware such as phones, mobile connectivity, and usability influenced the use of YendaNafe.

Conclusions

Despite the initial discomfort, CHWs found mHealth helpful in supporting their service delivery tasks. Identifying and addressing social and technical factors during mHealth implementation may help improve end users' attitudes and uptake.

Resilience outcomes and associated factors among workers in community-based HIV care centres during the Covid-19 pandemic: A multi-country analysis from the EPIC program

Introduction

Community health workers (CHW) were integral in the COVID-19 response, particularly concerning services for populations vulnerable to HIV. Little is known regarding the mental health of CHW during the COVID-19 crisis. The objective of this study was to study resilience of CHW working in HIV non-governmental organizations.

Methods

An anonymous online, cross-sectional questionnaire was implemented during 2021 among CHW in Benin, Colombia, Guatemala, and Spain. Three scales were used to assess mental health: the 6-item Brief-Resilience Scale, the 9-item Patient Scale Questionnaire and the 7-item Generalized-Anxiety-Disorder scale. Logistic regression models were used to identify factors associated with "low" resilience vs "normal" or "high" resilience.

Results

Among 295 respondents, the median standardized resilience score was 58.33 (IQR = [50.0-75.0], n = 267), 18.52 (IQR = [7.4-33.3], n = 282) for standardized depression score and 19.05 (IQR = [4.8-33.3], n = 274) for standardized anxiety score. Standardized resilience score was negatively correlated with standardized anxiety score (rho = -0.49, p < 0.001, n = 266) and standardized depression score (rho = -0.44, p < 0.001, n = 267).

Conclusions

Normal or high level of resiliency in the HIV CHW were observed during the COVID-19 crisis. Self-efficacy, through COVID-19 prevention training, was a factor associated with resilience. Health policy must place CHW at the core of the healthcare system response to Covid-19 and to future health emergencies, as they ensure continuity of care for many diseases including HIV among vulnerable populations.

Rethinking how development assistance for health can catalyse progress on primary health care

Global campaigns to control HIV, tuberculosis, malaria, and vaccine-preventable illnesses showed that large-scale impact can be achieved by using additional international financing to support selected, evidence-based, high-impact investment areas and to catalyse domestic resource mobilisation. Building on this paradigm, we make the case for targeting additional international funding for selected high-impact investments in primary health care. We have identified and costed a set of concrete, evidence-based investments that donors could support, which would be expected to have major impacts at an affordable cost. These investments are in: (1) individuals and communities empowered to engage in health decision making, (2) a new model of people-centred primary care, and (3) next generation community health workers. These three areas would be supported by strengthening two cross-cutting elements of national systems. The first is the digital tools and data that support facility, district, and national managers to improve processes, quality of care, and accountability across primary health care. The second is the educational, training, and supervisory systems needed to improve the quality of care. We estimate that with an additional international investment of between US$1·87 billion in a low-investment scenario and $3·85 billion in a high-investment scenario annually over the next 3 years, the international community could support the scale-up of this evidence-based package of investments in the 59 low-income and middle-income countries that are eligible for external financing from the World Bank Group's International Development Association.

Impact of youth lay health workers on HIV service delivery in South Africa: A pragmatic cluster randomized trial of the Youth Health Africa program

BACKGROUND

Innovative approaches are needed to increase lay health workers in HIV programs. The Youth Health Africa (YHA) program is a novel approach that places young adults seeking work experience in one-year internships in health facilities to support HIV-related programming (e.g., HIV testing) or administration (e.g., filing).

METHODS

We implemented a pragmatic, randomized trial among 20 facilities in Ngaka Modiri Molema district in North West province from October 2020-August 2021 to assess impact of YHA interns on HIV testing, treatment initiation, and retention in care. The primary outcome was proportion of patients tested for HIV. Secondary outcomes assessed HIV positivity, initiation in care, retention in care, and HIV testing among males and adolescents/young adults. We conducted an intention-to-treat analysis accounting for variations in baseline outcomes between control and intervention facilities using difference-in-difference and controlled time series approaches. We repeated this using as-treated groupings for sensitivity analyses.

RESULTS

Fifty interns were placed in 20 facilities; thirty-four interns remained at 18 facilities through August 2021. Compared to control facilities, intervention facilities had a greater improvement in HIV testing (ΔΔ+5.7%, 95% Confidence Interval (CI): -3.7%-15.1%) and treatment initiation (ΔΔ+10.3%, 95% CI: -27.8-48.5%), but these differences were not statistically significant. There was an immediate increase in HIV testing in intervention facilities after program interns were placed, which was not observed in control facilities; this difference was significant (ΔΔ+8.4%, 95% CI: 0.5-16.4%, p = 0.036). There were no other differences in outcomes observed between intervention and control facilities.

CONCLUSION

This was largely a null trial, but there were signals that program interns may have positive impact on HIV testing and treatment initiation. As implemented in this study, addition of YHA program interns had little impact on facility-based HIV service delivery. A higher number of interns placed per facility may be necessary to affect HIV services.

TRIAL REGISTRATION

Registration: This trial was registered with the ISRCTN (Registration number: ISRCTN67031403) in October 2022.

Challenges and experience of the Ethiopian rural health extension program: implications for reform and revitalization

BACKGROUND

Despite remarkable gains over the past decade, mounting evidence suggests that Ethiopia's rural health extension program (HEP) is facing serious implementation challenges. We investigated the current and potential future program design and implementation challenges of Ethiopia's rural HEP based on the lived experiences of health extension workers (HEW) implementing the program at the grassroots level.

METHODS

We employed a longitudinal qualitative exploration linked to a larger cluster-randomized trial (RCT) which was implemented in 282 villages randomly selected from 18 Kebeles of the Gedeo zone, southern Ethiopia. Data were collected using in-depth interviews with key informants, focus group discussion, and passive observation of program implementation. The data were analyzed manually using a thematic framework analysis approach. Themes and sub-themes were generated by condensing, summarizing, and synthesizing data collected in the field in the form of extended notes and field observation checklists.

FINDINGS

Despite considerable gains in availing basic health services to the rural population, HEP seems to suffer serious design and implementation flaws that demand thoughtful and immediate adjustment. The design constraints span from the number and type of intervention packages to the means of dissemination (vehicle) as well as the target population emphasized. As such, some low-cost high-impact interventions that were strongly desired by the community were overlooked, while others were inappropriately packed. The means of distribution - female health extension workers trained with basic prevention skills, were lacking essential skills. They also had high burnout rates and with little engagement with men, were repeatedly mentioned flaws of the program demanding revitalization. Furthermore, the sheer structure of HEP precluded adult and adolescent men, non-reproductive women, and the elderly.

CONCLUSION

Despite significant gains over the last couple of months, Ethiopia's rural HEP appears to have reached a tipping point that requires a comprehensive revamp of the program package, means of distribution, and target beneficiaries rather than the "usual" tweaks to reap maximum benefits.

Community health workers: essential in ensuring primary health care for equitable universal health coverage, but more knowledge and action is needed

Community health workers (CHWs) have helped improve access to quality primary health care (PHC). However, knowledge gaps exist in designing and implementing CHW-engaged models needed to ensure quality people-centered PHC. In this collection, we call for papers which bridge this knowledge gap, to build sustainable, resilient and equitable CHW programs.

Community Health Workers' experiences of a package providing increased support and supervision - a qualitative study of a home visiting model in rural South Africa

Deploying Community Health Workers is a crucial strategy to improve health at a community level in low and middle income countries. While there is substantial evidence for CHW effectiveness, there is a need for more research on the mechanisms through which these programs work. Understanding CHWs experiences of how programmes function is important. This article examines CHW's experiences of three key programmatic domains; training, logistical support and supervision. Data were gathered using a qualitative study embedded within a cluster randomized controlled trial of an enhanced supervision package delivered to government-employed CHWs in the rural Eastern Cape, South Africa. We interviewed CHWs (n = 16) and two supervisors. Three overarching areas and five sub-themes emerged from our interviews. CHW knowledge and confidence increased through additional training, that CHW motivation and community acceptance improved because of added logistical support, and that CHW supervision led to improved sense of accountability, feelings of respect, and sense of being supported. Our findings highlight the importance of a functional support system within which CHWs can operate, in a context where most CHWs operate in isolation and without support. CHWs receiving supportive supervision reported positive impacts on their motivation and ability to carry out their work effectively.

Cross-Training Pharmacy Professionals as Community Health Workers

Community health workers (CHWs) are health professionals that connect the populations they serve to health services. They play a valuable role in assessing patients' needs, linking patients with health and human resources, educating patients toward achieving optimal health, and advocating for their patients to have accessible resources to improve their health and wellbeing. Pharmacies are readily accessible and frequently utilized health locations that could employ CHWs. We describe a program to cross-train pharmacy professionals as CHWs. Pharmacy professionals were recruited to sign up for a 13-week CHW core competencies course that was offered in partnership with the state university Continuing Education Workforce Training. From March 2022 to June 2023, 23 pharmacy professionals completed the course. Post-course and program evaluations were completed by 10 participants, and they showed positive responses to their participation in the program. Participants appreciated learning the role of a CHW, and noted increased skills, and awareness of additional tools and resources. Participants reported 47 referrals to chronic disease programs and community resources. The program pilot results show successful partnerships for cross-training pharmacy professionals as CHWs. Cross-trained pharmacy professionals provide benefits to the communities they serve, by being a valuable resource for their patients.

Smoking behavior and hypertension among health workers during the COVID-19 pandemic: a case study in Java and Bali-Indonesia

Background

Health workers who should be role models for the community not to smoke and live a healthy life are still consuming cigarettes. Java and Bali (especially Java) are the biggest contributors to health worker deaths due to COVID-19 in Indonesia. This study aims to determine the association of smoking behavior and hypertension among health workers in Java and Bali. The researchers conducted this study in 2021 and designed it with a cross-sectional design. Data was collected online using the Lime Survey as a data collection tool. The data analysis used was logistic regression to determine the association of smoking and hypertension.

Result

A number of 7.6% of health workers were still smoking and 10.4% were suffering from hypertension during the COVID-19 pandemic. This study shows that the proportion of health workers with hypertension is two times that of smokers (18.0%) compared to non-smokers (9.8%). Logistic regression showed that smoking has a 20% higher risk of developing hypertension (OR = 1.97; 95%CI = 1.01-1.41; p = 0.034).

Conclusion

Among health workers on the islands of Java and Bali, there are still many who smoke, and this puts them at a higher risk of experiencing hypertension.

Community Health Workers: what do international studies tell us?

Abstract This is a narrative review whose objective is to understand the state of the art of the literature on Community Health Worker (CHW) programs worldwide, identifying their nomenclatures, practices, training, and working conditions. The major concentration of CHW programs can still be found in low- and middle-income countries in Africa (18), Asia (12), and Latin America (05), with a few experiences in high-income countries in North America (02) and Oceania (01). In total, 38 experiences were cataloged, and the practices of care, surveillance, education, health communication, administrative practices, intersectoral articulation, and social mobilization were described. The levels and duration of CHW training were characterized, as were the different working conditions in each country. Much of the work is precarious, often voluntary and carried out by women. This review provided a comparative overview that can contribute to enrich the view of managers and decision-makers in contexts of the implementation, expansion, and reconfiguration of such programs.

Community Health Workers: what do international studies tell us?

This is a narrative review whose objective is to understand the state of the art of the literature on Community Health Worker (CHW) programs worldwide, identifying their nomenclatures, practices, training, and working conditions. The major concentration of CHW programs can still be found in low- and middle-income countries in Africa (18), Asia (12), and Latin America (05), with a few experiences in high-income countries in North America (02) and Oceania (01). In total, 38 experiences were cataloged, and the practices of care, surveillance, education, health communication, administrative practices, intersectoral articulation, and social mobilization were described. The levels and duration of CHW training were characterized, as were the different working conditions in each country. Much of the work is precarious, often voluntary and carried out by women. This review provided a comparative overview that can contribute to enrich the view of managers and decision-makers in contexts of the implementation, expansion, and reconfiguration of such programs.

"They are gaining experience; we are gaining extra hands": a mixed methods study to assess healthcare worker perceptions of a novel strategy to strengthen human resources for HIV in South Africa

BACKGROUND

Lay health workers (LHWs) can support the HIV response by bridging gaps in human resources for health. Innovative strategies are needed to expand LHW programs in many low- and middle-income countries. Youth Health Africa (YHA) is a novel LHW approach implemented in South Africa that places young adults needing work experience in one-year non-clinical internships at health facilities to support HIV programs (e.g., as HIV testers, data clerks). While research suggests YHA can increase HIV service delivery, we need to understand healthcare worker perceptions to know if this is an acceptable and appropriate approach to strengthen human resources for health and healthcare delivery.

METHODS

We conducted a convergent mixed methods study to assess healthcare worker acceptance and perceived appropriateness of YHA as implemented in Gauteng and North West provinces, South Africa and identify issues promoting or hindering high acceptability and perceived appropriateness. To do this, we adapted the Johns Hopkins Measure of Acceptability and Appropriateness to survey healthcare workers who supervised interns, which we analyzed descriptively. In parallel, we interviewed frontline healthcare workers who worked alongside YHA interns and conducted an inductive, thematic analysis. We merged quantitative and qualitative results using the Theoretical Framework of Acceptability to understand what promotes or hinders high acceptance and appropriateness of YHA.

RESULTS

Sixty intern supervisors responded to the survey (91% response rate), reporting an average score of 3.5 for acceptability and 3.6 for appropriateness, on a four-point scale. Almost all 33 frontline healthcare workers interviewed reported the program to be highly acceptable and appropriate. Perceptions that YHA was mutually beneficial, easy to integrate into facilities, and helped facilities be more successful promoted a strong sense of acceptability/appropriateness amongst healthcare workers, but this was tempered by the burden of training interns and limited program communication. Overall, healthcare workers were drawn to the altruistic nature of YHA.

CONCLUSION

Healthcare workers in South Africa believed YHA was an acceptable and appropriate LHW program to support HIV service delivery because its benefits outweighed its costs. This may be an effective, innovative approach to strengthen human resources for HIV services and the broader health sector.

Community health workers and Covid-19: Cross-country evidence on their roles, experiences, challenges and adaptive strategies

Community health workers (CHWs) are a key part of the health workforce, with particular importance for reaching the most marginalised. CHWs' contributions during pandemics have received growing attention, including for COVID-19. This paper contributes to learning about CHWs' experiences during COVID-19, based on evidence from India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia. The paper synthesises evidence from a set of research projects undertaken over 2020-2021. A thematic framework based on the research focus and related literature was used to code material from the reports. Following further analysis, interpretations were verified with the original research teams. CHWs made important contributions to the COVID-19 response, including in surveillance, community education, and support for people with COVID-19. There was some support for CHWs' work, including training, personal protective equipment and financial incentives. However, support varied between countries, cadres and individual CHWs, and there were significant gaps, leaving CHWs vulnerable to infection and stress. CHWs also faced a range of other challenges, including health system issues such as disrupted medical supply chains, insufficient staff and high workloads, a particular difficulty for female CHWs who were balancing domestic responsibilities. Their work was also affected by COVID-19 public health measures, such as restrictions on gatherings and travel; and by supply-side constraints related to community access and attitudes, including distrust and stigmatization of CHWs as infectious or informers. CHWs demonstrated commitment in adapting their work, for example ensuring patients had adequate drugs in advance of lockdowns, and using their own money and time to address increased transport costs and higher workloads. Effectiveness of these adaptations varied, and some involved coping in a context of inadequate support. CHW are critical for effective response to disease outbreaks, including pandemics like COVID-19. To support CHWs' contribution and protect their wellbeing, CHWs need adequate resources, managerial support, and motivation.

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

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

Motivation and Performance of Community Health Workers: Nothing New Under the Sun, and Yet…

We know that both financial and nonfinancial incentives matter if we want community health workers (CHWs) who are motivated and performing. What are the practical implications for CHWs themselves and for effective management of viable CHW programs?

Effectiveness and Coverage of Treatment for Severe Acute Malnutrition Delivered by Community Health Workers in the Guidimakha Region, Mauritania

Geographical and economic access barriers to health facilities (HF) have been identified as some of the most important causes of the low coverage of severe acute malnutrition (SAM) treatment. The objective of this study is to assess the effectiveness and coverage of SAM treatment delivered by community health workers (CHWs) in the Guidimakha region in Mauritania, compared to the HF based approach. This study was a nonrandomized controlled trial, including two rural areas. The control group received outpatient treatment for uncomplicated SAM from HF, whilst the intervention group received outpatient treatment for uncomplicated SAM from HF or CHWs. A total of 869 children aged 6–59 months with SAM without medical complications were included in the study. The proportion of cured children was 82.3% in the control group, and 76.4% in the intervention group, we found no significant difference between the groups. Coverage in the intervention zone increased from 53.6% to 71.7%. In contrast, coverage remained at approximately 44% in the control zone from baseline to end-line. This study is the first to demonstrate in Mauritania that the decentralization model of CHWs treating SAM improves acute malnutrition treatment coverage and complies with the international quality standards for community treatment of acute malnutrition. The non-randomized study design may limit the quality of the evidence, but these results could be used by political decision-makers as a first step in revising the protocol for acute malnutrition management.