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

"I feel like my job is to give patients hope" - perspectives of Community Health Workers and employers in Iowa: a mixed methods study

INTRODUCTION

Community Health Workers (CHWs) play a crucial role in extending health services, particularly for people who are medically underserved. Despite efforts to expand CHW programs nationally and in Iowa, challenges persist in defining their roles and responsibilities. Few studies have considered the perspectives of both CHWs and CHW employers simultaneously.

METHODS

We conducted an exploratory sequential mixed-methods study, first involving key informant interviews with CHWs and employers, which then informed the development of surveys distributed to both populations. We performed thematic analysis of qualitative data and calculated descriptive statistics of quantitative data.

RESULTS

Key informant interviews were conducted with five CHWs and five employers. An additional 123 CHWs and 81 employers responded to the survey. From the interviews, we report six themes, including roles and responsibilities, interaction with the broader health care team, and support needed. Survey respondents reported 69 unique job titles, a wide range of populations served, and diverse training needs. Despite 93.6% (n = 102) of CHWs receiving on-the-job training, 48% (n = 52) indicated they would still benefit from more training to be effective in their roles. 46% (n = 21) of employers reported unstable funding as a major barrier to program implementation.

DISCUSSION

CHWs in Iowa felt supported and valued as members of the care team, yet challenges to growing the CHW workforce remain. Our findings highlight the need for continued role definition of the CHW workforce, as well as the need to establish more sustainable sources of funding to ensure the continuity and expansion of this health equity-enhancing workforce.

Strategies for effective and efficient delivery of primary health care by village health workers: A scoping review using the Rodgers' Evolutionary Concept Analysis Framework

BACKGROUND

 Village health workers (VHWs), popularly known as community health workers (CHWs) in some contexts and settings, should effectively complement health care providers in primary health care (PHC) delivery in Zimbabwe. However, they continue to offer services that do not address current and emerging health issues.

AIM

 This study aims to review the literature and develop a conceptual framework to improve the effectiveness and efficiency of VHWs in service delivery.

METHOD

 Rodgers' evolutionary framework was used to analyse the concept of 'strategies for effective and efficient delivery of PHC by VHWs'. Articles and reports published in English from 2010 to 2022 in peer-reviewed journals from the PUBMED, EBSCO, ScienceDirect and Google Scholar databases were reviewed.

RESULTS

 After screening and removal of duplicates a total of 52 articles and two reports were reviewed to identify antecedents, attributes and consequences of strategies to improve PHC services by village health workers. The antecedents included an enabling work environment, community participation, motivation, incentives, integration of community health into national health systems, and information and communication technology. The attributes consisted of ongoing training and skills development, mutual respect and trust, enhanced contact between VHWs and communities and supportive supervision. The consequences were equitable access to and improved quality of PHC service delivery.

CONCLUSION

 The concept of PHC service delivery by VHWs has evolved from health promotion to curative care through task shifting and is now an integral part of the health system. A supportive and enabling work environment, anchored in community participation, empowers VHWs to deliver equitable services effectively and efficiently.Contribution: The development of strategies for improving VHW service delivery and a conceptual framework informed by findings from the reviewed literature.

Leadership in federally qualified health centers: examining recruitment and retention in rural Oklahoma

PURPOSE

Healthcare workforce shortages, particularly in rural areas, present a global challenge. The purpose of this study is to explore the leadership dynamics within federally qualified health centers (FQHC) in rural Oklahoma, focusing on recruitment, retention, job satisfaction and development practices.

DESIGN/METHODOLOGY/APPROACH

Eighteen managers with five or more years of tenure from Oklahoma FQHCs were interviewed. Leadership's role in influencing job satisfaction, recruitment, retention and development practices was analyzed using a multilevel ecological framework through qualitative content analysis with NVivo.

FINDINGS

The analysis includes ten key themes including the critical role of leadership in addressing recruitment and retention challenges, the importance of aligning organizational culture, rural culture, access challenges, trainings and values with workforce development initiatives, and the impact of leadership practices on job satisfaction.

ORIGINALITY/VALUE

This study uniquely examines leadership strategies in rural FQHCs, integrating ecological considerations for cultural, logistical and community-specific factors. It emphasizes the pivotal role leadership plays in shaping workforce development. As rural healthcare evolves, refining these approaches is crucial for addressing workforce challenges, improving healthcare access and ensuring that rural FQHCs remain sustainable, driving positive outcomes for healthcare professionals and communities.

Involvement of community health workers in the COVID-19 pandemic response in Uganda: A qualitative study

Community Health Workers (CHWs) are a key human resource for health particularly in low- and middle-income countries. In many parts of the world, CHWs are known to have played an instrumental role in controlling the COVID-19 pandemic. This study explored the involvement of CHWs in the COVID-19 response in Uganda. A qualitative study that involved 10 focus group discussions (FGDs) among CHWs was conducted. The study was carried out in 5 districts of Amuria, Karenga, Kamwenge, Bugiri and Pader. The FGD guide used explored the role of CHWs in the COVID-19 response in their communities including lived experiences, challenges, and coping mechanisms. The data were analyzed thematically with the support of NVivo version 12 pro (QSR International). CHWs were at the frontline of COVID-19 prevention interventions at households and in the community. CHWs raised awareness on prevention measures including wearing face masks, hand hygiene, and social distancing. They identified suspected cases such as new members entering the community, as well as individuals returning from abroad with signs and symptoms of COVID-19. CHWs mobilized the community and increased awareness on COVID-19 vaccination which played an important role in reducing misinformation. They also supported home-based management of mild COVID-19 cases through isolation of patients; provided health and nutritional guidance among patients in their homes; and referred suspected cases to health facilities for testing and management. Both monetary and non-monetary incentives were provided to support CHWs in the COVID-19 response. However, the adequacy and timing of the incentives were inadequate. Routine services of CHWs such as health promotion and treatment of childhood illnesses were disrupted during the pandemic. CHWs played an instrumental role in response to the pandemic especially on surveillance, risk communication, and observance of preventing measures. Strategies to ensure that routine services of CHWs are not disrupted during pandemics are needed.

Vitamin A supplementation coverage and associated factors for children aged 6 to 59 months in integrated and campaign-based delivery systems in four sub-Saharan African countries

BACKGROUND

Vitamin A deficiency (VAD) is a leading contributor to the poor health and nutrition of young children in sub-Saharan Africa. Funding constraints are compelling many countries to shift from longstanding campaigns to integrating vitamin A supplementation (VAS) into routine health services. We assessed child VAS coverage and associated factors for integrated delivery systems in Mozambique, Senegal, and Sierra Leone and for a campaign-based delivery strategy in Tanzania.

METHODS

Data were obtained using representative household surveys administered to primary caregivers of N = 16,343 children aged 6-59 months (Mozambique: N = 1,659; Senegal: N = 7,254; Sierra Leone: N = 4,149; Tanzania: N = 3,281). Single-dose VAS coverage was assessed and bivariate and multivariable associations were examined for child VAS receipt with respect to rural or urban residence; child age and sex; maternal age, education, and VAS program knowledge; and household wealth.

RESULTS

VAS coverage for children aged 6-59 months was 42.8% (95% CI: 40.2, 45.6) in Mozambique, 46.1% (95% CI: 44.9, 47.4) in Senegal, 86.9% (95% CI: 85.8, 87.9) in Sierra Leone, and 42.4% (95% CI: 40.2, 44.6) in Tanzania and was significantly higher for children 6-11 vs. 24-59 months in Mozambique, Senegal, and Tanzania. In Sierra Leone, children aged 12-23 months (aOR = 1.86; 95% CI: 1.20, 2.86) and 24-59 months (aOR = 1.55; 95% CI: 1.07, 2.25) were more likely to receive VAS, compared to those 6-11 months. Maternal awareness of VAS programs was associated with higher uptake in Mozambique (aOR = 4.00; 95% CI: 2.81, 5.68), Senegal (aOR = 2.72; 95% CI: 2.35, 3.15), and Tanzania (aOR = 14.50; 95% CI: 10.98, 19.17). Increased household wealth was associated with a higher likelihood of child VAS in Senegal and Tanzania.

CONCLUSIONS

Our findings indicate routine delivery approaches for VAS are not achieving the level of coverage needed for public health impact in these settings. Intensive outreach efforts contributed to the higher coverage in Sierra Leone and highlight the importance of reducing the burdens associated with seeking supplementation at health facilities. As countries move towards incorporating VAS into routine health services, the essentiality of informed communities and potential losses for older children and socio-economically disadvantaged populations are key considerations in the sub-Saharan African context.

Enhancing sexual health and empowerment among migrant women sex workers: a community health worker-led intervention in Marseille, France

Introduction

Given the high infection rate of sexually transmitted infections (STI) among migrant women sex workers (WSWs), it is necessary to understand how to improve prevention, information and care for this vulnerable population. Community health workers (CHWs), by linking community to health services, are positioned to improve health outcomes in migrant communities. This article aims to describe a pilot innovative intervention performed by CHWs to improve sexual health in migrant WSWs.

Methods

This one-year intervention study used a respondent-driven sampling (RDS) to recruit a representative cohort of migrant WSWs in Marseille, France. Four CHWs were recruited from different communities and participated in all stages of the research. They performed individual and group interventions of prevention, support in care and empowerment. Data on participant characteristics, type of intervention and adherence to the intervention were reported via questionnaires given to participants. Simultaneously, semi-structured interviews and informal interviews of migrant WSW, CHWs and care providers were carried out.

Results

A total of 132 migrant WSWs were included in the cohort. Very few of them knew about PrEP (12%) or already used HIV post-exposure treatment (9%). Migrant WSWs were often victims of rape or racism, 15 and 21%, respectively. In two-thirds of cases the level of health literacy was low. Participants suffered from a combination of vulnerability factors: difficulties with access to social rights, food or housing. Only 13% reported having benefited from medical follow-up or assistance by an NGO in the 3 months prior to the program. By 3 months, more than one third of the participants had been tested for HIV (35%) and 63% knew about PrEP. A total retention rate of 70% was reported in the cohort after 6 months.

Conclusion

CHWs enabled to improve care access for migrant WSWs by improving the collaboration between care and social actors at a local level. Through these "bring-back-to" interventions for this hard-to-reach population, CHWs enabled an optimization of the care pathway. Our results also highlight the importance of a population-based approach for individual and group support of empowerment interventions in order to strengthen their capacity for action.

Labour conditions in dual-cadre community health worker programmes: a systematic review

BACKGROUND

Health care delivered by community health workers reduces morbidity and mortality while providing a considerable return on investment. Despite growing consensus that community health workers, a predominantly female workforce, should receive a salary, many community health worker programmes take the form of dual-cadre systems, where a salaried cadre of community health workers works alongside a cadre of unsalaried community health workers. We aimed to determine the presence, prevalence, and magnitude of exploitation in national dual-cadre programmes.

METHODS

We did a systematic review of available evidence from peer-reviewed databases and grey literature from database inception to Aug 2, 2021, for studies on unsalaried community health worker cadres in dual-cadre systems. Editorials, protocols, guidelines, or conference reports were excluded in addition to studies about single-tier community health worker programmes and those reporting on only salaried cadres of community health workers in a dual-cadre system. We extracted data on remuneration, workload, task complexity, and self-reported experiences of community health workers. Three models were created: a minimum model with the shortest time and frequency per task documented in the literature, a maximum model with the longest time, and a median model. Labour exploitation was defined as being engaged in work below the country's minimum wage together with excessive work hours or complex tasks. The study was registered with PROSPERO, CRD42021271500.

FINDINGS

We included 117 reports from 112 studies describing community health workers in dual-cadre programmes across 19 countries. The majority of community health workers were female. 13 (59%) of 22 unsalaried community health worker cadres and one (10%) of ten salaried cadres experienced labour exploitation. Three (17%) of 18 unsalaried community health workers would need to work more than 40 h per week to fulfil their assigned responsibilities. Unsalaried community health worker cadres frequently reported non-payment, inadequate or inconsistent payment of incentives, and an overburdensome workload.

INTERPRETATION

Unsalaried community health workers in dual-cadre programmes often face labour exploitation, potentially leading to inadequate health-care provision. Labour laws must be upheld and the creation of professional community health worker cadres with fair contracts prioritised, international funding allocated to programmes that rely on unsalaried workers should be transparently reported, the workloads of community health workers should be modelled a priori and actual time use routinely assessed, community health workers should have input in policies that affect them, and volunteers should not be responsible for the delivery of essential health services.

FUNDING

None.

Practical Strategies for Improving Sustainability and Scale-up of Noncommunicable Disease-related Public Health Interventions: Lessons from the Better Health Program in Southeast Asia

Introduction

The Better Health Program has been addressing key health system issues in the prevention and control of noncommunicable diseases (NCDs) in Malaysia, Thailand, Vietnam, and the Philippines. As the program comes to an end, the sustainability and scaling-up of issues have assumed importance.

Objectives

The objective is to assess how well sustainability and scale-up strategies have been integrated into the design and implementation of a 3-year multicountry technical program; to explore enablers and barriers of sustainability and scaling up; and to identify practical strategies that can improve sustainability and scale-up of Better Health Program interventions.

Methods

We applied a staged approach to explore barriers and enablers and to identify practical strategies to improve sustainability and scale-up of four NCD interventions: community-based obesity prevention, front-of-pack labeling, local learning networks (LLNs), and NCD surveillance. We extracted evidence from peer-reviewed literature and local documents. We also conducted in-depth interviews with the implementation teams and key stakeholders. We conducted a thematic synthesis of the resulting information to identify practical strategies that improve sustainability and scale-up of the four interventions.

Results

Strong engagement of stakeholders at higher levels of the health system was identified as the main enabler, while limited funding and commitment from local governments were identified as a key barrier to sustainability and scale-up. Strengthening the social and institutional anchors of community health volunteers, enhancing evidence-based advocacy for front-of-pack labeling, trailblazing the LLN innovation, and securing the commitment of local governments in the implementation of NCD surveillance were among the key strategies for improving sustainability and scale-up of Better Health Program interventions in Malaysia, Thailand, Philippines, and Vietnam, respectively.

Conclusions

This study identified practical strategies for improving sustainability and scale-up of NCD-related interventions. Implementation of the strategies that had high priority and feasibility will improve the sustainability of critical elements of the program in the respective countries.

It is not all about salary: a discrete-choice experiment to determine community health workers' motivation for work in Nigeria

INTRODUCTION

Community health workers (CHWs) constitute the majority of primary healthcare (PHC) workers in Nigeria, yet little is understood about their motivations or the most effective interventions to meet their needs to ensure quality health coverage across the country. We aimed to identify factors that would motivate CHWs for quality service delivery.

METHODS

A discrete-choice experiment was conducted among 300 CHWs across 44 PHC facilities in the Federal Capital Territory, Abuja Nigeria. Based on the literature review and qualitative research, five attributes, namely: salary, educational opportunities, career progression and in-service training, housing and transportation, were included in the experiment. CHWs were presented with 12 unlabelled choice sets, using tablet devices, and asked to choose which of two hypothetical jobs they would accept if offered to them, or whether they would take neither job. Mixed multinomial logistic models were used to estimate stated preferences for the attributes and the likely uptake of jobs under different policy packages was simulated.

RESULTS

About 70% of the respondents were women and 39% worked as volunteers. Jobs that offered career progression were the strongest motivators among the formally employed CHWs (β=0.33) while the 'opportunity to convert from CHW to another cadre of health workers, such as nursing' was the most important motivator among the volunteers' CHWs (β=0.53). CHWs also strongly preferred jobs that would offer educational opportunities, including scholarship (β=0.31) and provision of transport allowances (β=0.26). Policy scenario modelling predicted combined educational opportunities, career progression opportunities and an additional 10% of salary as incentives was the employment package that would be most appealing to CHWs.

CONCLUSION

CHWs are motivated by a mix of non-financial and financial incentives. Policy interventions that would improve motivation should be adequate to address various contexts facing different CHWs and be flexible enough to meet their differing needs.