The role of Community Health Workers (CHWs) in improving access to basic healthcare services, and mobilising community actions on health is broadly recognised. The Primary Health Care (PHC) approach, identified in the Alma Ata conference in 1978, stressed the role of CHWs in addressing community health needs. Training of CHWs is one of the key aspects that generally seeks to develop new knowledge and skills related to specific tasks and to increase CHWs’ capacity to communicate with and serve local people. This study aimed to analyse the CHW training process in Iran and how different components of training have impacted on CHW performance and satisfaction.
Data were collected from both primary and secondary sources. Training policies were reviewed using available policy documents, training materials and other relevant documents at national and provincial levels. Documentary analysis was supplemented by individual interviews with ninety-one Iranian CHWs from 18 provinces representing a broad range of age, work experience and educational levels, both male and female.
Recognition of the CHW program and their training in the national health planning and financing facilitates the implementation and sustainability of the program. The existence of specialised training centres managed by district health network provides an appropriate training environment that delivers comprehensive training and increases CHWs’ knowledge, skills and motivation to serve local communities. Changes in training content over time reflect an increasing number of programs integrated into PHC, complicating the work expected of CHWs. In-service training courses need to address better local needs.
Although CHW programs vary by country and context, the CHW training program in Iran offers transferable lessons for countries intending to improve training as one of the key elements in their CHW program.
Community health workers; Training; Primary health care
Over thirty years have passed since the Alma-Ata Declaration on primary health care in 1978. Many governments in the first decade following the declaration responded by developing national programmes of community health workers (CHWs), but evaluations of these often demonstrated poor outcomes. As many CHW programmes have responded to the HIV/AIDS pandemic, international interest in them has returned and their role in the response to other diseases should be examined carefully so that lessons can be applied to their new roles. Over half of the deaths in African children under five years of age are due to malaria, diarrhoea and pneumonia - a situation which could be addressed through the use of cheap and effective interventions delivered by CHWs. However, to date there is very little evidence from randomised controlled trials of the impacts of CHW programmes on child mortality in Africa. Evidence from non-randomised controlled studies has not previously been reviewed systematically.
We searched databases of published and unpublished studies for RCTs and non-randomised studies evaluating CHW programmes delivering curative treatments, with or without preventive components, for malaria, diarrhoea or pneumonia, in children in sub-Saharan Africa from 1987 to 2007. The impact of these programmes on morbidity or mortality in children under six years of age was reviewed. A descriptive analysis of interventional and contextual factors associated with these impacts was attempted.
The review identified seven studies evaluating CHWs, delivering a range of interventions. Limited descriptive data on programmes, contexts or process outcomes for these CHW programmes were available. CHWs in national programmes achieved large mortality reductions of 63% and 36% respectively, when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered, in addition to curative interventions.
CHW programmes could potentially achieve large gains in child survival in sub-Saharan Africa if these programmes were implemented at scale. Large-scale rigorous studies, including RCTs, are urgently needed to provide policymakers with more evidence on the effects of CHWs delivering these interventions.
Social participation has been recognized as an important public health policy since the declaration of Alma-Ata presented it as one of the pillars of primary health care in 1978. Since then, there have been many adaptations to the original policy but participation in health is still seen as a means to make the health system more responsive to local health needs and as a way to bring the health sector and the community closer together.
To explore the role that social participation has in a municipal-level health system in Guatemala in order to inform future policies and programs.
Documentary analysis was used to study the context of participation in Guatemala. To do this, written records and accounts of Guatemalan history during the 20th century were reviewed. The fieldwork was carried out over 8 months and three field visits were conducted between early January of 2009 and late March of 2010. A total of 38 in-depth interviews with regional health authorities, district health authorities, community representatives, and community health workers (CHWs) were conducted. Data were analyzed using thematic analysis.
Guatemala's armed civil struggle was framed in the cold war and the fight against communism. Locally, the war was fed by the growing social, political, and ethnic inequalities that existed in the country. The process of reconstructing the country's social fabric started with the signing of the peace agreements of 1996, and continued with the passing of the 2002 legal framework designed to promote decentralization through social participation. Today, Guatemala is a post-war society that is trying to foster participation in a context full of challenges for the population and for the institutions that promote it. In the municipality of Palencia, there are three different spaces for participation in health: the municipal-level health commission, in community-level social development councils, and in the CHW program. Each of these spaces has participants with specific roles and processes.
True participation and collaboration among can only be attained through the promotion and creation of meaningful partnerships between institutional stakeholders and community leaders, as well as with other stakeholders working at the community level. For this to happen, more structured support for the participation process in the form of clear policies, funding and capacity building is needed.
social participation; primary health care; guatemala; alma ata; community participation; community health workers; palencia
There is re-emerging interest in community health workers (CHWs) as part of wider policies regarding task-shifting within human resources for health. This paper examines the history of CHW programmes established in South Africa in the later apartheid years (1970s–1994) – a time of innovative initiatives. After 1994, the new democratic government embraced primary healthcare (PHC), however CHW initiatives were not included in their health plan and most of these programmes subsequently collapsed. Since then a wide array of disease-focused CHW projects have emerged, particularly within HIV care.
Thirteen oral history interviews and eight witness seminars were conducted in South Africa in April 2008 with founders and CHWs from these earlier programmes. These data were triangulated with written primary sources and analysed using thematic content analysis. The study suggests that 1970s–1990s CHW programmes were seen as innovative, responsive, comprehensive and empowering for staff and communities, a focus which respondents felt was lost within current programmes. The growth of these earlier projects was underpinned by the struggle against apartheid. Respondents felt that the more technical focus of current CHW programmes under-utilise a valuable human resource which previously had a much wider social and health impact. These prior experiences and lessons learned could usefully inform policy-making frameworks for CHWs in South Africa today.
Community health workers; Community health worker (CHW) policy; South Africa; Oral history; Apartheid; Task-shifting; Community participation
International commitments exist for the safeguarding of health and the prevention of ill health. One of the earliest commitments is the Declaration of Alma-Ata (1978), which provides 5 principles guiding primary health care: equity, community participation, health promotion, intersectoral collaboration and appropriate technology. These broadly applicable international commitments are premised on the World Health Organization's multifaceted definition of health. The environment is one sector in which these commitments to safeguarding health can be applied. Giant Mine, a contaminated former gold mine in the Northwest Territories, Canada, represents potential threats to all aspects of health. Strategies for managing such threats usually involve an obligation to engage the affected communities through consultation.
To examine the remediation and consultation process associated with Giant Mine within the context of commitments to safeguard health and well-being through adapting and applying the principles of primary health care.
Semi-structured interviews with purposively selected key informants representing government proponents and community members were conducted.
In reviewing themes which emerged from a series of interviews exploring the community consultation process for the remediation of Giant Mine, the principles guiding primary health were mapped to consultation in the North: (a) “equity” is the capacity to fairly and meaningfully participate in the consultation; (b) “community participation” is the right to engage in the process through reciprocal dialogue; (c) “health promotion” represents the need for continued information sharing towards awareness; (d) “intersectoral collaboration” signifies the importance of including all stakeholders; and (e) “appropriate technology” is the need to employ the best remediation actions relevant to the site and the community.
Within the context of mining remediation, these principles form an appropriate framework for viewing consultation as a means of meeting international obligations to safeguard health.
mining; remediation; contaminants; consultation; Giant Mine; community participation; Yellowknife; health; well-being
The year 2008 celebrated 30 years of Primary Health Care (PHC) policy emerging from the Alma Ata Declaration with publication of two key reports, the World Health Report 2008 and the Report of the Commission on the Social Determinants of Health. Both reports reaffirmed the relevance of PHC in terms of its vision and values in today's world. However, important challenges in terms of defining PHC, equity and empowerment need to be addressed.
This article takes the form of a commentary reviewing developments in the last 30 years and discusses the future of this policy. Three challenges are put forward for discussion (i) the challenge of moving away from a narrow technical bio-medical paradigm of health to a broader social determinants approach and the need to differentiate primary care from primary health care; (ii) The challenge of tackling the equity implications of the market oriented reforms and ensuring that the role of the State in the provision of welfare services is not further weakened; and (iii) the challenge of finding ways to develop local community commitments especially in terms of empowerment.
These challenges need to be addressed if PHC is to remain relevant in today's context. The paper concludes that it is not sufficient to revitalize PHC of the Alma Ata Declaration but it must be reframed in light of the above discussion.
This study examined the performance motivation of community health workers (CHWs) and its determinants on India's Accredited Social Health Activist (ASHA) programme.
Cross-sectional study employing mixed-methods approach involved survey and focus group discussions.
The state of Orissa.
386 CHWs representing 10% of the total CHWs in the chosen districts and from settings selected through a multi-stage stratified sampling.
Primary and secondary outcome measures
The level of performance motivation among the CHWs, its determinants and their current status as per the perceptions of the CHWs.
The level of performance motivation was the highest for the individual and the community level factors (mean score 5.94–4.06), while the health system factors scored the least (2.70–3.279). Those ASHAs who felt having more community and system-level recognition also had higher levels of earning as CHWs (p=0.040, 95% CI 0.06 to 0.12), a sense of social responsibility (p=0.0005, 95% CI 0.12 to 0.25) and a feeling of self-efficacy (p=0.000, 95% CI 0.38 to 0.54) on their responsibilities. There was no association established between their level of dissatisfaction on the incentives (p=0.385) and the extent of motivation. The inadequate healthcare delivery status and certain working modalities reduced their motivation. Gender mainstreaming in the community health approach, especially on the demand-side and community participation were the positive externalities of the CHW programme.
The CHW programme could motivate and empower local lay women on community health largely. The desire to gain social recognition, a sense of social responsibility and self-efficacy motivated them to perform. The healthcare delivery system improvements might further motivate and enable them to gain the community trust. The CHW management needs amendments to ensure adequate supportive supervision, skill and knowledge enhancement and enabling working modalities.
Health Services Administration & Management
Haiti is among the countries facing serious human resource shortages for healthcare. In rural Haiti, Partners In Health works with the Ministry of Health at public clinics to provide HIV and primary healthcare services. The needs of daily, long term adherence to medication for the treatment of HIV and TB drove recruitment of community health workers (CHW) who ultimately play a key role in the delivery of care. This qualitative study evaluated CHW role in the health system in the context of both HIV and non-HIV related services, as well as challenges and facilitating factors they faced in this role.
We used qualitative methods including focus group discussions and group interviews in four sites in rural Haiti. Data from 462 CHW were analyzed for themes and content according to standard ethnographic methods.
CHW contributed to a wide range of primary health services and non-HIV related activities. Recognition from the community, status, satisfaction of contributing to the well-being of their people and remuneration were facilitating factors to performing their work. Among the challenges, insufficient materials to cope with the obstacles on the ground, lack of diagnostic and treatment roles in their activities, high work load, and desire for ongoing training and a higher salary were described.
CHW initially hired to assist with HIV prevention and treatment represent an important part of the health system in rural Haiti in both HIV-related and primary healthcare services. CHW programs have important potential for building capacity in the health workforce and thereby contributing to strengthening of the health system as a whole. Attention must be paid to adequate remuneration, training and provision of materials.
Community health worker; health system strengthening
Access to water is a right and a social determinant of health that should be provided by the state. However, when it comes to access to water in rural areas, the current trend is for communities to arrange for the service themselves through locally run projects. This article presents a narrative of a single community's process of participation in implementing and running a water project in the village of El Triunfo, Guatemala.
Using an ethnographic approach, we conducted a series of interviews with five village leaders, field visits, and participant observations in different meetings and activities of the community.
El Triunfo has had a long tradition of community participation, where it has been perceived as an important value. The village has a council of leaders who have worked together in various projects, although water has always been a priority. When it comes to participation, this community has achieved its goals when it collaborated with other stakeholders who provided the expertise and/or the funding needed to carry out a project. At the time of the study, the challenge was to develop a new phase of the water project with the help of other stakeholders and to maintain and sustain the tradition of participation by involving new generations in the process.
This narrative focuses on the participation in this village's efforts to implement a water project. We found that community participation has substituted the role of the central and local governments, and that the collaboration between the council and other stakeholders has provided a way for El Triunfo to satisfy some of its demand for water.
El Triunfo's case shows that for a participatory scheme to be successful it needs prolonged engagement, continued support, and successful experiences that can help to provide the kind of stable participatory practices that involves community members in a process of empowered decision-making and policy implementation.
community participation; community organization; water projects; Guatemala; social development councils
The model of volunteer community health workers (CHWs) is a common approach to serving the poor communities in developing countries. BRAC, a large NGO in Bangladesh, is a pioneer in this area, has been using female CHWs as core workers in its community-based health programs since 1977. After 25 years of implementing of the CHW model in rural areas, BRAC has begun using female CHWs in urban slums through a community-based maternal health intervention. However, BRAC experiences high dropout rates among CHWs suggesting a need to better understand the impact of their dropout which would help to reduce dropout and increase program sustainability. The main objective of the study was to estimate impact of dropout of volunteer CHWs from both BRAC and community perspectives. Also, we estimated cost of possible strategies to reduce dropout and compared whether these costs were more or less than the costs borne by BRAC and the community.
We used the ‘ingredient approach’ to estimate the cost of recruiting and training of CHWs and the so-called ‘friction cost approach’ to estimate the cost of replacement of CHWs after adapting. Finally, we estimated forgone services in the community due to CHW dropout applying the concept of the friction period.
In 2009, average cost per regular CHW was US$ 59.28 which was US$ 60.04 for an ad-hoc CHW if a CHW participated a three-week basic training, a one-day refresher training, one incentive day and worked for a month in the community after recruitment. One month absence of a CHW with standard performance in the community meant substantial forgone health services like health education, antenatal visits, deliveries, referrals of complicated cases, and distribution of drugs and health commodities. However, with an additional investment of US$ 121 yearly per CHW BRAC could save another US$ 60 invested an ad-hoc CHW plus forgone services in the community.
Although CHWs work as volunteers in Dhaka urban slums impact of their dropout is immense both in financial term and forgone services. High cost of dropout makes the program less sustainable. However, simple and financially competitive strategies can improve the sustainability of the program.
BRAC CHWs; Impact of dropout; Ingredient approach; Friction cost approach; Sustainability; Urban slums
Hispanics in the USA are affected by the diabetes epidemic disproportionately, and they consistently have lower access to care, poorer control of the disease and higher risk of complications. This study evaluates whether a community health worker (CHW) intervention may improve clinically relevant markers of diabetes care in adult underserved Hispanics.
Methods and analysis
The Northern Manhattan Diabetes Community Outreach Project (NOCHOP) is a two-armed randomised controlled trial to be performed as a community-based participatory research study performed in a Primary Care Setting in Northern Manhattan (New York City). 360 Hispanic adults with poorly controlled type 2 diabetes mellitus (haemoglobin A1c >8%), aged 35–70 years, will be randomised at a 1:1 ratio, within Primary Care Provider clusters. The two study arms are (1) a 12-month CHW intervention and (2) enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls). The end points, assessed after 12 months, are primary = haemoglobin A1c and secondary = blood pressure and low-density lipoprotein-cholesterol levels. In addition, the study will describe the CHW intervention in terms of components and intensity and will assess its effects on (1) medication adherence, (2) medication intensification, (3) diet and (4) physical activity.
Ethics and dissemination
All participants will provide informed consent; the study protocol has been approved by the Institutional Review Board of Columbia University Medical Center. CHW interventions hold great promise in improving the well-being of minority populations who suffer from diabetes mellitus. The NOCHOP study will provide valuable information about the efficacy of those interventions vis-à-vis clinically relevant end points and will inform policy makers through a detailed characterisation of the programme and its effects.
Clinical trial registration number
NCT00787475 at clinicaltrials.gov.
Randomised controlled trial.
This community-based participatory research study is a collaboration between a community organisation and a university in Northern Manhattan, New York City.
The goal is to assess whether the CHW worker intervention may improve diabetes care in underserved adult Hispanics from the community.
The primary outcome of interest is haemoglobin A1c, a marker of diabetes control; secondary outcomes are blood pressure and low-density lipoprotein cholesterol levels.
Strengths and limitations of this study
This study will examine effects of the CHW intervention after 12 months, a longer time period than in previous studies.
The CHW intervention protocol was developed in a culturally appropriate manner to address the needs of Hispanics residing in our community.
If proven efficacious, it will warrant examination in other cultural socioeconomic milieus.
Community Health Workers (CHWs) play a pivotal role in primary care, serving as liaisons between community members and medical providers. However, the growing reliance of health care systems worldwide on CHWs has outpaced research explaining their praxis – how they combine indigenous and technical knowledge, overcome challenges and impact patient outcomes. This paper thus articulates the CHW Praxis and Patient Health Behavior Framework. Such a framework is needed to advance research on CHW impact on patient outcomes and to advance CHW training. The project that originated this framework followed Community-Based Participatory Research principles. A team of U.S.-Brazil research partners, including CHWs, worked together from conceptualization of the study to dissemination of its findings. The framework is built on an integrated conceptual foundation including learning/teaching and individual behavior theories. The empirical base of the framework comprises in-depth interviews with 30 CHWs in Brazil's Unified Health System, Mesquita, Rio de Janeiro. Data collection for the project which originated this report occurred in 2008–10. Semi-structured questions examined how CHWs used their knowledge/skills; addressed personal and environmental challenges; and how they promoted patient health behaviors. This study advances an explanation of how CHWs use self-identified strategies – i.e., empathic communication and perseverance – to help patients engage in health behaviors. Grounded in our proposed framework, survey measures can be developed and used in predictive models testing the effects of CHW praxis on health behaviors. Training for CHWs can explicitly integrate indigenous and technical knowledge in order for CHWs to overcome contextual challenges and enhance service delivery.
Brazil; Community Health Workers' Praxis; Patient outcome; CBPR
The orientation about Primary Health Care among staff working in the PHC centers was assessed. Staff members numbering 909 were studied. The main criteria for judging orientation were a working knowledge of the definition and elements of PHC in addition to knowledge of the meaning of the word Alma Ata. Differences of this knowledge depending on sex, age, spoken language, type of job, postgraduate experience, previous experience in PHC and previous training in PHC were assessed. The main findings of the study were that the correct definition of PHC was known by only 51.4%, functions of PHC by 62.6%, and what Alma Ata, means in terms of PHC was known by 76.2% of the staff. This knowledge was significantly better in females than males, non-Arabic speaking staff than those who spoke Arabic, General practitioners and nurses than other staff; it was better in those staff who had long postgraduate experience, previous experience or previous training in PHC.
In conclusion, the study reveals the current status of awareness of PHC staff of the implications of simple concepts of PHC and points to the importance of the orientation of staff towards these concepts in order to help them practice PHC effectively.
Primary health care; Alma Ata; General practitioners; Nurses
Breast cancer is a growing concern in low- and middle-income countries (LMCs). We explore community health worker (CHW) programs and describe their potential use in LMCs. We use South Africa as an example of how CHWs could improve access to breast health care because of its middle-income status, existing cancer centers, and history of CHW programs. CHWs could assume three main roles along the cancer control continuum: health education, screening, and patient navigation. By raising awareness about breast cancer through education, women are more likely to undergo screening. Many more women can be screened resulting in earlier-stage disease if CHWs are trained to perform clinical breast exams. As patient navigators, CHWs can guide women through the screening and treatment process. It is suggested that these roles be combined within existing CHW programs to maximize resources and improve breast cancer outcomes in LMCs.
In this paper we review two recent paradigmatic shifts and consider how a two-way flow in innovation has been critical to the emergence of new thinking and new practices. The first area relates to our understanding of the nature of public health systems and the shift from a medical paradigm to a more holistic paradigm which emphasises the social, economic and environmental origins of ill-health and looks to these as key arenas in which to tackle persistent inequalities in populations’ health experiences. In respect of this paradigmatic shift, it is argued, developing countries were in advance of their more developed counterparts. Specifically, the Alma Ata Declaration and the Primary Health Care Approach which was central to its implementation pre-figured elements of what was to be called in developed countries The New Public Health such as the need for greater community involvement and recognition of the importance of other sectors in determining health outcomes. But this paradigmatic shift added a new complexity to our understanding which made the identification of appropriate policy responses increasingly difficult. However, a parallel shift was taking place in the cognate field of operational research/systems analysis (OR/SA) which was adding greatly to our ability to analyse and to identify key points of intervention in complex systems. This led to the emergence of new techniques for problem structuring which overcame many of the limitations of formal mathematical models which characterised the old paradigm. In this paradigmatic shift developed countries have led the way, specifically in the new fields of Community Operational Research and Operational Research for Development, but only by drawing strongly on the experience and philosophies to be found in developing countries.
Public health; Systems analysis; Operational research; Reverse innovation
This article aims to describe the role of community health workers (CHWs) in health promotion research and address the challenges and ethical concerns associated with this research approach. A series of six focus groups are conducted with project managers and investigators (n = 5 to 11 per session) who have worked with CHWs in health promotion research. These focus groups are part of a larger study funded by the National Institutes of Health titled “Training in Research Ethics and Standards” (Project TRES). Participants are asked to describe their training needs for CHWs with respect to human subject protections as well as to identify associated challenges regarding research practice (i.e., recruitment, random assignment, protocol implementation, etc.). Findings reveal a number of challenges that investigators and project managers encounter when working with CHWs on research projects involving the community. These include characteristics inherent to CHWs such as education level and personal beliefs about their own community and its needs, institutional regulations regarding research practice, and problems inherent to research studies such as training materials and protocols that cannot account for the complexity of conducting research in community settings. Investigators should carefully consider the role that CHWs have in their communities before creating research programs that depend on the CHWs’ existing social networks and their propensity to be natural helpers. These strengths could lead to compromises in research requirements for random assignment, control groups, and fully informed consent.
lay health workers; ethical research practice; research integrity; promotores
Specific ways community health worker (CHW) programs affect participants’ health care behaviors and interactions with their health care providers, as well as mechanisms by which CHW programs influence these outcomes, are poorly understood. Through a qualitative descriptive study of participants in a successful CHW diabetes self-management program, we sought to answer: 1) What gaps in diabetes care, with a focus on patient-doctor interactions, do participants identify? And 2) How does the program influence participants’ diabetes care and interactions with health care providers, and what gaps, if any, does it address?
From 2005-2007, we conducted semi-structured interviews with 40 African American and Latino adults with diabetes who had completed or were active in a CHW-led diabetes self-management program developed and implemented using community-based participatory research (CBPR) principles in Detroit. Interviews were audiotaped, transcribed, and coded through a consensual and iterative process.
Participants reported that before participating in the intervention they had received inadequate information from health care providers for effective diabetes self-management, had had low expectations for help from their providers, and had not felt comfortable asking questions or making requests of their health care providers. Key ways participants reported that the program improved their ability to manage their diabetes were by providing 1) clear and detailed information on diabetes and diabetes care that they had not known before REACH; 2) education and training on specific strategies to meet diabetes care goals; 3) sustained and non-judgmental assistance to increase their motivation and confidence to improve their diabetes self-management; and 4) social and peer support that enabled them to better manage their diabetes. The knowledge and confidence gained through the CHW intervention increased participants’ assertiveness in asking questions to and requesting necessary tests and results from their providers.
Our interview findings suggest ways that CHW programs that provide both one-on-one support and group self-management training sessions may be effective in promoting more effective diabetes care and patient-doctor relationships among Latino and African American adults with diabetes. Through these mechanisms, such interventions may help to mitigate racial and ethnic disparities in diabetes care and outcomes.
Patient-Physician Communication; Chronic Disease; Diabetes; Patient Self-Management; Community Health Worker Intervention; Community-Based Participatory Research
Community Health Workers (CHWs) have been recommended to reduce diabetes disparities, but few robust trials of this approach have been conducted. Limitations of prior studies include: unspecified a priori outcomes; lack of blinded outcome assessments; high participant attrition rates; and lack of attention to intervention fidelity. These limitations reflect challenges in balancing methodologic rigor with the needs of vulnerable populations. The Mexican-American Trial of Community Health workers (MATCH) was a blinded randomized controlled trial testing CHW efficacy in improving physiologic outcomes and self-management behaviors among Mexican-Americans with type 2 diabetes. This paper describes methods used to overcome limitations of prior studies.
Research Design and Methods
The primary aim was to determine if a CHW intervention would result in significant reductions in Hemoglobin A1c and rates of uncontrolled blood pressure. 144 Mexican-Americans with diabetes were randomized. The intervention consisted of self-management training delivered by CHWs over a 24-month period; the comparison population received identical information via bilingual newsletter. Blinded research assistants completed assessments at baseline, 12 months, and 24 months post-randomization.
The MATCH cohort was characterized by low acculturation and socioeconomic status. Study participants had low rates of medication adherence and glucose monitoring. 70% had poor glycemic control with A1c levels over 7.0, and 57.3% had blood pressures worse than ADA target levels (<130/80).
MATCH preserved community sensitivity and methodologic rigor. The study’s attention to intervention fidelity, behavioral attention control, blinded outcomes assessment, and strategies to enhance participant retention can be replicated by researchers testing culturally-tailored CHW interventions.
behavioral clinical trial; community-based research; diabetes self-management; community health workers
To obtain experiential data regarding African American older adult survivors’ perceptions of and recommendations on the role of community health workers (CHWs) in providing a cancer navigation intervention.
Rural Virginia and urban Maryland.
48 African American solid-tumor cancer survivors, aged 65 years or older, with Medicare insurance.
Analysis was accomplished through a reflexive process of transcript review, categorization, and interpretation.
Themes and accompanying categories identified were uneasiness surrounding the CHW role (disconnect between identified support needs and CHW role, essential CHW characteristics, and potential application of CHWs), recommendations to adequately address cancer needs (coordinating cancer treatment and unmet needs during cancer), and the importance of individualized interventions. Participants provided specific recommendations regarding the role of the CHW and how to develop supportive interventions.
Study participants had surprisingly limited prior exposure to the CHW role. However, they stated that, in certain circumstances, CHWs could effectively assist older adult African Americans undergoing cancer diagnosis or treatment.
Study findings can be helpful to researchers and to healthcare providers engaged in assisting older African Americans during cancer diagnosis and treatment. The results lay a foundation for developing culturally appropriate interventions to assist this at-risk population.
Whether postpartum visits by trained community health workers (CHW), reduce newborn breastfeeding problems.
CHWs made antenatal and postpartum home visits promoting newborn care practices including breastfeeding. CHWs assessed neonates for adequacy of breastfeeding and provided hands on support to mothers to establish breastfeeding. History and observation data of 3,495 neonates were analyzed to assess effects of CHW visitation on feeding problems.
Inappropriate breastfeeding position and attachment were the predominant problems (12% –15%). 6% of newborns who received home visit by CHWs within 3 days had feeding difficulties, compared to 34% of those who did not (OR: 7.66, 95% CI: 6.03–9.71, p=0.00). Latter group was 11.4 times (95% CI: (6.7–19.3, p=0.00) more likely to have feeding problems as late as day 6–7, than the former.
Counselling and hands on support on breastfeeding techniques by trained workers within first 3 days of birth, should be part of community based postpartum interventions.
Breastfeeding; Community Health Workers; Newborn care; Postpartum visit; Bangladesh
The provision of HIV treatment and care in sub-Saharan Africa faces multiple challenges, including weak health systems and attrition of trained health workers. One potential response to overcome these challenges has been to engage community health workers (CHWs).
A systematic literature search for quantitative and qualitative studies describing the role and outcomes of CHWs in HIV care between inception and December 2012 in sub-Saharan Africa was performed in the following databases: PubMed, PsychINFO, Embase, Web of Science, JSTOR, WHOLIS, Google Scholar and SAGE journals online. Bibliographies of included articles were also searched. A narrative synthesis approach was used to analyze common emerging themes on the role and outcomes of CHWs in HIV care in sub-Saharan Africa.
In total, 21 studies met the inclusion criteria, documenting a range of tasks performed by CHWs. These included patient support (counselling, home-based care, education, adherence support and livelihood support) and health service support (screening, referral and health service organization and surveillance). CHWs were reported to enhance the reach, uptake and quality of HIV services, as well as the dignity, quality of life and retention in care of people living with HIV. The presence of CHWs in clinics was reported to reduce waiting times, streamline patient flow and reduce the workload of health workers. Clinical outcomes appeared not to be compromised, with no differences in virologic failure and mortality comparing patients under community-based and those under facility-based care. Despite these benefits, CHWs faced challenges related to lack of recognition, remuneration and involvement in decision making.
CHWs can clearly contribute to HIV services delivery and strengthen human resource capacity in sub-Saharan Africa. For their contribution to be sustained, CHWs need to be recognized, remunerated and integrated in wider health systems. Further research focusing on comparative costs of CHW interventions and successful models for mainstreaming CHWs into wider health systems is needed.
HIV; care; community health workers; sub-Saharan Africa; systematic review
The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns.
Delivery of healthcare; Health services; Care-seeking; Referral and consultation; Community health workers; Neonatal health; Maternal health; Bangladesh
Provision of integrated community case management (iCCM) for common childhood illnesses by community health workers (CHWs) represents an increasingly common strategy for reducing childhood morbidity and mortality. We sought to assess how iCCM availability influenced care-seeking behavior. In areas where two different iCCM approaches were implemented, we conducted baseline and post-study household surveys on healthcare-seeking practices among women who were caring for children ≤ 5 years in their homes. For children presenting with fever, there was an increase in care sought from CHWs and a decrease in care sought at formal health centers between baseline and post-study periods. For children with fast/difficulty breathing, an increase in care sought from CHWs was only noted in areas where CHWs were trained and supplied with amoxicillin to treat non-severe pneumonia. These findings suggest that iCCM access influences local care-seeking practices and reduces workload at primary health centers.
Despite resurgence in the use of community health workers (CHWs) in the delivery of community case management of childhood illnesses, a paucity of evidence for effective strategies to address key constraints of worker motivation and retention endures. This work reports the results of semi-structured interviews with 15 international stakeholders, selected because of their experiences in CHW program implementation, to elicit their views on strategies that could increase CHW motivation and retention. Data were collected to identify potential interventions that could be tested through a randomized control trial. Suggested interventions were organized into thematic areas; cross-cutting approaches, recruitment, training, supervision, incentives, community involvement and ownership, information and data management, and mHealth. The priority interventions of stakeholders correspond to key areas of the work motivation and CHW literature. Combined, they potentially provide useful insight for programmers engaging in further enquiry into the most locally relevant, acceptable, and evidence-based interventions.
Community health workers (CHWs) are lay individuals who are trained to serve as liaisons between members of their communities and healthcare providers and services.
A systematic review was conducted to synthesize evidence from all prospective controlled studies on effectiveness of CHW programs in improving screening mammography rates. Studies reported in English and conducted in the United States were included if they: (1) evaluated a CHW intervention designed to increase screening mammography rates in women 40 years of age or older without a history of breast cancer; (2) were a randomized controlled trial (RCT), case-controlled study, or quasi-experimental study; and (3) evaluated a CHW intervention outside of a hospital setting.
Participation in a CHW intervention was associated with a statistically significant increase in receipt of screening mammography [Risk Ratio (RR):1.06 (favoring intervention); 95% Confidence Interval (CI:1.02, 1.11),p=0.003]. The effect remained when pooled data from only RCTs were included in meta-analysis (RR:1.07,95% CI:1.03,1.12,p=0.0005), but was not present using pooled data from only quasi-experimental studies (RR:1.03,95% CI:0.89,1.18,p=0.71). In RCTs, participants recruited from medical settings (RR:1.41,95% CI:1.09,1.82,p=0.008), programs conducted in urban settings (RR:1.23,95% CI:1.09,1.39,p=0.001), and programs where CHWs were matched to intervention participants on race or ethnicity (RR:1.58, 95%CI:1.29,1.93,p=0.0001) demonstrated stronger effects on increasing mammography screening rates.
CHW interventions are effective for increasing screening mammography in certain settings and populations.
CHW interventions are especially associated with improvements in rate of screening mammography in medical settings, urban settings, and in participants who are racially or ethnically concordant with the CHW.
breast cancer; community health worker; mammography; systematic review; meta analysis