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.
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
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
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.
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
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
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 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
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
Due to the multifaceted aspect of child malnutrition, a comprehensive approach, taking social factors into account, has been frequently recommended in health literature. The Alma-Ata declaration explicitly outlined comprehensive primary health care as an approach that addresses the social, economic and political causes of poor health and nutrition.
Iran as a signatory country to the Alma Ata Declaration has established primary health care since 1979 with significant progress on many health indicators during the last three decades. However, the primary health care system is still challenged to reduce inequity in conditions such as child malnutrition which trace back to social factors. This study aimed to explore the perceptions of the Iranian health stakeholders with respect to the Iranian primary health care performance and actions to move towards a comprehensive approach in addressing childhood malnutrition. Health stakeholders are defined as those who affect or can be affected by health system, for example health policy-makers, health providers or health service recipients.
Stakeholder analysis approach was undertaken using a qualitative research method. Different levels of stakeholders, including health policy-makers, health providers and community members were interviewed as either individuals or focus groups. Qualitative content analysis was used to interpret and compare/contrast the viewpoints of the study participants.
The results demonstrated that fundamental differences exist in the perceptions of different health stakeholders in the understanding of comprehensive notion and action. Health policy-makers mainly believed in the need for a secure health management environment and the necessity for a whole of the government approach to enhance collaborative action. Community health workers, on the other hand, indicated that staff motivation, advocacy and involvement are the main challenges need to be addressed. Turning to community stakeholders, greater emphasis has been placed on community capabilities, informal link with other social sectors based on trust and local initiatives.
This research provided a picture of the differences in the perceptions and values of different stakeholders with respect to primary health care concepts. The study suggests that a top-down approach, which still exists among health policy-makers, is a key obstacle that delays, and possibly worse, undermines the implementation of the comprehensive strategy codified by the Alma-Ata Declaration. A need to revitalise primary health care to use its full potential and to combine top-down and bottom-up approaches by narrowing the gap between perceptions of policy makers and those who provide and receive health-related services is crucial.
Community health workers (CHWs) are increasingly recognized as a critical link in improving access to services and achieving the health-related Millennium Development Goals. Given the financial and human resources constraints in developing countries, CHWs are expected to do more without necessarily receiving the needed support to do their jobs well. How much can be expected of CHWs before work overload and reduced organizational support negatively affect their productivity, the quality of services, and in turn the effectiveness of the community-based programmes that rely on them? This article presents policy-makers and programme managers with key considerations for a model to improve the work environment as an important approach to increase CHW productivity and, ultimately, the effectiveness of community-based strategies.
A desk review of selective published and unpublished articles and reports on CHW programs in developing countries was conducted to analyse and organize findings on the elements that influence CHW productivity. The search was not exhaustive but rather was meant to gather information on general themes that run through the various documents to generate perspectives on the issue and provide evidence on which to formulate ideas. After an initial search for key terminology related to CHW productivity, a snowball technique was used where a reference in one article led to the discovery of additional documents and reports.
CHW productivity is determined in large part by the conditions under which they work. Attention to the provision of an enabling work environment for CHWs is essential for achieving high levels of productivity. We present a model in which the work environment encompasses four essential elements—workload, supportive supervision, supplies and equipment, and respect from the community and the health system—that affect the productivity of CHWs. We propose that when CHWs have a manageable workload in terms of a realistic number of tasks and clients, an organized manner of carrying out these tasks, a reasonable geographic distance to cover, the needed supplies and equipment, a supportive supervisor, and respect and acceptance from the community and the health system, they can function more productively and contribute to an effective community-based strategy.
As more countries look to scale up CHW programmes or shift additional tasks to CHWs, it is critical to pay attention to the elements that affect CHW productivity during programme design as well as implementation. An enabling work environment is crucial to maximize CHW productivity. Policy-makers, programme managers, and other stakeholders need to carefully consider how the productivity elements related to the work environment are defined and incorporated in the overall CHW strategy. Establishing a balance among the four elements that constitute a CHW’s work environment will help make great strides in improving the effectiveness and quality of the services provided by CHWs.
In Pakistan, where gendered norms restrict women's mobility, female community health workers (CHWs) provide doorstep primary health services to home-bound women. The program has not achieved optimal functioning. One reason, I argue, may be that the CHWs are unable to make home visits because they have to operate within the same gender system that necessitated their appointment in the first place. Ethnographic research shows that women’s mobility in Pakistan is determined not so much by physical geography as by social geography (the analysis of social phenomena in space). Irrespective of physical location, the presence of biradaria members (extended family) creates a socially acceptable ‘inside space’ to which women are limited. The presence of a non-biradari person, especially a man, transforms any space into an ‘outside space’, forbidden space. This study aims to understand how these cultural norms affect CHWs’ home-visit rates and the quality of services delivered.
Data will be collected in district Attock, Punjab. Twenty randomly selected CHWs will first be interviewed to explore their experiences of delivering doorstep services in the context of gendered norms that promote women's seclusion. Each CHW will be requested to draw a map of her catchment area using social mapping techniques. These maps will be used to survey women of reproductive age to assess variations in the CHW's home visitation rates and quality of family planning services provided. A sample size of 760 households (38 per CHW) is estimated to have the power to detect, with 95% confidence, households the CHWs do not visit. To explore the role of the larger community in shaping the CHWs mobility experiences, 25 community members will be interviewed and five CHWs observed as they conduct their home visits. The survey data will be merged with the maps to demonstrate if any disjunctures exist between CHWs’ social geography and physical geography. Furthermore, the impacts these geographies have on home visitation rates and quality of services delivered will be explored.
The study will provide generic and theoretical insights into how the CHW program policies and operations can improve working conditions to facilitate the work of female staff in order to ultimately provide high-quality services.
Reproductive health services; Primary health care services; Pakistan; Family planning; Community health workers; Lady health worker; Gender; Women’s mobility; Social geography; Mixed methods
In South Africa, there are renewed efforts to strengthen primary health care and community health worker (CHW) programmes. This article examines three South African CHW programmes, a small local non-governmental organisation (NGO), a local satellite of a national NGO, and a government-initiated service, that provide a range of services from home-based care, childcare, and health promotion to assist clients in overcoming poverty-related barriers to health care.
The comparative case studies, located in Eastern Cape and Gauteng, were investigated using qualitative methods. Thematic analysis was used to identify factors that constrain and enable outreach services to improve access to care.
The local satellite (of a national NGO), successful in addressing multi-dimensional barriers to care, provided CHWs with continuous training focused on the social determinants of ill-health, regular context-related supervision, and resources such as travel and cell-phone allowances. These workers engaged with, and linked their clients to, agencies in a wide range of sectors. Relationships with participatory structures at community level stimulated coordinated responses from service providers. In contrast, an absence of these elements curtailed the ability of CHWs in the small NGO and government-initiated service to provide effective outreach services or to improve access to care.
Significant investment in resources, training, and support can enable CHWs to address barriers to care by negotiating with poorly functioning government services and community participation structures.
primary health care; access to care; community health workers; social determinants of health; accountability; South Africa
Based on the principles of primary health care as outlined by WHO at the Alma Ata Conference in 1978, many voluntary organizations in India have been formulating, organizing and experimenting with the comprehensive rural community health Schemes. The goal is to indentify the felt needs at both individual and community levels and facilitate direct participation in decision making, develop suitable alternative, ecologically Sound indigenous models for socioeconomic well-being. In this context the Indian system of medicine has a useful and complementary role to play in the preventive and curative aspects of primary health care programmes. With the above objectives in mind the investigators undertook a brief survey of a “comprehensive rural health” project. The primary aim of this project is to develop a community health care model using innovative alternative methods using Indian indigenous system of medicine and participatory research techniques to improve rural health services of the surrounding under privileged villages. Many gaps exist in the assessment, however, a birds eye-view is presented here.
Curative interventions delivered by community health workers (CHWs) were introduced to increase access to health services for children less than five years and have previously targeted single illnesses. However, CHWs in the integrated community case management of childhood illnesses strategy adopted in Uganda in 2010 will manage multiple illnesses. There is little documentation about the performance of CHWs in the management of multiple illnesses. This study compared the performance of CHWs managing malaria and pneumonia with performance of CHWs managing malaria alone in eastern Uganda and the factors influencing performance.
A mixed methods study was conducted among 125 CHWs providing either dual malaria and pneumonia management or malaria management alone for children aged four to 59 months. Performance was assessed using knowledge tests, case scenarios of sick children, review of CHWs’ registers, and observation of CHWs in the dual management arm assessing respiratory symptoms. Four focus group discussions with CHWs were also conducted.
CHWs in the dual- and single-illness management arms had similar performance with respect to: overall knowledge of malaria (dual 72%, single 70%); eliciting malaria signs and symptoms (50% in both groups); prescribing anti-malarials based on case scenarios (82% dual, 80% single); and correct prescription of anti-malarials from record reviews (dual 99%, single 100%). In the dual-illness arm, scores for malaria and pneumonia differed on overall knowledge (72% vs 40%, p < 0.001); and correct doses of medicines from records (100% vs 96%, p < 0.001). According to records, 82% of the children with fast breathing had received an antibiotic. From observations 49% of CHWs counted respiratory rates within five breaths of the physician (gold standard) and 75% correctly classified the children. The factors perceived to influence CHWs’ performance were: community support and confidence, continued training, availability of drugs and other necessary supplies, and cooperation from formal health workers.
CHWs providing dual-illness management handled malaria cases as well as CHWs providing single-illness management, and also performed reasonably well in the management of pneumonia. With appropriate training that emphasizes pneumonia assessment, adequate supervision, and provision of drugs and necessary supplies, CHWs can provide integrated treatment for malaria and pneumonia.
CHW; ICCM; Health system research; Performance; Malaria; Pneumonia; Children; CMDs
Research evaluating community health worker (CHW) programs inherently involves these natural community leaders in the research process, and often represents community-based participatory research (CBPR). Interpreting the results of CHW intervention studies and replicating their findings requires knowledge of how CHWs are selected and trained.
A summative content analysis was performed to evaluate the description of CHW selection and training in the existing literature. First-level coding focused on contextual information about CHW programs. Second-level coding identified themes related to the selection and training of CHWs.
There was inconsistent reporting of selection and training processes for CHWs in the existing literature. Common selection criteria included personal qualities desired of CHWs. Training processes for CHWs were more frequently reported. Wide variation in the length and content of CHW training exists in the reviewed studies. A conceptual model is presented for the role development of CHWs based on the results of this review, which is intended to guide future reporting of CHW programs in the intervention literature.
Consistent reporting of CHW selection and training will allow consumers of intervention research to better interpret study findings. A standard approach to reporting selection and training processes will also more effectively guide the design and implementation of future CHW programs. All community-based researchers must find a balance between describing the research process and reporting more traditional scientific content. The current conceptual model provides a guide for standard reporting in the CHW literature.
A principle strategic insight of the Final Report for WHO’s Commission on Social Determinants of Health (SDOH) is that the nurturant qualities of the environments where children grow up, live, and learn matter the most for their development. A key determinant of early childhood development is the establishment of a secure attachment between a caregiver and child. We report initial field-tests of the integration of caregiver-child attachment assessment by community health workers (CHWs) as a routine component of Primary Health Care (PHC), focusing on households with children under 5 years of age in three slum communities near Nairobi, Kenya. Of the 2,560 children assessed from July–December 2010, 2,391 (90.2%) were assessed as having a secure attachment with a parent or other caregiver, while 259 (9.8%) were assessed as being at risk for having an insecure attachment. Parent workshops were provided as a primary intervention, with re-enforcement of teachings by CHWs on subsequent home visits. Reassessment of attachment by CHWs showed positive changes. Assessment of caregiver-child attachment in the setting of routine home visits by CHWs in a community-based PHC context is feasible and may yield valuable insights into household-level risks, a critical step for understanding and addressing the SDOH.
social determinants of health; early childhood development; caregiver-child attachment
We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a Medicaid managed care system. We conducted a retrospective study on a sample of 448 enrollees who were assigned to field-based CHWs in 11 of New Mexico’s 33 counties. The CHWs provided patients education, advocacy and social support for a period up to 6 months. Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention. For all measures, there was a significant reduction in both numbers of claims and payments after the community health worker intervention. Costs also declined in the non-CHW group on all measures, but to a more modest degree, with a greater reduction than in the CHW group in use of ambulatory services. The incorporation of field-based, community health workers as part of Medicaid managed care to provide supportive services to high resource-consuming enrollees can improve access to preventive and social services and may reduce resource utilization and cost.
Community health workers; Managed care; Medicine & Public Health; Health Promotion and Disease Prevention; Community and Environmental Psychology; Ethics