Community Health Research Round-Up Archive
The Community Health Impact Coalition curates a fortnightly update on newly-released community health worker papers.
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An abridged version of the round-up is also available on twitter—please follow the Coalition's handle, @CHW_impact, and tag relevant colleagues!
Community Health Research Round-Up, Issue 001
Oct 15-Oct 29, 2018
Comments: By our own team Muso + Medic! Way to go!
Methods: RCT; N=148 CHW; follow-up=6 months
Takeaway: Use of a personalised performance dashboard (metrics: quantity, speed, and quality of CHW care) during monthly supervision upped quantity of care without compromising speed or quality. (mean number of home visits increased significantly while effects on secondary outcomes of timeliness and quality were positive but not statistically significant)
Methods: non-randomised trial; 2 int districts (289 CHW), 2 control districts; follow-up=12 months
Takeaway: CHW home visiting during the antenatal and postnatal periods can improve health service use (Facility delivery, Attendance for at least one antenatal care +postnatal care visit) in fragile- and conflict-affected countries
Comments: From our friends at Oxford, James! Interesting re: role of human-centred design in CHW program design/implementation
Methods: Systematic scoping review
Takeaway: Participatory visual methodologies (e.g. participatory photography, film, digital storytelling, mapping, and drawing - PVMs) can help assist CHWs' reflective practice, understanding of complex health issues, identifying key issues in the community to potentially leverage social action.
Comment: Interesting re: role of CHWs for NCDs
Methods: quasi-experimental study; health care provider advice and assistance (Arm 1) vs. Arm 1 plus CHW counseling; N=1,318 tobacco users; 6 month follow-up
Takeaway: Evidence for a team approach to tobacco dependence treatment: smokers in Arm 2 were almost three times more likely to quit compared with those in Arm 1.
Comment: From our friends at the REACH-OUT Consortium
Methods: development + validation of a simple tool to measure perceived supervision across seven LMICs
Takeaway: The 6-item measure of perceived supervision (capturing regular contact, two-way communication, and joint problem-solving elements - PSS) is the first validated tool that measures supervisory experience from the perspective of CHWs; available in 11 languages
Comment: From our own Celia Taylor + the Living Goods team!
Methods: cohort study of CHWs working for LG in 8 districts (N=547); Kendall's tau-b correlations between each selection score and performance outcome were calculated
Takeaway: None of the correlations between selection scores and outcomes (e.g. number of household and pregnancy registrations, number of child assessments, proportion of on-time follow-ups and value of goods sold) reached the 0.3 threshold of an "adequate" predictor of performance. N.B. important outcomes, retention in post and quality of care were not included in study.
Comment: From our friends at the Penn Center, Shreya et. al!
Methods: RCT; N=592 patients; follow-up: 6, 9 months
Takeaway: CHW intervention reduced total hospital days by 65% while doubling quality!
Interesting trial registrations:
Implementing community health worker-patient pairings at the time of hospital discharge: A randomized control trial (Clinical Trials.gov ID# NCT03085264)
Methods: RCT designed to determine if linking hospitalized patients with chronic disease to CHWs can decrease 30-day readmissions (USA)
Community Health Research Round-Up, Issue 002
Oct 29-Nov 12, 2018
Comments: Giant SR on health worker performance generally, that complements other reviews of CH performance (Kok 2015, Ballard 2017). Interestingly, you can download this review’s database and perform rapid analyses with an online tool: www.hcpperformancereview.org
Methods: Systematic Review
Takeaway: For CHWs the effect of training alone was small. Strategies with larger effect sizes included community support plus health-care provider training. Contextual and methodological heterogeneity made comparisons difficult, and most strategies had low quality evidence.
Comments: May be of particular interest to our colleagues in Mada
Methods: Cross-sectional survey; N=874 CHW
Takeaway: 92% of CHWs were food insecure and 89% had experienced a shock in the past year. Overall, 18% of ACs financed commodity resupply from their personal savings. Stock-outs at point of supply & financial and time constraints were the main reported challenges in getting health products.
Comments: From team Possible!
Methods: Descriptive (implementation, lessons learned)
Takeaway: Self-identified keys to approach - CHWs continuously engaging with populations through household visits every 3 months; CHWs using digital tools during the routine course of clinical care; individual and population-level data generated routinely being utilized for program improvement; and being responsive to privacy, security, and human rights concerns.
The use of low-cost Android tablets to train community health workers in Mukono, Uganda, in the recognition, treatment and prevention of pneumonia in children under five: a pilot randomised controlled trial
Comments: From our friends in Oxford! Of interest to team Community Health Academy
Methods: Pilot RCT; N= 129 CHWs
Takeaway: Tablet-based training is comparable to traditional training in terms of knowledge acquisition.
Comments: A good implementation science paper...
Methods: Focus groups
Takeaway: "Applying process-oriented measurement tools are needed to better understand CHW performance-related factors and build a supportive environment for CHW program effectiveness and sustainability." (Heck yes!) CHW team performance (in this context) were highly correlated with the quality of supervision and relationships with other healthcare workers.
Comments: Complement to the existing lit on CHWs for healthy feeding practices more generally (le Roux et al., 2010; le Roux et al., 2011; Pachón et al., 2002; Rahman et al., 2008; Saleem et al., 2014; Vazir et al., 2013; Yousafzai et al., 2014)
Methods: Narrative (unsystematic) lit review
Takeaway: CHWs can identify and treat uncomplicated cases of SAM, achieving cure rates above the minimum standards and reducing default rates to less than 8%
Community Health Research Round-Up, Issue 003
Nov 13-Nov 26, 2018
Comments: Yet more evidence that CHWs can safely + effectively use RDTs
Methods: Poisson regressions, N=103 randomly selected CHWs; F/U = 12 months
Takeaway: With training, most CHWs performing RDTs maintain diagnostic testing competency over at least 12 months. CHWs generally perform RDTs safely and accurately interpret results.
Comments: Another interesting task shifting for NCDs pilot. Rural setting particularly interesting
Methods: cross-sectional comparative study; N=51 healthcare workers (incl. CHW)
Takeaway: Of the 63 women rescreened by CHEWs and CHOs for cervical cancer in rural Nigeria (data grouped), 88.1% agreed with expert team review (κ = 0.76)
Comments: Shared with me by the Muso team last week.Another performance framework (see also: Naimoli 2014, Kok 2014, Kok 2015, Ballard + Mongomery 2017). Note that they ID CHW characteristics asa being important to performance. While the ways a CHW’s innate characteristics affect outcomes has been much debated in the literature (e.g. Bhattacharyya, 2001; López Quiñones, 1999; Ofosu- Amaah, 1983) it is worth considering the ethics of conducting such analyses in the future. As we note in our GHD CHW Case Study, many high-income countries have employment discrimination laws that prohibit selection on these criteria. Though similar legislation is often poorly enforced in LMICs, researchers and implementers should consider the equity issues at the heart of these debates (Heymann, Stein, & Moreno, 2014). While more factorial trials and component selection experiments on CHW programme features are warranted, I'd leave CHW characteristics out of the mix.
Methods: Systematic review
Takeaway: They conclude that effectively analyzing and promoting the performance of CHWs in malaria prevention and control programs may require adopting a framework that considers health systems factors (nature of training of CHWs, type of supervision etc), community factors (nature of community connectedness, utilization of services by the community), and community health worker characteristics (e.g. marital status, sex etc.)
Comments: Interesting evidence that, in addition to being questionably ethical to track, CHW characteristics get washed out by structural factors...
Methods: N.B. also only an observational study! N = 41 CHWs, 185 patients
Takeaway: Patients whose CHWs had to travel one or more hours had a 71% lower odds of virologic suppression (adjusted OR = 0.29, 95% CI = 0.13-0.65, p = .002) and a 4.52 times higher mortality hazard rate (adjusted HR = 4.52, 95% CI = 1.20-17.09, p = .026) compared to patients whose CHWs had to travel less than one hour. Notably, sociodemographic characteristics of CHWs were not as important as the geographic distance they had to travel to patients.
Comments: More CHWs for NCDs. A good round-up for our US-based colleagues
Takeaway: Mixed yet promising evidence of the impact of CHW interventions on glycemic control among Latinos with T2D and some evidence of the impact on diabetes-related behaviors, knowledge, and self-efficacy.
Community Health Research Round-Up, Issue 004
Nov 27-Dec 18, 2018
Comments: While this is not explicitly mentioned in the study, in light of the WHO Guidelines it is interesting to note that Table 2 seems to indicate that the majority of those conducting the intervention were dedicated supervisors. A "hidden" component we should all be talking about more.
Methods: In-depth interviews and repeated cross-sectional surveys in Ethiopia, Kenya, Malawi and Mozambique. Ethiopia study:
Takeaway: Interview participants reported that the supervision intervention improved CHW motivation, quant data did not bear that out. Ceiling effect may have limited the detection of observable differences in the survey.
Comments: What would motivate you if you weren't currently being paid for your day job? Find out if CHWs feel the same way! Sigh.
Methods: Cross-sectional survey + Mann-Whitney U test
Takeaway: When will these studies stop passing ethics? Career development came out on top in this study--that should tell us something.
Comments: See also Shreya's article in JAMA if you haven't. Great to see more of this being tried all over the US
Takeaway:The LHW intervention involved assessment and development of a personalized social needs plan for enrolled patients (e.g. transportation and community resource identification), with post- discharge follow-up calls.56% decrease in odds of being readmitted within 30-days among those in the intervention phase compared with those in the baseline phase.
Comments: CHW can improve cancer screening and treatment adherence, now we're beginning to accumulate evidence that they can enhance other aspects of care.
Takeaway: An outpatient lay health worker program can improve documentation of patients’ goals of care at the end of life.
Comments: Of interest to those thinking about how to measure performance
Methods: Cross-sectional study, N=140 village health team members (CHWs)
Takeaway: No correlation was observed between productivity and performance scores. This lack of correlation suggests that interventions to improve CHV effectiveness may affect the two dimensions of effectiveness differently. Given this, important to measure both (e.g. like Muso's speed, quantity, quality triptych).
Comments: Interesting model of the cost and benefit of a national community health worker workforce in the UK
Methods: Modelling exercise based on all general practices in England
Takeaway: They conclude that a scaled community health worker workforce integrated into primary care could be a valuable policy option
Community Health Research Round-Up, Issue 005
Dec 19, 2018-Feb 4, 2019
Comments: I feel like a lot of these conclusions have been previously unearthed, but this is a recent, high-quality synthesis. Interestingly, the authors limited the review to community volunteers not paid regular salaries, contending that they were "a different cadre" than paid workers. (I would not agree...)
Methods: Umbrella review
Takeaway: Most included SRs concluded that services provided by CHVs were not inferior to those provided by other health workers, and sometimes better. [N.B. Would argue that the question was never, 'can volunteer CHWs perform as well as their paid counterparts', but, in what way is it ever ethical to ask the poor to volunteer for their own right to health?'] Authors note CHV performance could be strengthened by regular supportive supervision, in-service training and adequate logistical support, as well as a high level of community ownership.
Comments: The abstract and main text describe the participants as "paid volunteer CHWs." Any clue what that is? On a different note, great to see more studies on workload and routine data on services provided by CHWs used in combination with ITS as a rigorous way to support informed decision-making
Methods: Interrupted time-series analysis
Takeaway: HIV-focused CHWs successfully added maternal, newborn and child health (MNCH) promotion activities to their workload, with only a small and temporary reduction in HIV household visits when the intervention began.
Comments: Great new implementation science
Methods: RCT (intervention Supervisors were trained on supervisory skills and written feedback to LHW)
Takeaway:Supervisors in the intervention arm provided better quality supervision more frequently, and health workersin the intervention arm performed better in assessingdehydration and in correct classification of disease, particularly diarrhoea.
Comments: Interesting pilot where CHWs perform multiple types of NCD screening at once
Methods: Cross-sectional (CHWs CHWs made home visits to educate the participants about healthy lifestyles and symptoms of common cancers and counsel the tobacco/alcohol users to quit. They measured height, weight, blood pressure (BP) and random blood sugar for all and performed oral visual examination (OVE) to screen the tobacco/alcohol users for oral cancer. For cervical cancer screening, the women themselves provided self-collected vaginal samples that the CHWs delivered to the laboratory for high-risk Human Papillomavirus (HPV) detection.)
Takeaway: Delivery of NCD screening services at home by trained CHWs is feasible and well-accepted by the study population.
Comments: An all-too-rare history of a fairly dramatic time in the history of community health workers
Methods: History of visual politics of CHWs '70-89
Takeaway: Since 1948, the WHO had used mass communications strategies to publicise its initiatives and shape public attitudes, and the policy shift in the 1970s required a new visual strategy. CHWs played a central role as key visual identifiers of Health for All--in sometimes fraught ways.
Comments: CHW programs in high-income countries--long overdue to be expanded!
Methods: Literature review
Takeaway: CHWs serve a range of functions in various contexts in Australian PHC system and such programs offer a promising opportunity to enhance equity of access to PHC in for communities facing disadvantage, especially in the face of rising chronic disease.
Comments: Because I am home in Canada this week--some applications of CHW programs in remote communities of the far North!
Methods: 7 yr prospective data collection
Takeaway: CHW were beneficial in promoting enrolment for and augmenting the delivery of preventive dental services
Community Health Research Round-Up, Issue 006
Feb 4, 2019-March 4, 2019
Comments: Many of you will have taken this survey on the acceptability and feasibility of the policy options being considered by the WHO CHW Guideline development group. A bit anti-climactic given that these results were already used and published in the Guideline itself, but just an FYI that they're now also out in HRH should you want more details!
Methods: X-sectional online questionnaire
Takeaway: Outcomes of interest and policy options proposed were rated highly by most stakeholders.
Comments: New scoping review by our friends at Oxford! Of interest esp. to those working on disability (Phyllis!)
Methods: Systematic scoping review
Takeaway: CHWs could potentially play an important role in improving access to ear & hearing services, including in screening, raising community awareness and delivery of basic treatment. More research needed particularly on costs.
Comments: Have already shared this with the Community Health Academy team, may be a useful framework/standardization of competencies for other practitioners
Methods: Lit review + validation of competencies by expert panel
Takeaway: The workforce framework delineates 3 categories of CHWs based upon training, workplace, and scope of practice. Twenty-seven competencies listed.
Comments: Another new SR on "CHWs for x." The limits of task shifting are still being tested. Great to see long-running work in mental health systematically summarized.
Methods: Systematic Review
Takeaway: The majority of trials found that CHW-delivered interventions led to symptom reduction.
Comments: Ditto above.
Methods: Systematic Review (results = high income countries)
Takeaway: Interventions focused primarily on children from underserved populations. Meta-analytic findings demonstrated a small but significant impacton BMIz and BMI percentile.
Comments: Very cool piece commissioned by our friends at Mothers2Mothers! Great to see questions being surfaced by and sourced directly from practitioners!
Methods: Scoping Review
Takeaway: The most commonly performed roles of LHWs in HIV specific MCH programmes included: community engagement and sensitisation, psychosocial support, linkage to care, encouraging women to bring their infants back for HIV testing and supporting default tracing. Community awareness on Mother to Child Transmission of HIV (MTCT), proper and consistent use of condoms, clinic attendance and timely HIV testing of HEIs, as well as retention in care for infected persons, have all improved because of LHW programmes.
Comments: CHWs in clinics! A great addition to the care-team lit
Methods: Realist evaluation in a C-RCT
Takeaway: Task shifting from nurses to LHWs improved a range of process outcomes (the appointment systems, filing, prepacking medication, managing the chronic care pathway and patients’ adherence to their appointments). Lay health workers can be valuable member of a clinic team, and an important resource for managing increasing patient demand in primary healthcare.
Comments: Cool methods article that wades into several strands of the logic-modelling debate
Methods: They describe the process of developing a logic model as part of an ongoing realist evaluation of a CHW programme in Nigeria (the actual evaluation is still ongoing)
Takeaway: Lessons for researchers and programme planners who wish to develop and use logic models in future evaluations are discussed.
Comments: The paper examines the available evidence on cost, economic benefit, and cost effectiveness of interventions that engage community health workers to prevent cardiovascular disease, prevent type 2 diabetes, and manage type 2 diabetes. Funny how in LMICs we need to prove models that are <10 bucks per person but suddenly in the USA the acceptable cost goes up x5000...
Methods: Systematic economic review
Takeaway: Interventions engaging community health workers are cost effective for cardiovascular disease prevention and type 2 diabetes management, based on a conservative $50,000 benchmark for cost per quality-adjusted life year gained. Two cost per quality-adjusted life year estimates for type 2 diabetes prevention were far below the $50,000 benchmark.
Comments: Barriers to care are similar all over the world! Interesting data from a minority population in the USA
Methods: Qualitative interviews/focus groups
Takeaway: Five themes emerged regarding barriers to medication adherence: (1) financial, (2) transportation, (3) language, (4) health literacy and understanding of Western medicine, and (5) mistrust. Four themes emerged regarding facilitators to medication adherence: (1) in-depth patient education strategies, (2) efforts to address the language barrier, (3) family engagement, and (4) public transportation and prescription home delivery.
Comments: Great, rare date on stock-outs at community level. Of interest to colleagues at VillageReach & the UNICEF group doing work on supply chain
Methods: Questionnaires at facilities selected by probability proportionate to the number of CHWs at each facility.
Takeaway: CHWs reported receiving an average of 6.7 kits in the last year, although they are intended to receive kits monthly. One-tenth of CHWs reported receiving kits with missing RDTs, and 28% reported lacking some AL treatments.
Comments: Test of a simplified SAM treatment protocol and a set of low‐literacy‐adapted tools developed by IRC
Methods: Mixed: Fifty‐seven CBDs were randomly selected to receive training. CBD performance was assessed immediately after training, and 44 CBDs whose performance score met a predetermined standard were deployed to test the delivery of SAM treatment in their communities. CBDs were observed and scored on their performance on a biweekly basis through the study.
Takeaway: Low‐literate community‐based distributors in South Sudan were able to follow a simplified treatment protocol for uncomplicated severe acute malnutrition with high accuracy using low‐literacy‐adapted tools
Improving health worker performance through text messaging: A mixed-methods evaluation of a pilot intervention designed to increase coverage of intermittent preventive treatment of malaria in pregnancy in West Nile, Uganda
Comments: Another for the ICT4D crowd. Complements earlier work work by Chang 2011 +DeRenzi 2012
Methods: non-randomized control pilot
Takeaway: Complementing classroom training with text messaging was found to be a feasible, acceptable and inexpensive approach to improving health worker performance. The messages served as reminders to those who had attended the classroom training and helped spread information to those who had not. Health workers in the district where text messages were sent had significantly better knowledge of IPTp, compared with those in the district where only classroom training was provided. Average facility coverage of three doses of IPTp was also significantly higher where text messages were sent compared with the district where only classroom training was provided.
Comments: "A practical framework for the design and strengthening of CHW programme governance at scale" - a bold claim. Of interest to CHIC, AMP + FAH colleagues who are doing this in realtime
Methods: See paper
Takeaway: The framework is presented as a set of principles and a matrix of 5 key governance purposes (or outputs). These purposes are: a negotiated fit between policy mandates and evidence, histories and strategies of community-based services; local organisational and accountability relationships that provide community-based actors with sufficient autonomy and power to act; aligned and integrated programme management systems; processes that enable system learning, adaptation and change; and sustained political support. These purposes are further elaborated into 17 specific tasks, distributed across levels of the health system (national, regional, and local).
Comments: Report by UPenn's Center for High Impact Philanthropy featuring a number of Coalition members
Methods: See paper
Takeaway: A resource for donors who wish to make a greater impact in the health of vulnerable communities worldwide.
Community Health Research Round-Up, Issue 007
March 4, 2019-March 18, 2019
Comments: The objective of the study was to evaluate the feasibility and acceptability of weekly training and support by telemedicine (videoconferencing). Of interest to CHAcademy folks + beyond!
Methods: N = 6(!!). Cross-sectional measurement of telemedicine usability, knowledge of diabetes (baseline to 6 months), & program satisfaction.
Takeaway: Telemedicine is a feasible and acceptable modality to train and support CHWs.
Comments: Interesting new work on gender and workflow
Methods: Qualitative (meetings, photovoice)
Takeaway: Although responsibilities were the same for both male and female CHWs, they reported that in practice, CHWs were predominantly involved in different types of work depending on their gender. The differing roles and perspectives about the nature of male and female CHWs while performing their roles should be considered while designing and implementing CHW programmes, without further retrenching gender inequalities or norms.
Evaluation of the cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by lady health workers as compared to an outpatient therapeutic feeding programme in Sindh Province, Pakistan.
Comments: Complement to the Can community health workers manage uncomplicated severe acute malnutrition? review included around in research round-up 002 & the IRC's SAM treatment protocol/low‐literacy‐adapted tools study included in round-up 006.
Methods: Activity-based cost model, employing a societal perspective to include costs incurred by beneficiaries and the wider community.
Takeaway: The similarity of cost-effectiveness outcomes between the two models resulted in uncertainty as to which strategy was the most cost-effective. The cost to the beneficiary household of outpatient facility-based care was double that of LHW-delivered care.
Comments: Of interest to implementation scientists/users of RE-AIM, PRECEDE-PROCEDE etc.
Methods: Scoping review
Takeaway: Few studies used implementation theories to understand the facilitators and barriers to CHW integration. Some constructs of implementation such as fidelity or perceived benefits were assessed. In addition, studies that reported intervention development often cited specific theories, such as the transtheoretical or health belief model, that helped facilitate the development of their program.
Comments: This came out last year but was just indexed in some databases this week. An important read by our friends at Oxford if you haven't already come across it!
Methods: Systematic scoping review.
Takeaway: There is a diverse range of approaches in the design, delivery and reported outcomes of ongoing training for CHWs in LMICs, and a number of significant gaps remain.
Comments: Yet more evidence that proximity + trust are critical to access.
Takeaway: Factors associated with the use of CHWs services were lower asset index, mother being the decision maker for site of first consultation, distance to nearest CHW of <3 km, and trust for CHWs services. Programs should ensure that CHW are well located to enable easy access.
Comments: Interesting piece of work on accreditation comparing team climate among Texas CHWs who were certified by the 2 different methods: (a) completing a state-approved training program, and (b) providing evidence of work experience (grandfathering)
Takeaway: Analysis of survey results found no significant differences in Team Climate Inventory scores between CHWs who were certified either through state-approved training or through work experience. This research provides some preliminary evidence in support of experience-based certification, but there continues to be a need for more research evaluating CHW certification requirements and the impact of state certification of CHWs on population health outcomes.
Comments: Super interesting study examining the role of different levels of supervision and location of the community health worker (CHW) team on the team’s motivation, performance and integration into the health system.
Methods: Case studies of six purposively selected teams
Takeaway: Senior supervisors raised CHW skills, and successfully negotiated a place for CHWs in the health system. Collaboration with clinic staff reduced CHWs’ marginalisation and increased motivation. Despite being clinic-based, teams without senior supervisors had lower skill levels and were less integrated into the health system.
Comments: Good example of a policy review - could be applied to other policies
Methods: Policy review
Takeaway: Fantastic thematic overview of CHWs in Mozambique
Comments: Why quality improvement is important!
Methods: Comparative x-sectional
Takeaway: Overall knowledge about various birth control methods was more in uncovered areas, i.e., 71.4% than the covered ones which was 28.6%, p=0.67. No statistical difference p=0.86 was found in usage of contraceptive methods among couples living in LHW covered and uncovered areas.
Community Health Research Round-Up, Issue 008
March 19-April 1, 2019
Comments: Hot off the press! Fantastic food for thought + action from our friends at Pop Council. See also, Chapter 8 of the WHO CHW Guideline
Methods: Search for extant systematic reviews + technical advisory group/expert consultation
Takeaway: Priority research questions included queries on effective policy, financing, governance, supervision and monitoring systems for CHWs and community health systems, implementation questions around the role of digital technologies, CHW preferences, and drivers of CHW motivation and retention over time.
Comments: A phenomenal portrait of a longstanding national program at scale.
Methods: Systematic search for articles on ASHAs published between 2005 and 2016
Takeaway: Several interesting takeaways, here are two:
55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints.
The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication.
Comments: h/t to Prabhjot, who shared this with me this morning. Of interest to Pivot re: question of community interventions promoting facility based care
Methods: C-RCT as part of a 2x2 factorial
Takeaway: A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery.
Comments: Cool little innovations in primary care note on use of a smartphone app to provide algorithmic clinical decision support to CHWS, enabling them to directly deliver diabetes care (not just education), including the titration of oral medications and management of complication. The diabetes app will be freely available on the CommCare platform
Takeaway: Early data suggests efficacy in improving diabetes care. Compared with baseline values, mean A1c has improved at each time point through 12 months. The proportion of patients meeting treatment goals for A1c increased from 13.0% to 34.8% (P = 0.09) of patients followed to 3 months (data collection ongoing).
Comments: Interesting commentary on precision medicine and community health in the USA (+ relevant elsewhere). Why the supply side will be necessary even with all the funk demand-side innovations...
Takeaway: They argue that CHWs are ideal professionals to address ongoing gaps in health literacy and to empower members of the community to make informed decisions about precision-based management and novel therapies.
PROTOCOL: Effects of an mHealth intervention for community health workers on maternal and child nutrition and health service delivery in India: protocol for a quasi-experimental mixed-methods evaluation
Comments: h/t Ryan Schwarz. In his words: evaluation of the ICDS CAS roll-out in India. Dimagi's Commcare + an extremely ambitious roll-out as part of the national nutrition mission
Methods: Village-matched controlled design with repeated cross-sectional surveys to evaluate whether ICDS-CAS can enable more timely and appropriate services to pregnant women, children <12 months and their mothers, compared with the standard ICDS programme
Community Health Research Round-Up, Issue 009
April 1- April 15, 2019
Comments: The paper could do with an equity-based language update; nonetheless, an interesting qualitative piece on considerations for supporting CHWs who work in areas plagued by violence.
Methods: Telephone surveys of CHWs
Takeaway: The case study indicates that CHWs in Rio de Janeiro, Brazil are exposed to urban violence nearly daily. Calls for policymakers to incorporate the need to adapt to circumstances encountered in the field in their work (e.g. coordination with law enforcement to help CHWs feel safer etc.)
Profiling the best-performing community medicine distributors for mass drug administration: a comprehensive, data-driven analysis of treatment for schistosomiasis, lymphatic filariasis, and soil-transmitted helminths in Uganda
Comments: Fascinating study on CHW selection (in this case, community medicine distributors - CMD - in the context of mass drug administration)
Methods: CMD attributes (more than 25) were measured. The predictors of treatment rates achieved by CMDs were selected with least absolute shrinkage and selection operators and then analyzed in ordinary least squares regression with standard errors clustered by village
Takeaway: Criteria currently used to select CMDs—community-wide meetings, educational attainment, age, years as a CMD, etc.—were uninformative. Engaging CMD friend groups with MDA, selecting CMDs who practise good preventative health behaviours, and including CMDs with high-risk occupations for endemic infections may improve MDA treatment rates. Evidence-based guidelines are needed to improve the monitoring, selection, and replacement of CMDs during MDA.
Comments: Recent data on a nationwide mHealth intervention
Methods: ITS using data from Rwanda Demographic and Health Survey
Takeaway: RapidSMS did not appear to increase uptake of the maternal and newborn health services. In most instances, this was due to a ceiling effect, but the rate of women who completed the recommended standard regimen of 4 ANC visits (or more) during their most recent pregnancy (40.57%) & the rate of women who had the first ANC visit in the trimester (50.30%) were suboptimal and did not appear to have increased following RapidSMS implementation. Authors hypothesize that this was due to poor fidelity.
Comments: Interesting qualitative dive into how supportive supervision is being rolled out in a couple of districts in South Africa. Interestingly, the finding on dedicated supervision is in direct conflict with the WHO Guideline implementation consideration that "supervision may be carried out by both dedicated supervisors and other health workers as part of a broader set of responsibilities"
Methods: A qualitative, descriptive study that combined a document review of national policy and guidelines with key informant interviews in two districts of the North West Province
Takeaway: Primary health care clinic managers, who were supposed to supervise the ward-based outreach teams (WBOTs - comprised of a nurse & an average of six CHWs), struggled to fulfil this role amidst the high workloads in facilities, and relationships between WBOTs and facility staff often remained strained.
Comments: Another example of an economic analysis based on an RCT
Methods: Incremental cost-effectiveness ratio (ICER) from the societal perspective over a 2-year time horizon; costs in 2012 USD
Takeaway: Compared to a variety of willingness-to-pay thresholds from $39 000 to $154 353 per QALY gained, this ICER shows that the Diabetes Care in American Samoa (DCAS) intervention (a cluster-randomized, home-visiting CHW intervention that improved HbA1c levels) is highly cost-effective.
Comments: Recently re-shared by Lisa Hilmi over the Core list. A great paper by the same team behind the 10 year ASHA SR in the last issue.
Methods: Review of all publically available government documents (n = 96) as well as published academic literature (n = 122) on the ASHA programme. Also drew from the embedded knowledge of the paper’s government-affiliated co-authors, triangulated with key informant interviews (n = 12). Data were analysed thematically through a gender lens.
Takeaway: Although still grappling with significant gender inequalities, policy adaptations have increased ASHAs’ access to income, knowledge, career progression, community leadership, and safety.
SMARThealth India: A stepped-wedge, cluster randomised controlled trial of a community health worker managed mobile health intervention for people assessed at high cardiovascular disease risk in rural India
Comments: A second null outcome mHealth trial
Methods: Stepped-wedge, cluster randomised controlled trial of a complex intervention involving task-sharing between doctors and village-based community health workers using mHealth decision support.
Takeaway: It was not effective in improving BP control rates for people at high CVD risk. Given the mHealth literature is dominated by small studies the findings from this large trial are important. Despite great promise for mHealth interventions to improve access to effective health care, there remains considerable uncertainty about how this can be successfully achieved in practice.
Community Health Research Round-Up, Issue 010
April 16-May 20, 2019
Comments: People like community health! More than that, they feel more positively about the public health system overall
Takeaway: Households in intervention areas were 2.3 times as likely as households in control areas to have ever received a CHW visit (95% CI 1.8, 3.0). The intervention led to a 15-percentage-point increase in satisfaction with the public-sector health system (95% CI 3, 27).
Comments: Incredible paper looking at empirical evidence for the various claims made about how volunteer CHWs experience their work
Methods: Interviews and focus group discussions with health officials, salaried Health Extension Workers, volunteer CHWs, and other adult women
Takeaway: Volunteer CHWs are actually worse off than their peers in various psychosocial and economic respects & CHW recruitment processes are the most likely explanation for this difference. Additionally, the unpaid CHW position adds work to already burdened shoulders, and makes women—especially unmarried women—vulnerable to negative gossip and high levels of psychological distress.
Comments: Recent cost-effectiveness data on CHWs for vaccinations. Turns out we can increase payment by an order of magnitude and this would still be true.
Methods: Markov modeling simulating a cohort of children in villages with and without ASHAs
Takeaway: ASHA intervention was highly cost effective at $162 per DALY averted compared to no ASHA & remained cost effective with the ASHA incentive increased from $2 to $15, across the range of probabilities and cost parameters. The Government of India and individual state governments of India should consider increasing the incentives provided to ASHAs.
Methods: X-sectional survey - multivariate logistic regression was conducted to assess the odds of married female youth reporting current use of modern contraceptive methods based on being visited by a relais in the past three months.
Takeaway: Young married women visited by relais were more likely to use modern contraceptive methods compared to those not visited by a relais. These results are consistent with similar family planning studies from sub-Saharan Africa
Comments: Of interest to the budding CHW & disability working group (Phyllis, SO)
Methods: Semi-structured interviews and focus groups
Takeaway: There was a lack of knowledge & skill in managing childhood disorders and disabilities by CHWs. Enablers and restrictors affecting service delivery were highlighted. The challenges raised were generic to the holistic role of CHWs and not particularly specific to the CHW role in childhood disorders and disabilities.
Comments: New data on the unique insight of CHWs & their link to better outcomes. A nice compliment to the recent Health Affairs blog by Shreya + colleague
Methods: Quasi-experimental design
Takeaway: CHWs were effective at finding persons with greater needs & were better able to help them access a greater range of home and community-based long-term care (HCBS) services. Five times fewer HCBS beneficiaries helped by CHWs had to use nursing home care services than those not helped by the CHWs despite the fact that their health status was poorer than those not helped by the CHWs
Comments: Turns out the Alaskans were right... ;)
Methods: Inter-rater agreement was analyzed with Cohen's kappa coefficient (κ) test, and the diagnostic ability of CHWs, onsite specialist, and remote specialist was illustrated using receiver operating characteristic curve.
Takeaway: The inter-rater agreement between the CHW and the onsite specialist showed almost perfect agreement with the κ score of 0.92, and a substantial agreement between CHW and remote specialist showed a score of 0.62. The sensitivity, specificity, positive and negative predictive values of CHWs in the identification of oral lesion were 84.7, 97.6, 84.8, and 97.7%, respectively. The trained CHWs can aid in identifying oral potentially malignant disorders and they can be utilized in oral cancer-screening program mHealth effectively.
Community Health Research Round-Up, Issue 011
May 21-June 3, 2019
Comments: Interesting trial looking at CHW impacts on understudied outcomes of social determinants and caregiver distress
Methods: Retrospective pre/post
Takeaway: Significant improvement in caregiver distress scores (P < .001) & understanding of their children’s diagnoses (P < .001). The number of caregivers reporting food or housing issues (high at baseline) was significantly reduced (P < .01 and P < .01, respectively).
Comments: Great new editorial in the NEJM on CHW financing in the US
Takeaway: Documents several value-based payment systems that have been set up to support CHW financing and integration, but makes the case that, b/c fee-for-service payment is still a dominant force in U.S. health care it will be essential to establish billing codes for financing the work of CHWs in fee-for-service environments (though acknowledges important concerns regarding reimbursement of CHWs under fee-for-service structures would have to be addressed)
Comments: Time for some critical self-reflection!
Methods: A sub-set of 206 indexed journal articles reporting on CHW programmes in LICs was purposefully selected from a prior review of research authorship on CHW programmes in all LMICs over a five year period (2012–2016) and analysed
Takeaway: Knowledge production on CHW programmes in LICs flows predominantly through a pool of connected HIC authors and North–South collaborations. There is a need for strategies harnessing more diverse, including South–South, forms of partnership.
Comments: Would be curious as to your take on this, Isaac. It's in HP&P but not the most nuanced in its conclusions...
Methods: Structured narrative review
Takeaway: 3 Benefits: 1-it will help improve the access and quality of services, notwithstanding its higher establishment and maintenance costs. 2- it will add efficiency in training and personnel management. 3- it will leverage the use of data generated across grass-roots platforms to further research and evaluation. 3 Challenges: 1- funding, 2- health literacy of CHWs and 3- systemic challenges related to motivating CHWs.
Comments: Thoughtfully conceived study w/the aim of determining what type of formal mental health training and programming could most benefit CHWs in India. Of interest to the SO team as they plan their disability curriculum, perhaps
Takeaway: CHWs were dismissive of faith healers ability to treat mental illness (72.9%) showing a strong approval for recommending psychiatric care for the mentally ill (84.4%). Over 50% of participants believed that mentally ill have a lower IQ and that they were unpredictable, but at the same time asserted that people with mental illness can live in the community (80.8%), and recover if given treatment and support (91.8%). Results are promising with CHWs displaying basic knowledge of the etiology and treatment of disease harboring positive attitudes towards psychiatrist’s ability to treat mental illness. Future direction should focus on training CHWs towards minimizing stigmatizing views and increasing their knowledge of mental illness in order to scale up mental health services
Interesting trial registrations:
PROTOCOL: Effect of a community health worker delivered health, nutrition and responsive stimulation package and conditional cash transfers on child development and growth in rural Tanzania: protocol for a cluster-randomized trial
A C-RCT of a supply-side CHW delivered child health, nutrition, and responsive stimulation intervention alone and in combination with a demand-side conditional cash transfer (CCT) intervention to promote antenatal care and child growth monitoring attendance in rural Morogoro region, Tanzania.
PROTOCOL: A community health worker-led multimedia intervention to increase cervical cancer screening uptake among South Asian women: study protocol for a cluster randomized wait-list controlled trial
Community Health Research Round-Up, Issue 012
June 4 - June 17, 2019
Comments: Turns out CHWs want to get paid, receive healthcare benefits, and have the opportunity to get promoted. Who knew?
Methods: Discrete choice experiment
Takeaway: ASHAs were found to exhibit a strong preference for jobs that incorporated training leading to promotion, a fixed salary and free family healthcare. ASHAs were willing to sacrifice 2530 Indian rupee (INR) from their monthly salary, for a job offering training leading to promotion opportunity and 879 INR for a free family health-check. However, there was significant heterogeneity in preferences across the respondents.
Comments: Pair w/recent evidence re: psychosocial distress among unpaid community health workers and this recent C-RCT showing Ethiopia's iCCM program did not generate levels of demand and utilization sufficient to achieve significant increases in intervention coverage and a resulting acceleration in reductions in child mortality.
Methods: A pool of 42 Sub-Saharan African countries, covering the period 1990 to 2016, is used to construct a synthetic comparator
Takeaway: On average, since 2004, maternal mortality in the control countries exhibits a moderate downward trend. In Ethiopia, the downward trend is considerably steeper as compared to its synthetic control. By 2016, maternal mortality in Ethiopia was lower by 171 (p-value 0.048) maternal deaths per 100,000 live births as compared to its synthetic control. Between 2003 and 2016, Ethiopia's maternal mortality ratio declined from 728to 357. These estimates suggest that a substantial proportion of this decline may be attributed to Health Extension Program/Health Development Army
Comments: Much needed study identifying and describing over ten years of studies on the use, effectiveness, and potential of mHealth involving CHWs.
Methods: Scoping review
Takeaway: Large-scale, longitudinal, and clinical studies are lacking. The existing evidence indicates that interventions, which include both CHWs and mHealth tools, are effective. Challenges include the scarcity of culturally relevant mHealth interventions, lack of a consistent methodology to assess mHealth outcomes, the need for effective training for CHWs to adopt mHealth tools, and improved communication within health care teams working with CHWs.
Comments: Great new piece from our friends at Oxford
Methods: Systematic scoping review
Takeaway: The roles of CHWs in cervical cancer screening in LMICs have largely to date focused on education, outreach, and awareness programmes. Community-based approaches to cervical cancer screening are feasible, although the sociocultural context plays an important role in the acceptability of these interventions. Further in-depth contextually grounded studies exploring the acceptability of such interventions are required, as well as studies exploring the cost-effectiveness of involving CHWs in cervical cancer screening activities.
Comments: Of relevance to the CHAcademy crew
Methods: Single-blind, non-inferiority, randomized controlled trial
Takeaway: Results indicated no significant differences between health workers trained using 'Technology-Assisted Cascaded Training and Supervision system’ and supervised from distance v. those trained and supervised by a specialist face-to-face and at 3 months follow-up assessment
Comments: Timely article with the first cases from the latest ebola outbreak surfacing in Uganda this past week
Methods: Qualitative interviews
Takeaway: Health workers responding to outbreaks have frequently encountered isolation and stigma from their communities; this avoidance was sometimes accompanied by mistrust and, in rare instances, violence. Health workers also suffered emotional trauma, depressive symptoms, and fear from witnessing colleagues suffer violent deaths.
Comments: In hono(u)r of today's event, hosted by UBS Optimus and USAID's Centre for Innovation and Impact, on unlocking private capital for global health innovation
Takeaway: This needs assessment focused on understanding both innovator
challenges in successfully scaling up and investor challenges to
deploying more private capital. The ultimate goal is to stand-up
a new (or add to an existing) blended finance and/or technical
assistance (TA) facility that catalyzes the right type of private
capital, to the right innovators, at the right time to help them scale.
Community Health Research Round-Up, Issue 013
June 18 - July 15, 2019
Comments: Would vigorously dispute the characterization of the evidence base for the efficacy of CHW programs as "limited"--the six year old Singh & Sachs article cited in this piece does not make this claim & frankly, in what other field is 100+ positive RCTs characterized in this way? That said, this is an important paper on something that is understudied: the potential unintended consequences of these programs when they are not integrated into the health system
Takeaway: In the context of a bureaucratically weak health system and local grassroots dynamics that jeopardized long-term CHW program sustainability and eroded national health goals, unintended consequences were (a) CHWs moonlighting for multiple organizations, (b) CHWs freelancing in communities without regulation, and (c) adverse patient outcomes resulting from uncoordinated care.
2. The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey [version 2; peer review: 2 approved]
Comments: Great use of the Performance Monitoring and Accountability 2020 survey by Lisa, Dan and others!
Methods: Descriptive analyses of survey data
Takeaway: There was variability in supervision frequency and CHW activities. A high proportion of CHWs already meet the
expected frequency of supervision while there were substantial differences by region in CHW service provision, which requires further
Comments: Of interest to our US colleagues and all who care about accreditation/organizing! (Part of a special issue on community-clinical linkages within health care in Hawai‘i)
Takeaway: Presents the perspectives of allies (governmental, university & public health organizations) in support the efforts of Hawai'i CHWs as they organize and move towards establishing a professional association.
Comments: Add to the arsenal of 'CHWs are pro-equity!' arguments
Methods: Mixed-methods systematic review of quantitative and qualitative studies
Takeaway: CHW interventions involving home visits, cash transfers, participatory women’s groups or multiple components can improve equity in maternal and newborn health
Comments: While community health agents remain at the core of many birth and death reporting efforts, previous literature has not explored elements for their successful integration into civil registration and vital statistics (CRVS) systems
Methods: Systematic review
Takeaway: Creating a programmatic norm of integrating with CRVS systems the vital events information collected from existing community health programs has the potential to provide governments with information essential for public health decision-making.
Comments: New report out this week by Phyllis Heydt, a longtime member of the community health family, and team! A cross-cutting issue that I believe is relevant to all our work
Takeaway: People with disabilities have poorer healthcare access, coverage, and outcomes for all SDG 3 indicators.
Community Health Research Round-Up, Issue 014
July 16 - July 29, 2019
Comments: Contextualize with recent mHealth scoping review
Methods: Two-arm cluster randomized trial
Takeaway: The mHealth application led to modestly improved QoC through better assessment of the sick children and better referral decisions by CHWs, but not to improvement in the actual treatment of malaria, pneumonia and diarrhea. Considering mHealth’s additional costs and logistics, this study did not support the overall value of the mHealth intervention.
Comments: Interesting that proactive case finding was not one of the alternatives considered to solve this problem...
Methods: Population-based survey
Takeaway: There was low coverage of home visits during pregnancy and soon after delivery in a well-supported program delivery environment. Most HSAs were conducting home visits, but not at the level needed to reach high coverage.
Comments: Interesting data from the States - CHWs feeling unconfident to provide one of the services they were first allowed to conduct
Methods: Survey of CHWs in Idaho, Indiana, Nevada, and Oregon
Takeaway: CHWs provide medication management services but have low confidence in their ability to provide such services. A greater emphasis on medication management training should be included in CHW certificate and continuing education programs.
Comments: The importance of implementation science + reliable supply chains all rolled up in one study:
Takeaway: Community health worker home-visit deployment had 2 years of initial impact among children over 1 month of age, but a null effect when tests were based on over 1 month of age data merged for all four project years. The atrophy of under age five effects arose because workers were not continuously equipped with essential medicines in years three and four. Analyses that controlled for stock-out effects suggest that adequately supplied workers had survival effects on children aged 1 to 59 months.
Comments: Pay them! When the moral case is not enough, here's another pragmatic paper to add to the empirical evidence pile.
Methods: Comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries.
Takeaway: Introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives
Community Health Research Round-Up, Issue 015
July 30 - August 12, 2019
Comments: Very cool application of social network analysis
Methods: Focus group discussions + social network analysis
Takeaway: In Kenya, Community Health Committees (CHC) were established to enhance community participation in a health services. Their role is to provide leadership, oversight in delivery of community health services, promote social accountability and mobilize resources for community health. The researchers found, however, that CHCs played a peripheral role in the flow of health-related information.
Comments: Traditional healers may be acting as de facto CHWs in many settings, particularly when (as in this case) CHWs did not receive adequate training, supervision or supplies to provide child health services. Of interest to all, particularly colleagues @ Lwala
Methods: In-depth interviews and focus group discussions
Takeaway: In Tshopo Province, Democratic Republic of the Congo, traditional healers fulfil many of the functions nominally ascribed to CHWs (e.g. providing affordable, acceptable care close to home, referrals etc.). Policymakers should engage with and consider this cadre of health workers when planning child health services.
Takeaway: A 12-month CHW-led intervention at household level improved adherence to prescribed drugs, but did not impact systolic blood pressure. To be more impactful, a more comprehensive solution that addresses escalation and access to useful therapies is needed.
Comments: If I see the phrase "Although not a replacement for professional health providers, CHWs" one more time...CHW care (e.g. IMCI) is part of the Basic Package of Health Services (BPHS) in Afghanistan--just because they are not paid for their essential labour, doesn't mean they are not proper health workers. The paper also claims "One of the main reasons for the considerable size of the workforce is the voluntary nature of the program." Not sure how they arrived at that conclusion given that other countries have expanded paid CHW programs at an equally rapid clip...? Rant aside, this paper has an interesting section on CHWs’ relation with other health workers--a critical question in every setting.
Methods: Participant observation and in-depth interviews with community members, CHWs, health managers, and policymakers
Takeaway: CHWs in Afghanistan are a viable option to meet the basic health needs of the population, but their full integration into the health system is limited and hampers their effectiveness. Attention to career progress is needed.
5 & 6. Assessment of tuberculosis knowledge among Lesotho village health workers and utilisation of their tuberculosis services by the communities they serve & Assessment of the knowledge of Brazilian Community Health Workers regarding prenatal care
Comments: Two articles demonstrating the need for continuous/ongoing/refresher training of CHWs (like other health cadres)
Methods: Both were cross-sectional
Takeaway: Lesotho: Low utilisation of VHWs’ TB services by community members emanated from inadequate TB knowledge of VHWs. Brazil: CHWs have an important role in assisting pregnant women in the community, though the study indicates the areas of knowledge that require more specific attention from training providers.
Community Health Research Round-Up, Issue 016
August 13 - August 26, 2019
1&2. The impact of India’s accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study & Are community health workers effective in retaining women in the maternity care continuum? Evidence from India
Comments: Two related papers from our friends at Hopkins + UNC
Methods: Difference-in-difference analysis with cluster-level fixed effects (utilization & multinomial logistic regression model (dropout along continuum). Data from Indian Human Development Surveys done in 2004–2005 and in 2011–2012
Substantial variations in the receipt of ASHA services were reported
(66% of women in northeastern states, 30% in high-focus states, & 16% in other states).
In areas where active ASHA activity was reported, the poorest and most marginalized women had the highest odds of receiving ASHA services.
Exposure to ASHA services was associated with a 17% (95% CI 11.8–22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI − 1.6–11.1), 26% increase in SBA (95% CI 20–31.1), and 28% increase (95% CI 22.4–32.8) in facility births.
While ASHA is effective in supporting women to initiate and continue care along the continuum, it does not significantly affect the completion of all services along the continuum.
--> The ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, there is a need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.
Comments: Of interest to IPA team. Pair with recent evidence that introducing and/or sustaining a form of financial incentive is key for strengthening community health worker motivation (Research Round-Up 014) and psychosocial distress among unpaid community health workers (RR 010)
Methods: Cross-sectional survey w/factor analysis
Takeaway: Findings reveal a 4-factor model of motivations among VHWs that includes social, personal, job related, and organizational factors. Necessity of adequate and sustainable financial and nonfinancial context-specific incentives.
Comments: Of interest to CHAcademy team. Pair w/related recent scoping review here (RR 012)
Methods: Evidence mapping methodology, based on systematic review guidelines
Takeaway: While the evidence map shows a positive shift away from information dissemination towards approaches that use more interactive learner-centred pedagogies, including supervision and peer learning, this was not seen across all areas of global health. The evidence map shows significant gaps in the use of mobile technologies for training: no studies of trauma, disability, nutrition or mental health that use information dissemination, peer learning or supervision for training CHWs in LMICs were found.
Comments: Gentle PSA for use of "patients" rather than "clients"; otherwise a helpful ethnography on structural barriers to care and CH-led solutions in Indiana, USA
[Note: The preference for patient expressed in the research round-up comes from the idea that patients have a right to health (access, equity...), whereas clients typically pay for services in a transaction. The ongoing (global) fight against point-of-care user fees thus jives better w/the word patient. One of the authors of this piece, Ryan Logan, reached out to us following the publication of issue 016 w/the following explanatory note: “For the population of CHWs I worked with in Indiana, they (and the association that organized CHWs) preferred the use of the term client for CHWs and patients for medical professionals (doctors, nurses, etc.). As it was a collaborative project in which I worked closely with the CHWs, I wanted to ensure that my research reflected their verbiage hence the usage of client rather than patient.”]
Takeaway: Key barriers encountered by CHWs included difficulty in accessing resources for clients, lack of effective public transportation, barriers within the professional workforce, and the overarching negative impact of structural violence on client motivation. In spite of these issues, CHWs can address these barriers via adoption of a structural competency approach
Comments: More evidence of CHWs for NCDs
Takeaway: Trained CHWs can decentralise hearing services to vulnerable communities using smartphone screening incorporating automated testing and measures of quality control
Comments: Of interest to PIVOT crew (+ all, really)
Takeaway: Providing pregnancy tests to CHWs to distribute to their clients for free significantly increased the number of women at risk of pregnancy who sought services from CHWs--enabling more women to confirm they are pregnant and receive antenatal counselling.
Community Health Research Round-Up, Issue 017
August 27 - September 9, 2019
Comments: Treatment rates achieved by community medicine distributors (CMDs) vary widely and can undermine morbidity control. An interesting finding re: increasing efficacy of these programs
Takeaway: The study found that a more equal division of labour (e.g. 50–50 split between how many people each CMD treated) was associated with higher treatment rates when compared to CMDs with an unequal division of labour (e.g. one CMD treating no one). CMDs who were friends were more likely to have a division of labour that was nearly twofold more equal than CMDs who were not friends ∴ Ntl programmes should explore interventions that seek to facilitate communication, friendship, and equal partnership between CMDs.
Comments: Interesting mapping of MNH packages delivered by CHWs
Methods: Policy doc review + focus groups (thematic analysis)
Irrespective of training duration (8 days to 3 years), all CHWs identify pregnant women, provide health education and screen for health conditions that require a referral to a higher level of care.
Exclusive to CHWs w/>3 months of training: Therapeutic care, antenatal care and skilled birth attendance, and provision of long-acting reversible contraceptives
Typical of CHWs w/<3 months of training: community mobilisation and patient tracking are often done by CHWs with training shorter than 3 months.
Comments: The study described in the protocol included in RR 011 has been published
Methods: Randomized wait-list controlled trial design
Takeaway: No significant difference was noted in screening uptake and screening intention between arms--CHW-led multimedia intervention was as feasible + effective.
Comments: Interesting qual work re: the strain on (particularly unpaid) CHWs
Methods:semi-structured interviews (N=25)
Takeaway: Three themes emerged around VHTs’ perceptions of their roles: community insiders, professional outsiders, and intermediaries. A caregiver “insider” role facilitated rapport and discussion of sensitive issues. As community members, VHTs leveraged existing community structures to educate clients in familiar settings such as “drinking places”. However, this role posed challenges as some VHTs felt compelled to share their own resources including food and transport money. Occupying a professional outsider role offered VHTs respect. Their specialized knowledge gave them authority to counsel others on effective forms of family planning. However, some VHTs faced opposition, suspicions about their motives, and violence in this role. In balancing these two roles, the VHTs adopted a third as intermediaries, connecting the community to services in the formalized health care system --> As countries scale up family planning and HIV services using VHTs, supportive supervision and ethical dilemma training are recommended so VHTs are prepared for the challenges of assuming multiple roles within communities
5. “Because Even the Person Living With HIV/AIDS Might Need to Make Babies” – Perspectives on the Drivers of Feasibility and Acceptability of an Integrated Community Health Worker Model in Iringa, Tanzania
Comments: This qualitative study was conducted within an existing program in Tanzania where HIV-focused CHWs working as volunteers received additional training on MNCH promotion. Compare with an ITS on a similar workload question featured in RR 005. N.B. The challenges noted in the study would be overcome were the CHWs...paid! (No apologies for the round-up being an absolute broken record on this point)
Methods: qualitative in-depth interviews
Takeaway: CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload (drew time away from other income-generating activities on which volunteer CHWs rely)
Comments: From Katharine Shelley, Research Round-up community member!
Takeaway: There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care.
Comments: The Engagement of Patients with Advanced Cancer (EPAC), comprised of a CHW who assists patients with advance care planning
Takeaway: Incorporating an CHW into end-of-life cancer care is an approach supported and viewed as highly effective in improving care by patients and caregivers.
Community Health Research Round-Up, Issue 018
September 10 - October 6, 2019
Comments: Using screening audiometry (Android-based HearX Group) children 2–16 yrs underwent hearing screening by a community health worker and/or senior otolaryngology resident
Takeaway: Community health workers obtained a similar result to otolaryngology residents 96% of the time (p = 0.16). Profound implications in low-resourced settings where hearing healthcare specialists (audiologists and otolaryngologists) are limited
Comments: Previous studies have used community health workers (CHWs) to target single cardiovascular risk factors (this SR - RR 006, SMARTHealth India - RR 009, this trial in India - RR 015). This trial tests an integrated approach targeting hypertension, diabetes, & smoking via CHWs.
Takeaway: CHWs have a significant effect on hypertension, an inconclusive effect on diabetes, and no effect on smoking.
Comments: Helpful commentary outlining a brief history of CHWs in TB treatment (for any skeptics) + directions for future research
Takeaway: "With good training, adequate remuneration, careful supervision, opportunities for self-determination, community engagement, sufficient resources, unwavering political support, and close integration with the formal health system, CHW-based programmes should contribute substantially in our endeavours to end the global TB epidemic."
Comments: A paper of which to be aware. In their recent guideline (which came out at the end of 2018), the WHO suggests not paying CHWs exclusively or predominantly according to performance-based incentives (PBI). The rationale for this recommendation was based on the evidence of potential harm: (1) PBI encouraged uneven focus on certain activities due to their association with higher incentives, especially when CHWs had no basic remuneration, leading to the neglect of other important activities or responsibilities + (2) CHWs expressed dissatisfaction with performance-based incentive models in relation to amounts paid and inconsistent and incomplete payment of incentives. This paper does not address the first concern and, while it does note that CHWs expressed dissatisfaction in precisely the way noted in concern #2, they dismiss these concerns, asserting it is the CHW's "choice" to earn more or less.
Methods: Descriptive and analytic statistics on 12 months of program data
Takeaway: PBI has been used for seven years in Kisoro, Uganda. See commentary.
Comments: The latest from our friends at the Learning and new Technologies Research Group, Oxford
Methods: Photovoice, a participatory visual method which involves the capture of photographic images related to issues of social importance.
Takeaway: The photographs and resulting discussions revealed the diverse challenges faced by CHWs, ranging from a lack of appropriate training and equipment, to complex socio-political challenges. It is important to note that although photovoice was generally perceived as a feasible methodology to explore daily challenges from the perspectives of CHWs, a small number of community members expressed concern with how their images might be used due to negative past experiences of non-native researchers capturing their images without gaining their permission.
Comments: A potentially helpful tool for intervention evaluations or routine support and management of community health workers.
Methods: Development based on literature, direct observation and field testing
Takeaway: Researchers in South Africa have developed a tool for use by non-clinical fieldworkers for assessing the quality of care delivered by community health workers providing comprehensive care in households
Comments: Another NCD application - this study looks at a CHW-led symptom screening intervention for patients with stage 3 or 4 solid tumors or hematologic malignancies who were receiving care in a community oncology practice
Methods: Historic cohort control
Takeaway: There were no survival differences between the groups. Relative to the control group, the intervention group experienced improvements in satisfaction with care, overall health, and mental or emotional health over time; fewer hospitalizations and emergency department visits, and lower median (interquartile range) total health care costs
Comments: Of interest to the Community Health Academy team. Contextualize w/this systematic review on mobile technologies to support the training of CHWs (RR 016) and this related scoping review (RR 012)
Methods: Prototyping via focus groups analyzed using framework analysis approach
Takeaway: Digital technology appears acceptable and feasible for supporting training of community health workers to deliver evidence-based depression care in rural India.
Comments: One of a host of 'CHWs improve x capacity when they receive training!' studies. Yet another illustration of what Berman et al. (1987) note in their seminal paper on CHWs, “CHW programs represent a mode for the organization of services rather than a type of intervention [task]”
Methods: pre-post survey
Takeaway: Baseline familiarity with surgically treatable conditions appears modest among rural Central American populations, and improves with access to a contextualized, pictorial manual focused on recognizing and appropriately referring surgical conditions.