Strengthening the role of community health workers in supporting the recovery of ill, undernourished children post hospital discharge: qualitative insights from key stakeholders in Bangladesh and Kenya

Rita Wanjuki Njeru,Mercy Kadzo Mwadhi,Michael Ogutu,Scholastica Mutheu Zakayo,Kui Muraya,Anderson Charo,Md Aminul Islam,James A Berkley,Mary Kimani,Md Alamgir Hossain,Md Fakhar Uddin,Haribondhu Sarma,Tahmeed Ahmed,Sassy Molyneux,Mohammod Jobayer Chisti,Judd L Walson,Caroline Jones,Sally Theobald,Gladys Sanga

doi:10.1186/s12913-021-07209-2

Abstract

BackgroundUndernourished children in low- and middle-income countries remain at elevated risk of death following hospital discharge, even when treated during hospitalisation using World Health Organisation recommended guidelines. The role of community health workers (CHWs) in supporting post-discharge recovery to improve outcomes has not been adequately explored.MethodsThis paper draws on qualitative research conducted as part of the Childhood Acute Illnesses and Nutrition (CHAIN) Network in Bangladesh and Kenya. We interviewed family members of 64 acutely ill children admitted across four hospitals (a rural and urban hospital in each country). 27 children had severe wasting or kwashiorkor on admission. Family members were interviewed in their homes soon after discharge, and up to three further times over the following six to fourteen months. These data were supplemented by observations in facilities and homes, key informant interviews with CHWs and policy makers, and a review of relevant guidelines.ResultsGuidelines suggest that CHWs could play a role in supporting recovery of undernourished children post-discharge, but the mechanisms to link CHWs into post-discharge support processes are not specified. Few families we interviewed reported any interactions with CHWs post-discharge, especially in Kenya, despite our data suggesting that opportunities for CHWs to assist families post-discharge include providing context sensitive information and education, identification of danger signs, and supporting linkages with community-based services and interventions. Although CHWs are generally present in communities, challenges they face in conducting their roles include unmanageable workloads, few incentives, lack of equipment and supplies and inadequate support from supervisors and some community members.ConclusionA multi-pronged approach before or on discharge is needed to strengthen linkages between CHWs and children vulnerable to poor outcomes, supported by clear guidance. To encourage scale-ability and cost-effectiveness of interventions, the most vulnerable, high-risk children, should be targeted, including undernourished children. Intervention designs must also take into account existing health worker shortages and training levels, including for CHWs, and how any new tasks or personnel are incorporated into hospital and broader health system hierarchies and systems. Any such interventions will need to be evaluated in carefully designed studies, including tracking for unintended consequences.

Highlights

Undernourished children in low- and middle-income countries remain at elevated risk of death following hospital discharge, even when treated during hospitalisation using World Health Organisation recommended guidelines
Few families we interviewed reported any interactions with Community Health Workers (CHW) post-discharge, especially in Kenya, despite our data suggesting that opportunities for CHWs to assist families post-discharge include providing context sensitive information and education, identification of danger signs, and supporting linkages with communitybased services and interventions
CHWs are generally present in communities, challenges they face in conducting their roles include unmanageable workloads, few incentives, lack of equipment and supplies and inadequate support from supervisors and some community members

Summary

Introduction

Undernourished children in low- and middle-income countries remain at elevated risk of death following hospital discharge, even when treated during hospitalisation using World Health Organisation recommended guidelines. A review of the coverage of CMAM programmes in 21 countries shows that coverage is often sub-optimal [7] Even where these programmes are in place, they require patients to be taken back to a facility, which is difficult for many families given distance and cost implications, and their additional domestic and income earning responsibilities [8, 9]. For these reasons, there is growing interest in the potential for Community Health Workers (CHWs) to offer home-based support for undernourished children [10]

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Results

Discussion

Conclusion