Frontline Community Health Workers Research Articles

Community health workers as rights defenders: the Mitanin experience in India

ABSTRACT Women community health workers from a government-run program in India have been uncommonly successful in combining rights-based advocacy (accountability to their communities) with (nominal) paid work on healthcare tasks by the state. Over two decades, 70,000 Indigenous women Mitanins or community health workers have advanced community health and gender rights of the broader communities they are part of, and their own labour rights. Being able to strategically advocate for both types of rights is an experience unmatched by their global counterparts. This Note focuses on two elements of the Mitanin pre-emptive learning strategy, the movement-building approach of a government run program to empower frontline community health workers , and the role of a hybrid agency in prioritising social mobilisation by these workers to improve healthcare delivery.

Community health worker insights on promoting research engagement with diverse populations.

Representation of diverse populations in health research enhances our ability to understand the factors that impact health, generalize results, implement findings, and promote social justice. The primary objective of the study was to understand the unique perspectives of frontline community health workers (CHWs) to identify actionable barriers and facilitators that may impact representation of diverse groups in health research. Focus groups with CHWs were conducted followed by thematic analysis. Results revealed five main themes: barriers/risks to research participation, facilitation of research, CHW roles, recommendations, and transparency. A novel finding was that some CHWs see themselves as both facilitators and gatekeepers. As facilitators, CHWs ensure their patient populations receive resources and benefit from being involved in research; as gatekeepers CHWs feel that they protect patient populations from experiencing further trauma, especially when engaging in research. Recognizing that in many communities there is a high reliance and trust with CHWs, can promote genuine and informed participation at all stages of research.

Schizophrenia Assessment, Referral and Awareness Training for Health Auxiliaries (SARATHA): Protocol for a Mixed-Methods Pilot Study in Rural India.

Workforce shortages pose major obstacles to the timely detection and treatment of schizophrenia, particularly in low-income and middle-income countries. The SARATHA (Schizophrenia Assessment, Referral, and Awareness Training for Health Auxiliaries) project involves the systematic development, iterative refinement, and pilot testing of a digital program for training community health workers in the early detection and referral of schizophrenia in primary care settings in rural India. SARATHA is a three-phase study. Phase 1 involves consulting with experts and clinicians, and drawing from existing evidence to inform the development of a curriculum for training community health workers. Phase 2 consists of designing and digitizing the training content for delivery on a smartphone app. Design workshops and focus group discussions will be conducted to seek input from community health workers and service users living with schizophrenia to guide revisions and refinements to the program content. Lastly, Phase 3 entails piloting the training program with a target sample of 20 community health workers to assess feasibility and acceptability. Preliminary effectiveness will be explored, as measured by community health workers' changes in knowledge about schizophrenia and the program content after completing the training. If successful, this digital training program will offer a potentially scalable approach for building capacity of frontline community health workers towards reducing delays in early detection of schizophrenia in primary care settings in rural India. This study can inform efforts to improve treatment outcomes for persons living with schizophrenia in low-resource settings.

Exploring ethics in the implementation of the Community Health Worker programmes in India.

The public health machinery in India is largely driven by the frontline community health workers (CHWs), namely the Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), Anganwadi Workers (AWWs) and other multipurpose health workers. They play a vital role as intermediaries between the community and the health system. The ANMs perform important tasks such as spreading health promotion messages, supporting behavioural change, surveillance of diseases, delivery of maternal and child health services at the doorsteps of beneficiaries, prevention of common minor ailments and other public health tasks, as and when the need arises [1]. The ASHAs are trained female health workers who mobilise people to utilise health services and also provide basic primary healthcare.

Design of a randomized controlled trial of digital health and community health worker support for diabetes management among low-income patients

BackgroundInsulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin. MethodsThe study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study consisted of three arms: usual diabetes care; digital health self-monitoring; or combined digital health and community health worker support. The primary outcome was adherence to blood glucose self-monitoring. The exploratory outcome was change in glycosylated hemoglobin. ConclusionThe design of this trial was grounded in social justice and community engagement. The study protocols were designed in collaboration with frontline community health workers, the study aim was explicit about furthering knowledge useful for advancing health equity, and the population was focused on low-income people. This trial will advance knowledge of whether combining digital health and community health worker interventions can improve glucose self-monitoring and diabetes-related outcomes in a high-risk population.

Changing Perceptions of Rural Frontline Workers and Caregivers About Management of Childhood Diarrhea and Pneumonia Despite Several Inequities: The Nigraan Plus Trial in Pakistan.

PurposeDiarrhea and pneumonia greatly contribute to high childhood mortality in Pakistan. Frontline community health workers or the Lady Health Workers (LHWs) provide care at the doorstep of over 60% of Pakistan’s rural residents. Difficult terrain, lack of supplies, and inadequate supervision put these LHWs at an added disadvantage in the timely diagnosis and delivery of known treatment options to community caregivers (CCGs). This study aims to assess whether a supportive supervision intervention through Lady Health Supervisors (LHSs) using enhanced mentorship and written feedback cards have the potential to improve case management of childhood diarrhea and pneumonia.Study Setting and DesignThis perception-based qualitative inquiry nested within the Nigraan Plus trial included LHSs, LHWs, and CCGs as the participants. Twenty-two in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were conducted before a supportive supervision intervention in 2017, and 10 FGDs were conducted in 2019 once the intervention concluded. Data were analyzed using manual content analysis.ResultsThe perceived ability of LHWs and LHSs to describe the danger signs of diarrhea and pneumonia, classify dehydration and relate respiratory rate to the severity of pneumonia improved over time. Appropriate prescription of zinc in diarrhea and antibiotics in pneumonia was noted. Furthermore, CCGs’ trust in LHWs increased following the intervention, and they reported a growing inclination to contact LHWs as their first point of care. LHWs in the intervention arm were more satisfied with their job due to frequent supervisory visits and continuous feedback by LHSs.ConclusionDespite geographic, social, and economic inequities, supportive supervision has the potential to improve knowledge, practice, and skills of frontline health workers related to CCM of childhood diarrhea and pneumonia in disadvantaged rural communities. Additionally, the trust of CCGs in the health workers’ ability to manage such cases is also enhanced.

COVID-19 Prevention Practices and Associated Factors Among Frontline Community Health Workers in Jimma Zone, Southwest Ethiopia.

BackgroundA timely understanding of the frontline community health care workers’ prevention practices towards COVID-19 is very crucial to combat the pandemic. Despite this, no study has been conducted among frontline community health workers in Africa, particularly in Ethiopia. The study aimed to determine the status of implementation of preventive measures of frontline community health care workers towards COVID-19 and its associated factors.MethodsAn institution-based cross-sectional study was conducted on 421 health extension workers among selected districts. Data were collected using a pretested structured questionnaire adapted from different pieces of literature. Respondents who scored above mean score on the item measurement such as knowledge, attitude, and practice questions were categorized as knowledgeable, having positive attitude, and having good prevention practices, respectively. Data were entered in EpiData 3.1 and analyzed using Statistical Package for Social Sciences (SPSS) version 23.0 software. A multivariable logistic regression model was used to identify significant predictors. P– values less than or equal to 0.05 were declared as statistically significant.ResultsThe mean age of study participants was 31.35 years (±4.83 SD), and almost half (217; 51.54%) of respondents were single and 273 (62.47%) were trained for COVID-19 prevention measures. Of the total study subjects, 194 (46.08%; 95% CI=41.6–50.7%) had good prevention practices towards COVID-19. Being married (AOR=3.36, 95% CI=2.20–5.13), being trained (AOR=2.28, 95% CI=1.39–3.74), having good knowledge (AOR=2.4, 95% CI=1.52–3.99), and having positive attitude towards COVID-19 prevention measures (AOR=5.88, 95% CI=3.52–9.80) increase the likelihood of implementing prevention measures.ConclusionThis study showed that prevention status was low; therefore, government and non-governmental organizations working around the study area should emphasize providing training to increase their level of knowledge and to change the attitude towards implementation of prevention measures, and these can ultimately increase the status of prevention practices.

Effectiveness of a Female Community Health Volunteer–Delivered Intervention in Reducing Blood Glucose Among Adults With Type 2 Diabetes

Female community health volunteers (FCHVs) are frontline community health workers who have been a valuable resource in improving public health outcomes in Nepal, but their value is understudied in diabetes care. To assess whether an FCHV-delivered intervention is associated with reduced blood glucose levels among adults with type 2 diabetes. This community-based, open-label, 2-group, cluster randomized clinical trial with a 12-month delayed control group design was conducted in 14 clusters of a semiurban setting in Western Nepal. A total of 244 adults with type 2 diabetes were recruited between November 2016 and April 2017. The follow-up assessment was conducted at 12 months after enrollment. Data analysis was performed from January to February 2019. Seven clusters were randomized to the FCHV-delivered intervention in which 20 FCHVs provided home visits 3 times a year (once every 4 months) for health promotion counseling and blood glucose monitoring. If participants had blood glucose levels of 126 mg/dL or higher, the FCHVs referred them to the nearest health facility, and if participants were taking antihyperglycemic medication, they were followed up by the FCHVs for adherence to their medication. Seven clusters were randomized to usual care (control group). The primary outcome was the change in mean fasting blood glucose from baseline to 12-month follow-up. Secondary outcomes included changes in mean systolic blood pressure, mean diastolic blood pressure, mean body mass index, percentage change in the proportion of low physical activity, harmful alcohol consumption, current smoking, low fruit and vegetable intake, and antihyperglycemic medication status. Of 244 participants, 120 women (56.6%) and 92 men (43.4%) completed the trial. At baseline, the mean (SD) age was 51.71 (8.77) years; 127 participants were in the intervention group, and 117 participants were in the control group (usual care). At baseline, the mean (SD) fasting blood glucose level was 156.06 (44.48) mg/dL (158.48 [45.50] mg/dL in the intervention group and 153.43 [43.39] mg/dL in the control group). At 12-month follow-up, the mean fasting blood glucose decreased by 22.86 mg/dL in the intervention group, whereas it increased by 7.38 mg/dL in the control group. The mean reduction was 27.90 mg/dL greater with the intervention (95% CI, -37.62 to -18.18 mg/dL; P < .001). In secondary outcome analyses, there was a greater decline in mean systolic blood pressure in the intervention group than in the control group (-5.40 mm Hg; 95% CI, -8.88 to -1.92 mm Hg; P = .002). There was detectable difference in the intake of antihyperglycemic medication between the groups (relative risk, 1.35; 95% CI, 1.1 to 1.74; P = .02). These findings suggest that an FCHV-delivered intervention is associated with reduced blood glucose levels among adults with type 2 diabetes in a low-resource setting in Nepal. ClinicalTrials.gov Identifier: NCT03304158.

Mental health orientation among ASHAs: A study from Karnataka State, India.

Introduction:The high mental health treatment gap in India, necessitates mental health service delivery through the primary health care system. Accredited Social Health Activists (ASHAs) as frontline community health workers are a key member of the primary health care team. The ASHAs training needs related to mental health, require to be determined in order to accordingly tailor capacity-building programs. In this context, the present study aims to examine the ASHAs mental health orientation utilizing a factorially validated Indian tool.Methods:In this cross-sectional study, 91 ASHAs from a taluk of Bengaluru Urban District, responded to the self-administered Orientation towards Mental Illness (OMI) scale. Data were analysed using descriptive statistics viz. frequencies, percentages, means, and standard deviations.Results:The ASHAs reported an overall unfavourable mental health orientation and the specific OMI factors on which unfavourable orientation was observed were Psychosocial stress, Non-restrained behaviour, Weak cognitive control, Fidgety behaviour, Bizarre behaviour, Psychosocial manipulation, and Hypo-functioning.Conclusion:The findings of the study suggest that capacity-building programs for ASHAs will need to first examine their orientation to mental health and collaboratively address an unfavourable orientation when present, as it would have a bearing on ASHAs mental health service delivery in the community.

Task shifting to frontline community health workers for improved diabetes care in low-resource settings in India: a phase II non-randomized controlled clinical trial

Background The epidemic of type 2 diabetes mellitus is growing at large globally, more so in Low- and Middle-Income Countries (LMIC) like India, who concurrently battles the burden of infectious diseases. In such a health setting, people with diabetes (PWD) often receive sub-optimal care due to lack of understanding, physician-patient time, social support, and financial resources. Thus, there is a need for innovative, feasible, targeted interventions that strengthen health system to reduce the impact of diabetes in the rural communities in India. We hypothesised that structured interventions delivered by trained community health workers (CHWs) would improve outcomes in PWD and sought to demonstrate non-inferiority compared to standard care. Methods A phase II, non-randomized, controlled clinical trial was conducted in a rural block in Tamil Nadu, India. Two sub-center areas (cluster) each were allocated to the control and intervention arms, with 50 participants in each cluster. The control group received standard care routinely provided and the intervention group received interventions namely – CHW delivered, Engage communities, Screen, Examine, Refer and Follow up with the aid of ‘education tools’ and a ‘tablet based SmartHealth Application for follow-up’. Non-inferiority of the intervention in terms of early case detection, reduction in number of unnecessary physician consultations and glycaemic control was demonstrated using generalized estimating equation (GEE) for repeated measures with exchangeable correlation structure, adjusting for age, duration of diabetes and family history of diabetes. Results Baseline characteristics of both groups were comparable. CHWs were successfully able to Engage, Screen, Examine, Refer and Follow-up patients in the community. The multipronged interventions delivered by CHWs were demonstrated to be non-inferior to standard care, with significant difference in case detection rate (P=0.003), early recognition of complications, reduction in unnecessary physician consultations (P=0.041) and better glycaemic control (P=0.036). Conclusions The study has shown promising results in the limited sample size and a small geographic area and has been able to show that the task shifting to frontline community health workers for diabetes care works in this rural population. We recommend a scale up of the intervention by conducting a multicentric randomized controlled trial including cost-effectiveness analysis and taking into account stakeholders’ opinions regarding this model of diabetes care.

Uptake of routine vitamin\xa0A supplementation for children in Humbo district, southern Ethiopia: community-based cross-sectional study

BackgroundIn low- and middle-income countries routine vitamin A supplementation (VAS) is a key strategy for reducing vitamin A deficiency and mortality and morbidity of preschool children. However, in Ethiopia, there is paucity of evidence regarding the level and determinants of the uptake of the supplement. This study was designed to assess the coverage and predictors of VAS among preschool children in Humbo district, Southern Ethiopia.MethodsA cross-sectional study was conducted in April 2016. A total of 840 mothers/caregivers having children 6–59 months of age were selected using multistage cluster sampling technique from six rural villages implementing routine VAS program. Data were collected using interviewer administered questionnaire. Possible predictors considered in the study include distance from the nearby health facility, household socio-economic status, type of the household (model vs non-model), maternal access to health education on VAS, and knowledge on vitamin A and VAS. Multivariable logistic regression analysis was performed to identify predictors of uptake of VAS. The outputs are presented using adjusted odds ratio (AOR) with the respective 95% confidence interval (CI).ResultsThe coverage of VAS was 75.0% (95% CI: 72.1–77.9). Better knowledge of mothers about the importance of the supplement (AOR: 1.49, 1.02–2.17), obtaining VAS related information from frontline community health workers (AOR: 1.51, 1.34–2.72) than health professionals and being from households in the “rich” wealth tertile (AOR: 1.80, 95% CI: 1.07–3.03) were positively associated with uptake VAS.ConclusionThe VAS coverage of the area was approaching the expected national target of 80%. However, the uptake can be enhanced though awareness creation and improving socio-economic status of the community.

Knowledge and Attitudes toward HIV and People Living with HIV (PLWH) among Public Health Midwives in the Galle District, Sri Lanka

This cross-sectional study aimed to assess HIV-related knowledge and attitudes of PHMs, the frontline community health workers in Sri Lanka. Two-hundred and ninety-one PHMs were recruited. PHMs’ knowledge level was good (79.9% of answers were correct) but could be improved. Those more knowledgeable about HIV and with higher education demonstrated a more positive attitude toward PLWH. A more negative attitude, less training and older age were associated with having a stronger intention to engage in extra precautionary behaviors. PHMs need further HIV training to improve their knowledge to better educate the community. By reducing PHMs misperceptions about HIV, they may develop a more positive attitude and thus help reduce the general public’s stigma associated with PLWH.&#x0D; &#x0D; Keywords: HIV, PLWH, Stigma, attitude, community health workers, midwives, Asia, Sri Lanka

The role of frontline community health workers in the non-communicable disease screening program in Assam, India: Current trends, challenges and scope - A time and motion study

BackgroundAuxiliary Nurse Midwife (ANM) and Accredited Social Health Activist (ASHA) are community workers who play a critical role in awareness, mobilization, screening and referral under the National Cancer Prevention and Control Programme in India.The aim of this study was to assess the time utilisation and factors affecting the work of community workers in Assam, to understand how the cancer control programme could be better integrated into their existing work pattern. MethodsAn observational cross-sectional study was conducted with ASHAs and ANMs and their supervisors across two districts of Assam (Jorhat and Dhubri) in September 2018. This included a) Time and motion study with ASHAs and ANMs to capture time spent to accomplish respective tasks. b) Structured interviews with ASHAs, ANMs and their supervisors to understand perceptions of supervisors about the role ANMs and ASHAs play in cancer-related activities. ResultsOn any working day, the ANMs spent an average of 255 min (4 h 15 min) and ASHAs 246 min (4 h 6 min) on the job including travel time. Maternal and child health received greatest priority with ANMs on average spending 11 min and ASHAs 28 min to address these issues. Both ANMs and ASHAs spent only a few minutes on average to discuss cancer awareness and screening. Proper training, supervision and support for transport for them were among several factors highlighted by ASHAs and ANMs for improvement to make their role more effective in NCDs. ConclusionPolicymakers should re-evaluate the required workforce and workload of community health workers with the goal of improving cancer outcomes.

Mobile technology to give a resource-based knowledge management advantage to community health nurses in an emerging economies context

PurposeKnowledge is a key success factor in achieving competitive advantage. The purpose of this paper is to examine how mobile health technology facilitates knowledge management (KM) practices to enhance a public health service in an emerging economies context. Specifically, the acceptance of a knowledge-resource application by community health workers (CHWs) to deliver breast cancer health care in India, where resources are depleted, is explored.Design/methodology/approachFieldwork activity conducted 20 semi-structured interviews with frontline CHWs, which were analysed using an interpretive inductive approach.FindingsThe application generates knowledge as a resource that signals quality health care and yields a positive reputation for the public health service. The CHW’s acceptance of technology enables knowledge generation and knowledge capture. The design facilitates knowledge codification and knowledge transfer of breast cancer information to standardise quality patient care.Practical implicationsKM insights are provided for the implementation of mobile health technology for frontline health-care professionals in an emerging economies context. The knowledge-resource application can deliver breast cancer care, in localised areas with the potential for wider contexts. The outcomes are valuable for policymakers, health service managers and KM practitioners in an emerging economies context.Social implicationsThe legacy of the mobile heath technology is the normalisation of breast cancer discourse and the technical up-skilling of CHWs.Originality/valueFirst, this paper contributes three propositions to KM scholarship, in a public health care, emerging economies context. Second, via an interdisciplinary theoretical lens (signalling theory and technology acceptance model), this paper offers a novel conceptualisation to illustrate how a knowledge-resource application can shape an organisation’s KM to form a resource-based competitive advantage.

Maternal nutrition counselling is associated with reduced stunting prevalence and improved feeding practices in early childhood: a post-program comparison study

BackgroundDespite progress, suboptimal feeding practices and undernutrition particularly in the form of stunting still remains a major issue among children aged less than 5 years in Bangladesh. Since mothers are the primary caregivers of young children, maternal nutrition counselling can be effective in improving knowledge and practices on child feeding. The Building Resources Across Communities (BRAC) initiated a nutrition counselling intervention using its essential health care (EHC) skeleton in 114 sub-districts of Bangladesh in 2012. This study assessed the role of this intervention on the prevalence of stunting and feeding practices among children aged less than 5 years.MethodsThe data was collected as part of a nationwide cross-sectional survey, which followed a two-stage cluster random sampling procedure and was conducted between October 2015 and January 2016. The present study analyzed the information of 3009 mother-children dyads from two selected survey areas: i) areas where the EHC package was delivered (comparison; n = 1452), ii) areas with EHC plus nutrition counselling package (intervention; n = 1557) was delivered. The Chi-square test was done to compare the child feeding practices and stunting prevalence between intervention and comparison. The degree of strength of the association of stunting and the intervention was estimated using a mixed-effect logistic regression model.ResultsThe study revealed that the prevalence of stunting was significantly lower in areas where the intervention was delivered compared to the comparison areas (29% vs. 37%, P < 0.001). Furthermore, after adjusting for administrative zone, household wealth quintile, child’s age, gender, maternal age, education, occupation, cluster disparity, and variation between study groups, it was seen that the risk of stunting was 25% lower in the intervention areas compared to the comparison areas (aOR: 0.75, 95% CI: 0.60–0.94; P = 0.012). Optimal child feeding practices were also more common among mothers from intervention areas than those of the comparison areas (exclusive breastfeeding: 72.7 vs. 59.4%, P = 0.008; feeding 4+ food groups: 42.9 vs. 34.1%, P < 0.001; having minimum acceptable diet: 31.2 vs. 25.3%, P = 0.017; feeding multiple micro-nutrient powder: 16.2 vs. 7.4%, P < 0.001).ConclusionsThe study highlighted that nutrition counselling of mothers may be effective in reducing childhood stunting with concomitant improvement in optimal feeding practices in children under 5 years of age. The frontline community health workers can be trained to counsel mothers on optimal child feeding practices and this could help reduce the prevalence of stunting.

Integrated health system strengthening can generate rapid population impacts that can be replicated: lessons from Rwanda to Madagascar

At the turn of the century, the Millennium Development Goals (MDGs) set targets to dramatically improve human welfare by 2015. These ambitious aims included reducing extreme poverty by 50%, under-5...

Keeping secrets in the cloud: Mobile phones, data security and privacy within the context of pregnancy and childbirth in Tanzania

Growing evidence points to the potential value of mobile phone-based technologies ('mHealth') to help strengthen community health systems in low- and middle-income countries, but mHealth approaches also carry considerable risks with respect to data security, individual privacy, and confidentiality. We examined the perspectives of frontline community health workers and their female clients regarding data security and privacy within the context of an mHealth intervention to improve women's uptake of maternal health services from October 2013 to July 2014 in rural Tanzania. Qualitative findings demonstrate that the use of new technologies to capture health service user data during pregnancy and childbirth has both positive and negative impacts on perceptions of personal privacy and confidentiality. Women's concerns regarding privacy aligned closely with a belief that pregnancies and expected delivery dates must be kept secret, reflecting fears that pregnancy renders women vulnerable to witchcraft by jealous neighbors. Women also shared concerns that health workers' male partners could access their private information. Strong community-based engagement is recommended from the outset when developing a mHealth intervention to integrate beliefs and gender dynamics that may influence acceptability and implementation of new technologies.

The added value of a mobile application of Community Case Management on referral, re-consultation and hospitalization rates\xa0of children aged under 5 years in two districts in Northern Malawi: study protocol for a pragmatic, stepped-wedge cluster-randomized controlled trial

BackgroundThere is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary re-consultations and hospital admissions. This trial aims to evaluate the added value of the Supporting LIFE electronic Community Case Management Application (SL eCCM App) compared to paper-based CCM on urgent referral, re-consultation and hospitalization rates, in two districts in Northern Malawi.Methods/designThis is a pragmatic, stepped-wedge cluster-randomized trial assessing the added value of the SL eCCM App on urgent referral, re-consultation and hospitalization rates of children aged 2 months and older to up to 5 years, within 7 days of the index visit. One hundred and two health surveillance assistants (HSAs) were stratified into six clusters based on geographical location, and clusters randomized to the timing of crossover to the intervention using simple, computer-generated randomization. Training workshops were conducted prior to the control (paper-CCM) and intervention (paper-CCM + SL eCCM App) in assigned clusters. Neither participants nor study personnel were blinded to allocation. Outcome measures were determined by abstraction of clinical data from patient records 2 weeks after recruitment. A nested qualitative study explored perceptions of adherence to urgent referral recommendations and a cost evaluation determined the financial and time-related costs to caregivers of subsequent health care utilization. The trial was conducted between July 2016 and February 2017.DiscussionThis is the first large-scale trial evaluating the value of adding a mobile application of CCM to the assessment of children aged under 5 years. The trial will generate evidence on the potential use of mobile health for CCM in Malawi, and more widely in other low- and middle-income countries.Trial registrationClinicalTrials.gov, ID: NCT02763345. Registered on 3 May 2016.

Feasibility and acceptability of computer based online certifcation program for frontline community health workers of Wardha district, India

Background: In India, different types of Frontline Community Health Workers are recruited under different departments and health programmes. These include Anganwadi Workers (AWW) under ICDS, ASHA and ANMs under NRHM and health services. Training and recruitment of this staff cadre is an ongoing process. Most of the trainings are aimed at improving the knowledge and skills. A set of test is needed to assess the post training knowledge of trainees which should be feasible, acceptable and easy to administer. Team of Health Experts from DMIMSU, Wardha has developed such specifc Computer based online certifcation tests which were administered to selected Frontline Community Health Workers engaged with DMIMSU. This study was conducted to assess the feasibility and acceptability of these tests.Aims and Objectives: Team of Health Experts from DMIMSU,Wardha has developed specifc Computer based online certifcation tests which were administered to selected Frontline Community Health Workers engaged with DMIMSU. This study was conducted -1] To assess the feasibility and acceptability of Computer based online certifcation tests for frontline workers. 2] To assess the scope for generalization of these tests to entire frontline health cadre of the district.Materials and Methods: Data was collected from 30 randomly selected Frontline Health Workers who were engaged in Community Outreach Activities/Projects of DMIMS and had undergone trainings and Online Certifcation tests. Questionnaire with Likert type scoring scale was administered. Data was compiled in MS Excel and Weighted Means and proportions of responses towards agreement and disagreement were calculated.Results: Average Weighted Mean was 4.07 showing Strong Agreement towards the feasibility and acceptability. Only 10.3% participants showed disagreement towards the feasibility and acceptability of this test whereas 89.7% participants showed agreement and among them, 47.67% showed strong agreement towards the feasibility and acceptability of this test.Conclusion: These tests were found quite feasible and well accepted by Frontline Health Workers. Similar tests should be made compulsory for all Frontline Health Workers Cadre and their performance in tests should be linked to provisions of incentives and seniority benefits.Asian Journal of Medical Sciences Vol.8(2) 2017 82-85

Task shifting of frontline community health workers for cardiovascular risk reduction: design and rationale of a cluster randomised controlled trial (DISHA study) in India.

BackgroundEffective task-shifting interventions targeted at reducing the global cardiovascular disease (CVD) epidemic in low and middle-income countries (LMICs) are urgently needed.MethodsDISHA is a cluster randomised controlled trial conducted across 10 sites (5 in phase 1 and 5 in phase 2) in India in 120 clusters. At each site, 12 clusters were randomly selected from a district. A cluster is defined as a small village with 250–300 households and well defined geographical boundaries. They were then randomly allocated to intervention and control clusters in a 1:1 allocation sequence. If any of the intervention and control clusters were <10 km apart, one was dropped and replaced with another randomly selected cluster from the same district. The study included a representative baseline cross-sectional survey, development of a structured intervention model, delivery of intervention for a minimum period of 18 months by trained frontline health workers (mainly Anganwadi workers and ASHA workers) and a post intervention survey in a representative sample. The study staff had no information on intervention allocation until the completion of the baseline survey. In order to ensure comparability of data across sites, the DISHA study follows a common protocol and manual of operation with standardized measurement techniques.DiscussionOur study is the largest community based cluster randomised trial in low and middle-income country settings designed to test the effectiveness of ‘task shifting’ interventions involving frontline health workers for cardiovascular risk reduction.Trial registrationCTRI/2013/10/004049. Registered 7 October 2013.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-2891-6) contains supplementary material, which is available to authorized users.