Performance Of Community Health Workers Research Articles

‘Of’ the community but not ‘of’ the health system: Translating community health workers’ knowledge into credible advice in Aceh, Indonesia

Community health workers (CHWs)—or ‘cadres’ as they are known in Indonesia—are intermediaries between the health system and the community, providing maternal and child health services at a village level. However, systemic and contextual factors inhibit CHWs from realising their potential impact. Training is essential for improving CHW performance; however, there is a need to understand whether and how this affects the care communities receive. This paper explores how communities in Aceh Province, Indonesia, receive care from cadres and the extent to which training interventions of CHWs influence this care. Semi-structured interviews were conducted remotely with 10 cadres in two districts in Aceh between June and July 2021, and five focus group discussions were conducted face-to-face with 21 caregivers of young children in one district in September 2021. Data were iteratively and thematically analysed throughout data collection. Cadres were seen as ‘of’ the community but not ‘of’ the health system. Cadres found training valuable. However, training did not adequately address the contextual challenges cadres face. From the caregivers’ perspective, cadres’ enhanced knowledge did not translate into credible guidance. Their proximity to the community and perceived distance from the health system undermined caregiver perceptions of cadres’ credibility. Infrastructural limitations of Posyandu inhibited CHW’s perceived ability to perform their roles effectively. To maximise the potential of their role, there must be more investment in enhancing the credibility of cadres within their communities—and programmatic factors such as training must better account for and adapt to the local context.

Does mHealth influence community health worker performance in vulnerable populations? A mixed methods study in a multinational refugee settlement in Uganda.

Community Health Workers (CHWs) provide healthcare in under-served communities, including refugee settlements, despite various challenges hindering their performance. Implementers have adopted mobile wireless technologies (m-Health) to improve the performance of CHWs in refugee settlements. We assessed the CHWs' performance and associated factors in a multi-national refugee settlement, operating mHealth and paper-based methods. This cross-sectional study employed quantitative and qualitative data collection methods. Data for 300 CHWs was collected from implementing partners' (IPs) databases. Nine focus group discussions (FGDs) with the CHWs and community members, two in-depth interviews (IDIs) with CHW leaders, and eight key informant interviews (KIIs) with six IPs and two local leaders were conducted. The qualitative data were analysed thematically using AtlasTi version 9 while the quantitative data were analysed at the univariate, bivariate and multivariable levels using Stata version14. The study found that only 17% of the CHWs performed optimally. The factors that significantly influenced CHW performance included education level: secondary and above (APR: 1.83, 95% CI: 1.02-3.30), having a side occupation (APR: 2.02, 95% CI: 1.16-3.52) and mHealth use (APR: 0.06, 95% CI: 0.02-.0.30). The qualitative data suggested that performance was influenced by the number of households assigned to CHWs, monetary incentives, adequacy of materials and facilitation. Particularly, mHealth was preferred to paper-based methods. Overall, the CHWs' performance was sub-optimal; only 2 in 10 performed satisfactorily. The main factors that influenced performance included the level of education, use of mHealth, having another occupation, workload and incentivisation. CHWs and IPs preferred mHealth to paper-based methods. IPs should work to improve refugee settlement working conditions for the CHWs and adopt mHealth to improve CHW performance.

Improvement of community health worker counseling skills through early childhood development (ECD) videos, supervision and mentorship: A mixed methods pre-post evaluation from Tanzania.

Community health workers (CHWs) play significant roles in improving health practices in under- resourced communities. This study evaluated an early childhood development (ECD) project in Tanzania assessing the effect of mobile video use, supervision and mentorship to improve quality of CHW counseling skills. CHWs participating in the Malezi Project in Tabora Region were enrolled in a mixed methods pre-post evaluation. CHWs previously trained in UNICEF's Care for Child Development package were further trained in counselling caregivers on nurturing care and father engagement using videos. Health providers were trained to provide ECD-focused supervision/mentorship of CHWs in facilities and during home visits. At baseline and endline, CHWs completed interviews and trained study staff observed and scored CHW counseling sessions using a structured checklist which were reduced into six dimensions through principal component analysis: introduce, educate, ask, plan/problem solve, interact/encourage, and responsive care. Twenty-five in-depth interviews were completed with caregivers and four focus group discussions with CHWs were conducted. Almost all (n = 107; 95%) 119 enrolled CHWs completed the expected eight observations (n = 471 baseline; n = 453 endline). At endline, more CHWs reported having one-on-one meetings with their supervisors (51% increasing to 75%; p < .0002) and that supervisors accompanied them to households for mentoring (60% increasing to 89%; p < .0001). We observed a shift in CHW counselling skills in clinic and home sessions. Scores in the categories of introduce, plan/problem solve, and interact/encourage significantly improved between baseline and endline; scores for ask and educate remained unchanged or decreased at both timepoints. Two-thirds of caregivers interviewed reported that father's involvement with their child increased due to CHW visits. Male participation increased in home observation sessions from 5.6% at baseline to 17.6% at endline (p < .0001). Use of videos, supervision, and mentorship were associated with CHW performance improvements in providing nurturing care counselling and in father engagement, especially in home settings.

Training and experience outperform literacy and formal education as predictors of community health worker knowledge and performance, results from Rongo sub-county, Kenya.

There is a growing recognition that Community Health Workers are effective at improving health outcomes and expanding health access. However, the design elements that lead to high-quality Community Health Worker programing are relatively understudied. We looked at the predictors of Community Health Worker knowledge of obstetric and early infant danger signs as well as performance in achieving antenatal care and immunization uptake among their clients. The study takes place in the context of an intervention implemented jointly by Lwala Community Alliance and the Kenya Ministry of Health which sought to professionalize Community Health Worker cadres through enhanced training, payment, and supervision. There were four cohorts included in the study. Two cohorts started receiving the intervention prior to the baseline, one cohort received the intervention between the baseline and endline, and a final cohort did not receive the intervention. Data on Community Health Worker demographics, knowledge tests, and key performance indicators were collected for 234 Community Health Workers. Regression analyses were used to explore education, literacy, experience, training, and gender as potential predictors of CHW performance. We found that clients of Community Health Workers trained through the intervention were 15% more likely to be fully immunized and 14% more likely to have completed four or more antenatal care visits. Additionally, recency of training and experience caring for pregnant women were associated with increased Community Health Worker knowledge. Finally, we found no association between gender and CHW competency and tenuous associations between education/literacy and Community Health Worker competency. We conclude that the intervention was predictive of increased Community Health Worker performance and that recency of training and experience were predictive of increased knowledge. Though education and literacy are often used in the selection processes of Community Health Workers globally, the link between these characteristics and Community Health Worker knowledge and performance are mixed. Thus, we encourage further research into the predictive value of common Community Health Worker screening and selection tools. Further, we encourage policymakers and practitioners to reconsider the use of education and literacy as means of Community Health Worker selection.

Exploring the impact of COVID-19 on frontline health workers through a photovoice study in Kaduna, Kwara and Ogun States, Nigeria.

Described as the 'backbone of health systems', particularly in low- and middle-income countries, community health workers (CHWs) are a critical cadre on the frontline of any outbreak response. However, it is widely recognised that CHWs are frequently lacking in appropriate support from the health system due to inadequate physical, social and financial resources. Furthermore, despite their critical role in service delivery, the health and well-being of CHWs is seldom considered and the additional emotional and physical burdens that health systems shocks can present are frequently ignored. Thus a critical step in strengthening health systems to manage disease outbreaks or other system shocks is to ensure that CHWs are adequately supported. Within this study we document the experiences of CHWs within Nigeria during the coronavirus disease 2019 (COVID-19) outbreak to understand the impact of the pandemic on CHW well-being with a view to identifying strategies that could support CHWs during COVID-19 and subsequent health system shocks. This study was based in Ogun, Kaduna and Kwara States, Nigeria. We used the creative participatory methodology of photovoice with 30 CHWs (10 in each state). Participants were asked to take photos documenting their experiences of working and living through the pandemic. Participants sent photos with captions to the research team via WhatsApp following one-on-one discussions. Photos were co-analysed among participants in focus group discussions using thematic analysis. Our findings reveal similar experiences of CHWs across Ogun, Kwara and Kaduna States in Nigeria, providing a unique insight into how the Nigerian health system was impacted and how this closely aligns to the performance and well-being of CHWs. CHW experiences related to three overarching themes: major stressors and challenges experienced due to COVID-19 (fear of contracting COVID-19, food insecurity, personal and gendered impacts), the impact of COVID-19 on providing routine care (stigma from community members, heavy workloads and inadequate equipment provision) and motivation and support from the community (pride in their roles and valued support from community leaders). The challenges highlighted through photovoice led to developing recommendations to address some of the challenges. This included training, adequate resource provision, routine supervision and peer support. COVID-19 highlighted the burden health workers often face. Photovoice allowed a space for frontline health workers to come together to share common experiences, particularly the psychosocial impact of working during health system shocks and its impact on performance. This underlines the need to acknowledge mental health and prioritise the well-being of healthcare staff. Sharing stories from the perspectives of health workers provides a platform to share learning and strategies on how to best support health workers holistically, particularly during health system shocks.

Programa Nacional de Suplementação de Vitamina A na atenção primária: qual a realidade em Minas Gerais, Brasil?

Abstract The present study aimed to evaluate the National Vitamin A Supplementation Program in Minas Gerais, adopting the mixed sequential explanatory method. The quantitative approach adopted the multidimensional instrument per the components of vitamin A supplementation and food and nutrition education. We employed an analysis matrix with parameters to define the implementation as adequate, partially adequate, inadequate, and critical. We used semi-structured interviews in the qualitative approach. The “process” dimension was better evaluated than the “structure”, with an implementation level (IL) of 84.6% and 78.5%, respectively. The Program’s strengths include supplementation planning, achieving goals, recording information, supporting breastfeeding, and the performance of Community Health Workers. Weaknesses are fragmented work, analysis of information limits, access to the Program’s actions, implementation of educational actions, and lack of or insufficient availability of nutritionists and training. The Program’s reality only partially considered health promotion actions and focused on vitamin A supplementation. Implementing food and nutritional education actions is imperative to face vitamin A deficiency.

Assessing the Utility of a Quality-of-Care Assessment Tool Used in Assessing Comprehensive Care Services Provided by Community Health Workers in South Africa.

BackgroundFew studies exist on the tools for assessing quality-of-care of community health worker (CHW) who provide comprehensive care, and for available tools, evidence on the utility is scanty. We aimed to assess the utility components of a previously-reported quality-of-care assessment tool developed for summative assessment in South Africa.MethodsIn two provinces, we used ratings by 21 CHWs and three team leaders in two primary health care facilities per province regarding whether the tool covered everything that happens during their household visits and whether they were happy to be assessed using the tool (acceptability and face validity), to derive agreement index (≥85%, otherwise the tool had to be revised). A panel of six experts quantitatively validated 11 items of the tool (content validity). Content validity index (CVI), of individual items (I-CVI) or entire scale (S-CVI), should be >80% (excellent). For the inter-rater reliability (IRR), we determined agreement between paired observers' assigned quality-of-care messages and communication scores during 18 CHW household visits (nine households per site). Bland and Altman plots and multilevel model analysis, for clustered data, were used to assess IRR.ResultsIn all four CHW and team leader sites, agreement index was ≥85%, except for whether they were happy to be assessed using the tool, where it was <85% in one facility. The I-CVI of the 11 items in the tool ranged between 0.83 and 1.00. For the S-CVI, all six experts agreed on relevancy (universal agreement) in eight of 11 items (0.72) whereas the average of I-CVIs, was 0.95. The Bland-Altman plot limit of agreements between paired observes were −0.18 to 0.44 and −0.30 to 0.44 (messages score); and −0.22 to 0.45 and −0.28 to 0.40 (communication score). Multilevel modeling revealed an estimated reliability of 0.77 (messages score) and 0.14 (communication score).ConclusionThe quality-of-care assessment tool has a high face and content validity. IRR was substantial for quality-of-care messages but not for communication score. This suggests that the tool may only be useful in the formative assessment of CHWs. Such assessment can provide the basis for reflection and discussion on CHW performance and lead to change.

An Exploration of Attributes Effecting the Relationship between Competencies and Performance of CHWs in a Rural Block of Central India

International Journal of Medicine and Public Health,2022,12,2,65-70.DOI:10.5530/ijmedph.2022.2.13Published:April 2022Type:Original ArticleAn Exploration of Attributes Effecting the Relationship between Competencies and Performance of CHWs in a Rural Block of Central IndiaRevadi G, Ankur Joshi, and Abhijit P Pakhare Revadi G*, Ankur Joshi, Abhijit P Pakhare Department of Community and Family Medicine, All India Institute of Medical Sciences (AIIMS Bhopal), Saket Nagar, Bhopal, Madhya Pradesh, INDIA. Abstract:Introduction: Induction of Community Health Workers (CHWs) into various health programs is considered as an integral strategy to achieve universal health coverage. Thus, it is prudent to explore and understand the CHWs individual and the system level interactions and their further translation into performance and actionable domains. Objectives: To quantify the relationship structure between envisioned competencies and CHW performance with factors operating at individual and the immediate system level as effect modifiers. Methods: A cross-sectional study was done in primary rural health care settings of Madhya Pradesh state in Central India. CHWs were stratified as relatively low performing (RLP) and relatively high performing (RHP) based on their annual performance-based incentives for the year (April 2017- March 2018). CHWs were administered a self-reported questionnaire that included socio demographic details, knowledge, skills assessment and availability of logistics. Results: Among the 90 eligible CHWs, 31 RLP and 30 RHP CHWs were interviewed. The CHWs performance was found to be significantly associated with age, education, caste, presence of under 5 children, knowledge and competency scores. However, while adjusting for the confounders only age and educational status were found to be significant. Further cluster analysis revealed two clusters based on individual and system characteristics which was found to influence the CHWs performance. Conclusion: The relationship between the CHWs truest competencies and performance based incentivisation tends to have been influenced by age and education which could help in developing a more focused supportive supervision catering to their needs. Keywords:Care, Community health worker, Competency, Health system, Performance, Primary healthView:PDF (177.34 KB)

Evaluation of community health worker's performance at home-based newborn assessment supported by mHealth in rural Bangladesh

BackgroundIn low to middle-income countries where home births are common and neonatal postnatal care is limited, community health worker (CHW) home visits can extend the capability of health systems to reach vulnerable newborns in the postnatal period. CHW assessment of newborn danger signs supported by mHealth have the potential to improve the quality of danger sign assessments and reduce CHW training requirements. We aim to estimate the validity (sensitivity, specificity, positive and negative predictive value) of CHW assessment of newborn infants aided by mHealth compared to physician assessment.MethodsIn this prospective study, ten CHWs received five days of theoretical and hands-on training on the physical assessment of newborns including ten danger signs. CHWs assessed 273 newborn infants for danger signs within 48 h of birth and then consecutively for three days. A physician repeated 20% (n = 148) of the assessments conducted by CHWs. Both CHWs and the physician evaluated newborns for ten danger signs and decided on referral. We used the physician’s danger sign identification and referral decision as the gold standard to validate CHWs’ identification of danger signs and referral decisions.ResultsThe referrals made by the CHWs had high sensitivity (93.3%), specificity (96.2%), and almost perfect agreement (K = 0.80) with the referrals made by the physician. CHW identification of all the danger signs except hypothermia showed moderate to high sensitivity (66.7–100%) compared to physician assessments. All the danger signs assessments except hypothermia showed moderate to high positive predictive value (PPV) (50–100%) and excellent negative predictive value (NPV) (99–100%). Specificity was high (99–100%) for all ten danger signs.ConclusionCHW's identification of neonatal danger signs aided by mHealth showed moderate to high validity in comparison to physician assessments. mHealth platforms may reduce CHW training requirements and while maintaining quality CHW physical assessment performance extending the ability of health systems to provide neonatal postnatal care in low-resource communities.Trial registrationclinicaltrials.gov NCT03933423, January 05, 2019.

Core components of a Community of Practice to improve community health worker performance: a qualitative study

BackgroundCommunities of Practice (CoPs) offer an accessible strategy for healthcare workers to improve the quality of care through knowledge sharing. However, not enough is known about which components of CoPs are core to facilitating behavior change. Therefore, we carried out a qualitative study to address these important gaps in the literature on CoPs and inform planning for an interventional study of CoPs.MethodsWe organized community health workers (CHWs) from two tuberculosis (TB) clinics in Kampala, Uganda, into a CoP from February to June 2018. We conducted interviews with CoP members to understand their perceptions of how the CoP influenced delivery of TB contact investigation. Using an abductive approach, we first applied inductive codes characterizing CHWs’ perceptions of how the CoP activities affected their delivery of contact investigation. We then systematically mapped these codes into their functional categories using the Behavior Change Technique (BCT) Taxonomy and the Behavior Change Wheel framework. We triangulated all interview findings with detailed field notes.ResultsAll eight members of the CoP agreed to participate in the interviews. CHWs identified five CoP activities as core to improving the quality of their work: (1) individual review of feedback reports, (2) collaborative improvement meetings, (3) real-time communications among members, (4) didactic education sessions, and (5) clinic-wide staff meetings. These activities incorporated nine different BCTs and five distinct intervention functions. CHWs reported that these activities provided a venue for them to share challenges, exchange knowledge, engage in group problem solving, and benefit from social support. CHWs also explained that they felt a shared sense of ownership of the CoP, which motivated them to propose and carry out innovations. CHWs described that the CoP strengthened their social and professional identities within and outside the group, and improved their self-efficacy.ConclusionsWe identified the core components and several mechanisms through which CoPs may improve CHW performance. Future studies should evaluate the importance of these mechanisms in mediating the effects of CoPs on program effectiveness.

Community Health Worker-Led Community Clinical on the U.S. / Mexico Border: Lessons Learned.

Community-clinical linkages (CCLs) connect public health organizations and health care providers to better support patients. Community health workers (CHWs), representatives from priority populations with special connections to their community, can lead CCLs. Our objective was to learn about how to conduct a CHW-led CCL from the perspectives of those implementing the intervention. We conducted focus groups with CHWs and their supervisors and regularly consulted community partners while coding and analyzing data. We learned that CHWs thrive when supported by peers, supervisors, institutions, and researchers. Supervisors- who are new to the CHW role-should consider seeking training in CHW professional development and performance evaluation. Focus group participants agreed that by balancing the strengths and weaknesses of their organization, CHW-led CCLs benefit patients because the collaboration helps them to better manage their health. Future CHW-led CCL practitioners should consider how to best institutionally support CHWs to maximize benefits for patients.

Between bond and distance: challenges in the performance of Community Health Workers

Resumo Agentes Comunitárias de Saúde (ACS) são burocratas de nível de rua que desempenham um papel fundamental na implementação da Atenção Primária à Saúde (APS). Sua função envolve o estabelecimento de um vínculo com as famílias atendidas por este serviço de saúde, o que permite conhecer a realidade do território e as vulnerabilidades da população. Este artigo tem como objetivo analisar a configuração das interações de ACS na implementação da APS com enfoque nas alterações causadas pelas mudanças recentes nesta política e pela pandemia de Covid-19. Foi realizada uma etnografia em uma Unidade de Saúde de APS na cidade de Porto Alegre/RS. Durante quatro meses, observamos o trabalho de seis ACS, analisando suas principais atividades e as mudanças na sua rotina. Além disso, também foram realizadas seis entrevistas semiestruturadas para compor a análise. Foi possível identificar que a organização interna da Unidade de Saúde não está orientada ao trabalho comunitário e à identificação das demandas no território. ACS estão perdendo o vínculo com a população e limitando-se a funções burocráticas. Os territórios e as famílias mais vulneráveis são os mais afetados com essas mudanças, pois deixam de ter seus problemas reconhecidos pela política pública.

Agentes Comunitárias de Saúde na pandemia de Covid-19: scoping review

ABSTRACT This paper aimed to systematize and analyze the literature that addresses the role of Community Health Workers (CHWs) in addressing the Covid-19 pandemic. This scoping review was conducted in the Embase, Lilacs, SciELO, Medline, and Cochrane Virtual Libraries databases. It includes publications from January to December 2020, and the selected studies were submitted to analysis, considering the following categories: practices, training, working conditions, and legitimacy. Twenty-nine studies were included in the review whose CHW performance backdrops were African, South American, North American, Asian, and European countries. The results revealed diversified approaches to practice in the countries studied that involve care, surveillance, health communication, education, administrative, intersectoral articula- tion, and social mobilization actions. The training received does not seem to correspond to the list of practices and expected impact of the CHWs. Working conditions remain substandard, with some extra incentives offered in different backdrops. The recognition and legitimacy before the health authorities reveal the dispute over the direction of health care models and the scope of social protection systems in different countries.

Enhancing Performance and Sustainability of Community Health Worker Programs in Uganda: Lessons and Experiences From Stakeholders.

Community health worker (CHW) programs in Uganda have contributed to improved health outcomes in recent years. However, opportunities for engaging the various stakeholders supporting CHW programs have been limited. This article presents workshop findings where several stakeholders shared their lessons and experiences that can enhance performance and sustainability of CHW programs in Uganda. We collected qualitative data from stakeholders from government, private, and community organizations, as well as CHWs, involved in CHW programs in Uganda during a 1-day workshop. The workshop involved plenary presentations and group discussions on critical aspects of CHW programs. All proceedings from the workshop were audio-recorded, transcribed, and analyzed by thematic content analysis. Four major themes emerged from the workshop: lessons learned in implementing CHW programs, challenges affecting CHW programs, performance of CHWs, and ensuring sustainability of CHW programs. Key lessons learned related to 3 main subthemes: capacity building and use of technology, supervision and motivation, and stakeholder engagement and collaboration. Challenges affecting CHW programs identified included poor coordination, fragmented data collection systems, high program expectations, inadequate support mechanisms, and high dropout rates. Mechanisms for improving the performance of CHWs emphasized the need to: strengthen recruitment, training, and retention strategies; improve motivation; streamline coordination mechanisms; and develop and strengthen community health policies. The sustainability of CHW programs requires institutionalization; sustainable funding; economic empowerment of CHWs; local ownership; and a strengthened research agenda. To improve the performance and sustainability of CHWs programs, stakeholders such as policy makers and implementing partners need to consider CHW needs, existing structures and policies, as well as local support.

Motivation and Performance of Community Health Workers: Nothing New Under the Sun, and Yet….

<h3>Key Messages</h3> We consider the types of incentives that motivate community health workers9 (CHWs) performance and the implications at 2 levels of systems analysis—first, for CHWs themselves and then for appropriate management of an invaluable human resource by CHW programs. The World Health Organization recommendations on commensurability of CHW compensation with the job demands—and corresponding professionalization—represent the culmination of decades of work, advances, forgetfulness, rediscovery, collective wisdom, and available evidence. Tapping into communities9 own organizing potential through volunteerism is, however, a force in both high-income and low- and middle-income countries. We offer predictions for the future direction of CHW programs: National CHW programs—whether implemented by states or non-state partners—will be a growing opportunity to viably strengthen national health systems. Partnerships between state and non-state actors will be key to sustain effective CHW programs in national PHC strategies at scale. The social-versus-institutional anchoring of CHW programs will be an enduring challenge for their performance and sustainability. Dual models (paid CHWs and volunteers), if ethically managed, will be a promising approach for efficiency and scale.

Beyond Institutionalization: Planning for Sustained Investments in Training, Supervision, and Support of Community Health Worker Programs in Bangladesh.

Bangladesh has a long history of mature and institutionalized community health worker (CHW) programs in primary health care. However, there is a lot of variability in the performance of the CHW programs in Bangladesh, as well as challenges associated with retention of CHWs. This study describes the challenges for CHWs, which in turn affect their motivation and performance. This study was conducted from December 2019 to January 2020 in 4 districts in Bangladesh: Cox's Bazar, Khulna, Rajshahi, and Sylhet. Twenty focus group discussions were conducted with 121 participants, including family welfare assistants (FWA), health assistants (HA), and their direct supervisors. Thirty in-depth interviews were conducted with upazila and district-level stakeholders. Data were analyzed using a thematic approach with a particular focus on CHW motivation, job satisfaction, and incentive preferences for improving morale and performance. Several nonmonetary and monetary factors affect CHWs' motivation, performance, and job satisfaction. Recognition by the community, availability of promotions and technical recognition, increased training opportunities, reduced workloads, identification as government employees, access to transportation, provision of working tools, and improvements in the workplace environment were identified as important nonmonetary incentives. CHWs also discussed the importance of sufficient salaries and allowances. Several factors impede the effectiveness of the CHW programs in Bangladesh. Changes to technical ranks and wages for the health care sector need to take a sector-wide lens to enable systematic calibration of wages for all health care workers. This study highlights that institutionalization of CHWs without adequate and sustained support for continued training, compensation, supervision, access to working tools, and recognition is insufficient to drive change. Identifying pragmatic strategies that can be supported through existing government budgets to address these factors is vital to sustaining the community health workforce in Bangladesh.

Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis

IntroductionCommunity health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services.ObjectivesWe examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge.MethodsWe used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong.ResultsAmong 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge.ConclusionHigher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes.Trial registration : Trial registration number: https://doi.org/10.1186/ISRCTN83902145

Role of Socio-Demographic and Environmental Determinants on Performance of Community Health Workers in Western Kenya.

Background: The performance of community health workers remains an area of significant global focus. The role of community health workers in sub-Saharan Africa has evolved over time in response to changing health priorities, disease burdens, and workforce demands. Recently, Kenya revised its community health strategy in response to challenges faced with the implementation of grassroots primary health care initiative. Implementation of community health programs is often inconsistent, and they vary widely in many attributes. The purpose of this study was to explore factors influencing performance of community health workers in Vihiga County, Western Kenya in light of the political devolution. Methods: The study was a cross-sectional study design that involved a quantitative method of data collection. A sample of 309 participants was selected through cluster and simple random sampling. A self-administered and -structured questionnaire was used to gather data, s, and those who were not able to respond individually were guided by the research assistants. Results: The community health workers were 75.2% females and 24.8% males. Performance was significantly associated with not being employed, (OR = 2.4; 95% CI, 1.4–4.4), secondary education (OR = 0.7; 95% CI, 0.5–1.1), lack of conflict resolution mechanism (OR = 2.2; p = 0.017), lack of support (OR = 1.5; p = 0.03), and community health work not seen as important (OR = 1.5; p = 0.041). Poor communication skills were also more likely to influence performance of community health workers (OR = 0.5; p = 0.050) and poor road network (OR = 0.361; p = 0.000). Conclusions: These findings offer a deeper understanding of the interaction between CHWs contextual situations, structural challenges, and performance. Addressing influential factors of CHWs performance in multi-task settings is important in preventing overtaxing their work capacity and to maintain quality performance as countries move towards universal health coverage. Strategies for incentivizing, attracting, and sustaining men in CHWs is important to broaden perspectives about this critical role in society.

Performance-based incentives and community health workers' outputs, a systematic review.

ObjectiveTo review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low- and middle-income countries.MethodsWe conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes.FindingsTwo reviewers screened 2811 records; we included 12 studies, 11 of which were randomized controlled trials and one a non-randomized trial. We found that non-financial, publicly displayed recognition of CHWs’ efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported.ConclusionFinancial performance-based incentives alone can improve CHW service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed.

Factors influencing Community Healthcare Worker’s adoption of mobile health technology (mhealth): A case of sangini supportive supervision (sangini) app, Uttar Pradesh, India

Background: Community Health Workers (CHWs) are agents in delivering primary healthcare. mhealth is being used to improve their performance. However, there are little evidences on factors influencing adoption of technology. Henceforth, sangini app was undertaken for analysis. Objective: To investigate factors of adoption of sangini app among users and non-users. Methods &amp; statistical analysis: Constructs from Technology Acceptance Model (TAM) and Theory of Self-Efficacy (SE) were used as tools for study. The study used an experimental study design Kaushambi and Pratapgarh districts of Uttar Pradesh (U.P.), India was selected as intervention and control groups respectively. The study sample consisted of CHWs i.e. 90 Sangini and 270 ASHAs. Two sample t test with equal variances and univariate regression analysis was applied. Results: TA and SE were predicators however; individual characters didn’t impact adoption of mhealth. Conclusion: There is need to comprehend factors influencing adoption of mhealth to improve performance of CHWs.