Role Of Community Health Workers Research Articles

OPTIMAL HEALTH PROFESSIONAL STAFFING OF PRIMARY CARE AND GERIATRIC PRACTICES SERVING FRAIL OLDER ADULTS

This symposium will include 3 papers that provide critical interprofessional and interdisciplinary perspectives on our work to understand and measure staffing in health care teams caring for older adults, and frail older adults. The Health Teams for Frail Elders project was funded by the Gordon and Betty Moore Foundation from August 2016 to October 2018. Dr. Karen Donelan, project Principal Investigator, will chair the session, providing a brief project overview of project aims and activities. A survey and health services researcher, Dr. Donelan will set the context for this large scale project. Dr. Barbara Roberge, a geriatric nurse practitioner who established one of the first senior health programs in the nation along with Dr. Kenneth Minaker at Mass General Hospital, was our primary care and nursing lead on our site visits. She will talk about the care settings we visited, her development of a site assessment tool that covered a range of frail elder needs, and will summarize professional roles and staffing observed within different site types. Dr. Julie Berrett-Abebe, a junior investigator on our team (PhD 2017), will present a paper on the competencies and roles of social workers and community health workers in primary and geriatric practices, as well as the roles of community health workers. Dr. David Auerbach, a national expert in health policy and workforce analysis, will present 4 models of staffing of practices, demonstrating efficiencies in optimizing services for frail elders while minimizing costs.Dr. Joanne Spetz will be the discussant of cross-cutting themes.

Who are CHWs? An ethnographic study of the multiple identities of community health workers in three rural Districts in Tanzania

BackgroundNumerous studies have examined the role of community health workers (CHWs) in improving the delivery of health services and accelerating progress towards national and international development goals. A limited but growing body of studies have also explored the interactions between CHWs’ personal, communal and professional identities and the implications of these for their profession. CHWs possess multiple, overlapping roles and identities, which makes them effective primary health care providers when properly supported with adequate resources, but it also limits their ability to implement interventions that only target certain members of their community, follow standard business working days and hours. In some situations, it even prevents them from performing certain duties when it comes to sensitive topics such as family planning.MethodsTo understand the multiple identities of CHWs, a mixture of qualitative and ethnographic methods was utilized, such as participant observation, open-ended and semi-structured interviews, and focus group discussions with CHWs, their supervisors, and their clients. The observation period began in October 2013 and ended in June 2014. This study was based on implementation research conducted by the Connect Project in Rufiji, Ulanga and Kilombero Districts in Tanzania and aimed to understand the role of CHWs in the provision of maternal and child health services in rural areas.ResultsTo our knowledge, this was the first study that employed an ethnographic approach to examine the relationship between personal, communal and professional identities, and its implications for CHWs’ work in Tanzania. Our findings suggest that it is difficult to distinguish between personal and professional identities among CHWs in rural areas. Important aspects of CHW services such as personalization, access, and equity of health services were influenced by CHWs’ position as local agents. However, the study also found that their personal identity sometimes inhibited CHWs in speaking about issues related to family planning and sexual health. Being local, CHWs were viewed according to the social norms of the area that consider the gender and age of each worker, which tended to constrain their work in family planning and other areas. Furthermore, the communities welcomed and valued CHWs when they had curative medicines; however, when medical stocks were delayed, the community viewed the CHWs with suspicion and disinterest. Community members who received curative services from CHWs also tended to become more receptive to their preventative health care work.ConclusionAlthough CHWs’ multiple roles constrained certain aspects of their work in line with prevalent social norms, overall, the multiple roles they fulfilled had a positive effect by keeping CHWs embedded in their community and earned them trust from community members, which enhanced their ability to provide personalized, equitable and relevant services. However, CHWs needed a support system that included functional supply chains, supervision, and community support to help them retain their role as health care providers and enabled them to provide curative, preventative, and referral services.

Exploration of Community Health Workers\u2019 views about in their role and support in Primary Health Care in Northern Cape, South Africa

Community health workers (CHWs) play a significant role in Primary health Care due to their proximity to households, communities and the health care system. Many studies focus on CHWs and the work they do. However, few have examined their experiences and identity and how that might influence how they view and perform their roles. The objectives of the study were to: Describe the role of CHWs in community-based health care in Northern Cape, Identify the perceived barriers and enablers to CHWs role performance, Explore CHWs views regarding the support from the communities and the formal healthcare system in Northern Cape. An exploratory qualitative design using focus groups was adopted. Forty-six (46) CHWs were purposively selected using the critical case sampling approach. Data were collected through three focus group interviews in three regions. Analysis followed the Graneheim & Lundman thematic analysis. Three themes emerged from data: perceived contribution to Primary Health Care, recognition of CHWs role, measures to improve working conditions. Findings showed that CHWs were engaged in various health and social care roles, they believed that they made a significant contribution to PHC, and that the health system persistently relied on their services. The enabler for finding meaning in their work was the positive community response and the good relations they had with the team leaders. The major barrier was the structure of the CHWs programme and the perceived lack of support by the government. The complex issues CHWs address in the community call for a review of their roles and workload as well as the support they receive from the formal healthcare system.

The roles of community health workers who provide maternal and newborn health services: case studies from Africa and Asia

IntroductionA variety of community health workers (CHWs) provide maternal and newborn health (MNH) services in low-income and middle-income settings. However, there is a need for a better understanding of the...

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation

BackgroundThe recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation.MethodsWe undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members.ResultsWe found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related “expectation gaps”, including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector.ConclusionsWhether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or “broken promises”, which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.

Community health workers integration model in the National Health System (Benin, Togo)

At the international level, further reflection on the role of community health workers is in progress. The objective of this work is to develop a model of the integration of community health workers in the National Health System. The study was conducted in Benin and Togo. It was a cluster survey that involved 385Community Health Workers (CHW), 238village heads, 92health care managers selected responsibly, and 6150households selected in a probabilistic manner. The analysis of the strengths, weaknesses, opportunities and threats of interventions under Community directives has contributed to the development of the model.Results: In both countries, community health reference materials existed, and 98.4% community health workers were trained before the beginning of the activities, and all have an intrinsic motivation for the work they do. Only 31.3% of households participated in the selection of community health workers in their locality. The absence of laws recognizing the work of the CHW is a threat to their integration into the healthcare system. The main elements proposed in the model are, the development of the status of community health workers, their remuneration on a budget managed by the health district and fed by several sources. Community Health Workers should not be a health care alternative, but an integral part of the national health system.

Are community health workers effective in retaining women in the maternity care continuum? Evidence from India

ObjectivesDespite the recognised importance of adopting a continuum of care perspective in addressing the care of mothers and newborns, evidence on specific interventions to enhance engagement of women along the...

The everyday political economy of health: community health workers and the response to the 2015 Zika outbreak in Brazil

How is neoliberalism implicated in concrete health vulnerabilities? How do macro-level political economy, policy and institutions translate into everyday experiences? Drawing on Marxist, feminist and International Political Economy critiques of everyday life, the article advances an everyday political economy of health focused on four key components: power, agency, intersectionality and the mutual implication of the global and the local. These components enable a nuanced investigation of concrete experiences of health and disease, and of the local implementation of health policies in the context of neoliberalism. The framework is applied to the case of the 2015 public health response to Zika in Brazil, and specifically to the role of community health workers, close-to-community healthcare providers tasked with bridging the health system and vulnerable groups. The everyday practice of these workers, and their working conditions overwhelmingly characterized by precarity and low pay, reveal the presence of global neoliberal dynamics pertaining to the reconfiguration of the Brazilian state as healthcare provider in a context of encroaching austerity, privatization and narrowly-defined cost-efficiency. These dynamics impacted detrimentally upon the effectiveness of the Zika response.

Integrating Community Health Worker Roles to Improve Facility Delivery Utilization in Tanzania: Evidence from an Interrupted Time Series Analysis.

Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania. A 36-month time series data set (2014-2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility. 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, from an average of 202-234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001). Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. 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.

Making space for Aboriginal and Torres Strait Islander community health workers in health promotion.

Despite a clear need, ‘closing the gap’ in health disparities for Aboriginal and Torres Strait Islander communities (hereafter, respectfully referred to as Aboriginal) continues to be challenging for western health care systems. Globally, community health workers (CHWs) have proven effective in empowering communities and improving culturally appropriate health services. The global literature on CHWs reflects a lack of differentiation between the types of roles these workers carry out. This in turn impedes evidence syntheses informing how different roles contribute to improving health outcomes. Indigenous CHW roles in Australia are largely operationalized by Aboriginal Health Workers (AHWs)—a role situated primarily within the clinical health system. In this commentary, we consider whether the focus on creating professional AHW roles, although important, has taken attention away from the benefits of other types of CHW roles particularly in community-based health promotion. We draw on the global literature to illustrate the need for an Aboriginal CHW role in health promotion; one that is distinct from, but complementary to, that of AHWs in clinical settings. We provide examples of barriers encountered in developing such a role based on our experiences of employing Aboriginal health promoters to deliver evidence-based programmes in rural and remote communities. We aim to draw attention to the systemic and institutional barriers that persist in denying innovative employment and engagement opportunities for Aboriginal people in health.

Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi.

BackgroundHome visits by community health workers (CHWs) during pregnancy and soon after delivery are recommended to improve newborn survival. However, as the roles of CHWs expand, there are concerns regarding the capacity of community health systems to deliver high effective coverage of home visits. The WHO’s Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelines and to implement and evaluate the feasibility and coverage of home visits in Ntcheu district.MethodsA population-based survey of 150 households in Ntcheu district was conducted in July-August 2016 after approximately 10 months of CBMNC implementation. Thirty clusters were selected proportional-to-size using the most recent census. In selected clusters, five households with mothers of children under six months of age were randomly selected for interview. The Health Surveillance Assistants (HSAs) providing community-based services to the same clusters were purposively selected for a structured interview and register review.ResultsLess than one third of pregnant women (30.7%; 95% confidence interval CI = 21.7%-41.5%) received a home visit during pregnancy and only 20.7% (95% CI = 13.0%-29.4%) received the recommended two visits. Coverage of postnatal visits was even lower: 11.4% (95%CI = 6.8%-18.5%) of mothers and newborns received a visit within three days of delivery and 20.7% (95%CI = 12.7%-32.0%) received a visit within the first eight days. Reaching newborns soon after delivery requires timely participation of the family and/or health facility staff to notify the HSA – yet only 42.9% (95% CI = 33.4%-52.9%) of mothers reported that the HSA was informed of the delivery. Coverage of postnatal home visits among those who informed the HSA was significantly higher than among those in which the HSA was not informed (46.7% compared to 1.3%; P = 0.00). Most HSAs had the necessary equipment and supplies and were active in CBMNC: 83.9% (95% CI = 70.2%-97.6%) of HSAs had pregnancy home visits and 77.4% (95% CI = 61.8%-93.0%) had postnatal home visits documented in their registers for the previous three months.ConclusionsWe found 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. These findings were similar to previous studies, calling into question the feasibility of the current visitation schedule. It is time to re-align the CBMNC package with what the existing platform can deliver and identify strategies to better support HSAs to implement home visits to those who would benefit most.

Opportunities for Community Health Worker Training to Improve Access to Health Care for Medicaid Enrollees.

Limited access to care can negatively affect population health, which is particularly concerning for individuals of lower socioeconomic status. Shortages of US health care providers in areas that predominantly serve Medicaid enrollees contribute to a lack of access. The Ohio Medicaid Technical Assistance and Policy Program Healthcare Access Initiative was designed as a workforce development initiative to train and deploy community health workers (CHWs). The authors conducted 55 key informant interviews with preceptors, CHWs, and administrators across 5 sites with the specific aim of improving understanding of common barriers to and benefits of CHW program implementation across different CHW programs in Ohio. CHW programs reportedly act as a bridge between the patient and providers, and program benefits were reported for participants, organizations, and patients. This study found that CHW programs enabled training of health professionals that can empower participants while allowing them to also give back to their communities. Organizations employing CHWs reported being able to extend clinic services, increase utilization of community resources, and improve patient compliance through the efforts of CHWs; program impacts also led to increased patient support, patient education, and overall better care. To better integrate CHWs into health care organizations, organizations should focus on clearly defining the CHW role and ensuring adequate infrastructure to support CHW efforts.

“Someone who is in this thing that I am suffering from”: The role of peers and other facilitators for task sharing substance use treatment in South African HIV care

South Africa is home to the largest number of people living with HIV/AIDS in the world. Alongside the HIV/AIDS epidemic, problematic alcohol and other drug (AOD) use is prevalent and associated with poor HIV treatment and secondary HIV prevention outcomes. International guidelines and local policy both support the integration of mental health care and AOD treatment into HIV care, yet barriers exist to implementation. This study aimed to explore patient and provider perspectives on the integration of HIV and AOD treatment services in Cape Town, South Africa. This included barriers and facilitators to task sharing AOD treatment in HIV care and preferences for a task shared approach to integrating AOD treatment in HIV care, including who should deliver the behavioural intervention. We conducted thirty semi-structured qualitative interviews with HIV and AOD treatment staff, providers, and people living with HIV/AIDS (PLWH) with moderate, problematic AOD use and difficulties (personal or structural) adhering to HIV treatment. Findings illustrated several key themes: (1) the separation between AOD and HIV services (a “siloed treatment experience”), even in the context of geographic co-location; (2) low AOD treatment literacy among HIV patients and providers, including a low awareness of existing AOD use services, even when co-located; (3) substance use stigma as a barrier to HIV and AOD treatment integration; (4) a strong patient preference for peer interventionists; and (5) the role of community health workers (CHWs) in detecting AOD use among some PLWH who had not followed up in HIV care. These findings will inform a future type 1 hybrid effectiveness-implementation trial, guided by the RE-AIM framework, to evaluate a task shared, evidence-based intervention to address problematic AOD use and improve HIV medication adherence in this setting.

The role of community health workers in cervical cancer screening in low-income and middle-income countries: a systematic scoping review of the literature

IntroductionCommunity-based screening for cervical cancer and task sharing to community health workers (CHWs) have been suggested as a potential way to increase screening coverage in low- and middle-income countries (LMICs)....

Strengthening referral systems in community health programs: a qualitative study in two rural districts of Maputo Province, Mozambique

BackgroundEffective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care. The effectiveness of referral systems in Mozambique depends on multiple factors that involve three main stakeholders: clients/community members; community health workers (CHWs); and facility-based health care workers. Each stakeholder is dependent on the other and could form either a barrier or a facilitator of referral within the complex health system of Mozambique.MethodsThis qualitative study, aiming to explore barriers and enablers of referral within the lens of complex adaptive health systems, employed 22 in-depth interviews with CHWs, their supervisors and community leaders and 8 focus group discussion with 63 community members. Interviews were recorded, transcribed and read for identification of themes and sub-themes related to barriers and enablers of client referrals. Data analysis was supported by the use of NVivo (v10). Results were summarized in narratives, reviewed, discussed and adjusted.ResultsAll stakeholders acknowledged the centrality of the referral system in a continuum of quality care. CHWs and community members identified similar enablers and barriers to uptake of referral. A major common facilitator was the existence of referral slips to expedite treatment upon reaching the health facility. A common barrier was the failure for referred clients to receive preferential treatment at the facility, despite the presence of a referral slip. Long distances and opportunity and transport costs were presented as barriers to accessibility and affordability of referral services at the health facility level. Supervisors identified barriers related to use of referral data, rather than uptake of referral. Supervisors and CHWs perceived the lack of feedback as a barrier to a functional referral system.ConclusionsThe barriers and enablers of referral systems shape both healthcare system functionality and community perceptions of care. Addressing common barriers to and strengthening the efficiency of referral systems have the potential to improve health at community level. Improved communication and feedback between involved stakeholders – especially strengthening the intermediate role of CHWs – and active community engagement will be key to stimulate better use of referral services and healthcare facilities.

Community Health Workers and The Promotion of Health Care Services in Gasabo District, Rwanda

Health care is a primary need of human being. Life expectancy as an indicator of Human Development is below 40 years in most developing countries due to high Maternal Mortality Rate, HIV prevalence, Infant Mortality rate, Malaria prevalence and many other related diseases. This study examined the importance of Community Health Workers (CHWs) role in promoting Health Care services in Gasabo District of Rwanda. A simple random sampling method with the use of a self-administered questionnaire to get primary data was used as well as a literature review for secondary data. The target population was 1500 CHWs with a sample size of 183 CHWs. 55.6% of CHWs have a role of monitoring Malnutrition &amp; growth for children under the age of 5years, 43.2% monitor women during their pregnancy period and diagnose and treat Malaria, Diarrhoea &amp; Pneumonia for children under 5 years old. Other roles of CHWs include; providing health education (43% of CHWs), providing Family Planning services to women (24%), and sensitizing the community for HIV/AIDS testing (14.3%), psychosocial support (11%) and Vaccination (9.8%). The challenges faced by CHWs to accomplish their roles include; transportation facilitation (39.9%), limited time (32.8%), negative perception by communities (37.7%) and no monthly salary pay (38.8%). Although the work of CHWs in Rwanda is voluntary, however, the Ministry of Health should invest more in their work through the provision of transportation facilitation and motivational incentives CHWs.

What are the roles of community health workers? Looking back at the philosophies of primary health care.

This commentary discusses the different roles of community health workers (CHWs), their challenges and limitations in a historical perspective of primary health care (PHC). We first try to show that the comprehensive philosophy of PHC promulgated in Alma-Ata proposed the role of CHWs as actors who work in community development. On the other hand, in the 1980s, with the emergence of the selective philosophy of PHC, CHWs' role was more affiliated with the health system. We conclude our pitch about the balance that can exist between these different roles by suggesting that CHWs can work in continuity with the health system, but they should not be considered as affordable labor. Also, they must be supported in their activities to develop their communities, allowing them to participate effectively in programs and policies that concern them and their community.

The role of community health workers in addressing the global burden of ear disease and hearing loss: a systematic scoping review of the literature

IntroductionCommunity health workers (CHWs) have the potential to improve access to ear and hearing services for people across low-income or middle-income countries, remote, underserved, or resource-poor areas of the world....

3430 Promoting Stakeholder Research Competencies to Culturalize Health Science by the Miami CTSA: National Partnership for Training Community Health Workers in Patient-Centered Outcomes Research (PCOR) in 4 States

3430 Promoting Stakeholder Research Competencies to Culturalize Health Science by the Miami CTSA: National Partnership for Training Community Health Workers in Patient-Centered Outcomes Research (PCOR) in 4 States

Role of community health worker in a mobile health program for early detection of oral cancer.

The global incidence of oral cancer occurs in low-resource settings. Community-based oral screening is a strategic step toward downstaging oral cancer by early diagnosis. The mobile health (mHealth) program is a technology-based platform, steered with the aim to assess the use of mHealth by community health workers (CHWs) in the identification of oral mucosal lesions. mHealth is a mobile phone-based oral cancer-screening program in a workplace setting. The participants were screened by two CHWs, followed by an assessment by an oral medicine specialist. A mobile phone-based questionnaire that included the risk assessment was distributed among participants. On specialist recommendation an oral surgeon performed biopsy on participants. The diagnosis by onsite specialist that was confirmed by histopathology was considered as gold standard. All individuals received the standard treatment protocol. A remote oral medicine specialist reviewed the uploaded data in Open Medical Record System. Sensitivity, specificity, positive and negative predictive values were calculated. 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. CHWs identified oral lesions in 405 (11.8%) individuals; the onsite specialist identified oral lesions in 394 (11.4%) individuals; and the remote specialist diagnosed oral lesions in 444 (13%). 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.