Supervision Of Community Health Workers Research Articles

Expanded roles of community health workers beyond malaria in the Asia-Pacific: A systematic review.

In the Greater Mekong Subregion (GMS), community health workers (CHWs) are a key component of malaria elimination strategies. As malaria declines, support for, and uptake of, malaria services may also subsequently decrease. Expanding their roles beyond malaria has been proposed to sustain the services. A systematic review was conducted to identify and characterize programmes with CHWs providing services in addition to those for malaria in the Asia Pacific. This review describes the expanded roles, identifies evidence of impact or success of the programmes, and explores strategies to ensure sustainability and factors for effective implementation to inform the design of malaria CHW programmes. Searches were conducted in 6 databases, for grey literature, and in bibliographies of retrieved articles. Data were extracted from 38 published articles, 12 programme reports, and 4 programme briefs and analysed using thematic coding and descriptive analysis. Twenty-nine programmes were identified with CHWs performing both malaria and non-malaria roles in the Asia Pacific. There was evidence of impact on malaria incidence in 4 of these, none on malaria mortality, and 4 on other diseases. Monitoring and evaluation mechanisms, multi-sectoral stakeholder collaborations, and adequate training and consistent supervision of CHWs were key to effective programme implementation. Integration of programmes into broader health services, ongoing political and funding support, and engagement with local communities were found to contribute to sustaining provision of health services by CHWs. Expanding CHW roles depends on programme management and strengthening linkages with local health systems. To sustain malaria CHW services, countries need adequate policies and financing, and sufficiently strong health systems to deliver basic health services that are adapted to the health needs of the community which means transitioning away from vertical disease programs. Further research should explore programmes that have not been captured in this review and address gaps in measuring malaria outcomes.

A Mixed Method Study on Supportive Supervision of Community Health Workers From Central India

Abstract Background: Supportive supervision of the Community health workers (CHWs) is critical for their efficient functioning in various health programmes. CHWs in India are supervised by facilitators known as ASHA Sahyogini. Our study aimed to investigate the linkage between the knowledge and skills of CHW facilitators and their CHWs. To understand the problems encountered by the CHW facilitators while assisting their CHWs. Also, to determine the perceptions of CHWs on the nature of supportive supervision of their facilitators. Materials and Methods: A mixed-method explanatory study using purposive sampling was conducted in a rural block of Madhya Pradesh (Central India). The CHWs were categorized into relatively high performing (RHP) and relatively low performing (RLP) groups based on their performance-based incentives received during (2017-2018). The quantitative component comprised of self-administered questionnaire and skill assessment while the qualitative component comprised of three focused group discussions with RHP, RLP CHWs and their facilitators. Results: The mean (SD) supportive supervision score given by CHW facilitators were found to be significantly associated with CHW’s performance. Problems faced by CHW facilitators while assisting their CHWs resulted from inadequate education of CHWs, insufficient incentives, transport problems and repetitive surveys. While some CHWs perceived to have received good assistance from their facilitators, there were a few who were not dependent on their facilitators and executed duties by themselves. Conclusion: CHW’s performance cannot be ascribed completely to the CHW facilitator’s performance. The challenges perceived by CHW facilitators were unmodifiable and required them to strongly motivate and support their CHWs to improve their functionality.

Expanding community case management of malaria to all ages can improve universal access to malaria diagnosis and treatment: results from a cluster randomized trial in Madagascar

BackgroundGlobal progress on malaria control has stalled recently, partly due to challenges in universal access to malaria diagnosis and treatment. Community health workers (CHWs) can play a key role in improving access to malaria care for children under 5 years (CU5), but national policies rarely permit them to treat older individuals. We conducted a two-arm cluster randomized trial in rural Madagascar to assess the impact of expanding malaria community case management (mCCM) to all ages on health care access and use.MethodsThirty health centers and their associated CHWs in Farafangana District were randomized 1:1 to mCCM for all ages (intervention) or mCCM for CU5 only (control). Both arms were supported with CHW trainings on malaria case management, community sensitization on free malaria care, monthly supervision of CHWs, and reinforcement of the malaria supply chain. Cross-sectional household surveys in approximately 1600 households were conducted at baseline (Nov–Dec 2019) and endline (Nov–Dec 2021). Monthly data were collected from health center and CHW registers for 36 months (2019–2021). Intervention impact was assessed via difference-in-differences analyses for survey data and interrupted time-series analyses for health system data.ResultsRates of care-seeking for fever and malaria diagnosis nearly tripled in both arms (from less than 25% to over 60%), driven mostly by increases in CHW care. Age-expanded mCCM yielded additional improvements for individuals over 5 years in the intervention arm (rate ratio for RDTs done in 6–13-year-olds, RRRDT6–13 years = 1.65; 95% CIs 1.45–1.87), but increases were significant only in health system data analyses. Age-expanded mCCM was associated with larger increases for populations living further from health centers (RRRDT6–13 years = 1.21 per km; 95% CIs 1.19–1.23).ConclusionsExpanding mCCM to all ages can improve universal access to malaria diagnosis and treatment. In addition, strengthening supply chain systems can achieve significant improvements even in the absence of age-expanded mCCM.Trial registrationThe trial was registered at the Pan-African Clinical Trials Registry (#PACTR202001907367187).

Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar.

Despite widespread adoption of community health (CH) systems, there are evidence gaps to support global best practice in remote settings where access to health care is limited and community health workers (CHWs) may be the only available providers. The nongovernmental health organization Pivot partnered with the Ministry of Public Health (MoPH) to pilot a new enhanced community health (ECH) model in rural Madagascar, where one CHW provided care at a stationary CH site while additional CHWs provided care via proactive household visits. The program included professionalization of the CHW workforce (i.e., targeted recruitment, extended training, financial compensation) and twice monthly supervision of CHWs. For the first eighteen months of implementation (October 2019-March 2021), we compared utilization and proxy measures of quality of care in the intervention commune (local administrative unit) and five comparison communes with strengthened community health programs under a different model. This allowed for a quasi-experimental study design of the impact of ECH on health outcomes using routinely collected programmatic data. Despite the substantial support provided to other CHWs, the results show statistically significant improvements in nearly every indicator. Sick child visits increased by more than 269.0% in the intervention following ECH implementation. Average per capita monthly under-five visits were 0.25 in the intervention commune and 0.19 in the comparison communes (p<0.01). In the intervention commune, 40.3% of visits were completed at the household via proactive care. CHWs completed all steps of the iCCM protocol in 85.4% of observed visits in the intervention commune (vs 57.7% in the comparison communes, p-value<0.01). This evaluation demonstrates that ECH can improve care access and the quality of service delivery in a rural health district. Further research is needed to assess the generalizability of results and the feasibility of national scale-up as the MoPH continues to define the national community health program.

Community Health Workers’ experiences of an intervention to provide them with increased support and supervision: a qualitative study of a home visiting model in rural South Africa

Deploying Community Health Workers (CHWs) is a crucial strategy to improve health at a community level in low- and middle-income countries. While there is substantial evidence for CHW effectiveness, there is a need for more research on the mechanisms through which these programs work. Understanding CHWs experiences of how programmes function is important. This article examines CHW’s experiences of three key programmatic domains; training, logistical support and supervision. Data were gathered using through qualitative descriptive study drawing from semi-structured interviews. The study was embedded within a cluster randomized controlled trial, testing the effectiveness of an enhanced supervision package delivered to government-employed CHWs in the rural Eastern Cape, South Africa, on maternal and child health outcomes We conducted individual semi structured interviews with CHWs (n = 16) and two supervisors. Data were coded deductively and overall, three overarching areas and five sub-themes emerged from our interviews, the overarching teams were; 1) CHW knowledge and confidence increased through additional training, 2) CHW motivation and community acceptance improved because of added logistical support, and 3) CHW supervision led to improved sense of accountability, feelings of respect, and sense of being supported. Our findings highlight the importance of a functional support system within which CHWs can operate, in a context where most CHWs operate in isolation and without support. CHWs receiving supportive supervision reported positive impacts on their motivation and ability to carry out their work effectively. Clinicaltrials.gov, NCT02957799, 2016-11-08.

Training young adults as community health workers specializing in pediatric to adult health care transition to support emerging adults with sickle cell disease

BackgroundTransition to adulthood is a vulnerable time for emerging adults (16–25 years of age) with sickle cell disease (SCD), as there is a seven-fold increase in mortality rates during the transition period. Emerging adults with SCD also have the highest rates of hospitalizations, emergency room visits, and hospital readmissions compared to other age groups. Community health worker (CHW) programs have been developed to address outcomes such as patient activation which includes an individual’s knowledge, skill, and confidence for managing one’s health and healthcare, quality of life, and healthcare utilization for patients with chronic illnesses. However, few programs specifically target transition-age patients with SCD. MethodsThe aims of this study were to (1) create and adapt the existing Penn Center for Community Health Workers IMPaCT model trainings and materials to specifically support CHWs working with transition-age patients with SCD and (2) evaluate the feasibility of this adapted model to improve job readiness of the CHWs and perceived value of the CHWs by patients with SCD. A multidisciplinary workgroup defined specific goal-setting categories and developed a targeted CHW training curriculum. Additionally, the workgroup wrote a job manual including step-by-step guidelines with example talking points and defined an ongoing supervision of CHWs. Measures of implementation and impact on CHW job readiness included CHW training completion, job retention, knowledge evaluation, and patient reported CHW engagement. Results15 individuals completed CHW training with an average employment length of 1 year and 4 months. 7 (47%) CHWs had research experience, 8 (53%) had clinical experience, and 11 (73%) reported SCD experience. On post-training knowledge evaluations, CHWs successfully identified key aspects of SCD, role scope, and research ethics. Patients frequently reported that they reached their goals while working with trained CHWs. ConclusionThis CHW training program provides a novel adaptation to the evidence-based IMPaCT CHW model to support the needs of youth with SCD during the vulnerable time of transition from pediatric-focused to adulthood-focused healthcare.

Community health workers' experiences of supervision by nurses at clinics in Limpopo Province.

Supervision of community health workers (CHWs) is considered, among others, a strategy to achieve universal healthcare globally. In South Africa, it is incorporated in the ward-based primary healthcare (PHC) outreach teams' policy and strategy, a national health insurance policy component. Supervision of CHWs by nurses in the policy is considered a measure to facilitate PHC service provision to communities. However, CHWs experienced varying levels of supervision from nurses and other workers globally and in South Africa. This study explored and described the experiences of CHWs about supervision received from nurses at PHC facilities in Limpopo Province. Participants were drawn from seven PHC facilities in Polokwane and Lepelle-Nkumpi subdistricts of the Capricorn District. A qualitative exploratory-descriptive and contextual study design was employed. Participants were selected utilising a purposive sampling method. Semi-structured interviews were conducted to collect data. Data were analysed according to themes and their associated categories. Measures to ensure rigour and ethical principles were applied. Two main themes emerged: positive supervision experienced by CHWs and supervision challenges experienced by CHWs. The varying experiences of CHWs about supervision from nurses emerged and reflected the need for functioning supervision mechanisms. The experiences of CHWs indicated inconsistent delivery of supervision by nurses in PHC facilities. The findings highlighted the need for effective supervision measures that are vital for the success of the CHW supervision programme.

Training community health workers to limit the transmission of monkeypox virus in India: an urgent need for action.

Training community health workers to limit the transmission of monkeypox virus in India: an urgent need for action.

An evaluation of a peer supervision pilot project among community health workers in rural Uganda

Living Goods operates a Community Health Worker (CHW) program in 19 districts of Uganda, where CHWs are supervised by full time Community Health Supervisors. This model is effective, but expensive. Evidence indicates that peer supervision can be a substitute and cheaper model for CHW supervision. We describe our experience and outcomes while implementing peer supervision among CHWs in Mayuge district. 1. To compare health services delivery outcomes between the two supervision models. 2. To compare costs of the two supervision models.. Internal organizational records from January to December 2019 were reviewed. Focus group discussions and in-depth interviews with participating CHWs were also conducted. Qualitative analysis was performed using thematic content analysis. Quantitative data was summarized to generate averages, percentages and graphs. CHWs under the peer supervision performed better than those under standard supervision against all key performance indicators. The total cost to maintain the peer supervision model for 1 year was USD $176 per CHW versus USD $273 among CHWs under the standard supervision model. Peer supervision thus resulted in overall cost savings of 36%. There was lower attrition among CHWs under peer supervision compared to standard supervision (10% versus 17%). Peer supervision is a feasible and more affordable model of supervising CHWs.

Roles, Barriers, and Recommendations for Community Health Workers Providing Community-Based HIV Care in Sub-Saharan Africa: A Review.

While the impact of Community Health Workers (CHWs) on home-based human immunodeficiency virus (HIV) care has been documented, barriers and recommendations have not been systematically reviewed. Following the reporting requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used an aggregative narrative synthesis approach to summarize the results of qualitative studies published between January 1, 2000, and November 6, 2020 in the following databases: PubMed, CINAHL, PsychINFO, Web of Science, and Google Scholar. In total, 17 studies met the selection criteria and were included in the analysis. They reported on a range of roles played by CHWs in HIV care, including education and health promotion; HIV-specific care (HIV testing services; screening for opportunistic infections and acute illness); medication delivery; tracing persons who had defaulted from care; and support (treatment support; referral; home-based care; and psychosocial support).Many different barriers to community-based HIV care were reported and centered on the following themes: Stigma and nondisclosure; inadequate support (lack of resources, inadequate training, inadequate funding, and inadequate monitoring); and health system challenges (patients' preference for more frequent visits and poor integration of CHWs in the wider health care system). Recommendations to mitigate these barriers included: addressing HIV-related stigma; introducing updated and relevant CHW training; strengthening the supervision of CHWs; coordinating care between the home and facilities; incorporating patient-centered mHealth approaches; and committing to the funding and resources needed for successful community-based care. In summary, CHWs are providing a variety of important community-based HIV services but face challenges with regards to training, resources, and supervision.

Analysing 3429 digital supervisory interactions between Community Health Workers in Uganda and Kenya: the development, testing and validation of an open access predictive machine learning web app

BackgroundDespite the growth in mobile technologies (mHealth) to support Community Health Worker (CHW) supervision, the nature of mHealth-facilitated supervision remains underexplored. One strategy to support supervision at scale could be artificial intelligence (AI) modalities, including machine learning. We developed an open access, machine learning web application (CHWsupervisor) to predictively code instant messages exchanged between CHWs based on supervisory interaction codes. We document the development and validation of the web app and report its predictive accuracy.MethodsCHWsupervisor was developed using 2187 instant messages exchanged between CHWs and their supervisors in Uganda. The app was then validated on 1242 instant messages from a separate digital CHW supervisory network in Kenya. All messages from the training and validation data sets were manually coded by two independent human coders. The predictive performance of CHWsupervisor was determined by comparing the primary supervisory codes assigned by the web app, against those assigned by the human coders and calculating observed percentage agreement and Cohen’s kappa coefficients.ResultsHuman inter-coder reliability for the primary supervisory category of messages across the training and validation datasets was ‘substantial’ to ‘almost perfect’, as suggested by observed percentage agreements of 88–95% and Cohen’s kappa values of 0.7–0.91. In comparison to the human coders, the predictive accuracy of the CHWsupervisor web app was ‘moderate’, suggested by observed percentage agreements of 73–78% and Cohen’s kappa values of 0.51–0.56.ConclusionsAugmenting human coding is challenging because of the complexity of supervisory exchanges, which often require nuanced interpretation. A realistic understanding of the potential of machine learning approaches should be kept in mind by practitioners, as although they hold promise, supportive supervision still requires a level of human expertise. Scaling-up digital CHW supervision may therefore prove challenging.Trial registration: This was not a clinical trial and was therefore not registered as such.

Latino Community Health Workers: Meeting their Community's Emotional Needs in Intuitively Culturally Appropriate Ways.

Latino Community Health Workers: Meeting their Community’s Emotional Needs in Intuitively Culturally Appropriate Ways Martha Lucia Garcia, PhD, LCSW, Lorena Sprager, BA, CHW, and Elizur Bello Jiménez, MSW, CHW Purpose of the Study • The study aimed to determine if community health workers (CHWs) were responding to the mental health needs of the Latino community in Oregon. The researchers suspected that CHWs were filling a gap in services due to a lack of trained bilingual/bicultural mental health professionals. • Simultaneously, the stress of anti-immigrant sentiment and the rise of White supremacist groups who target immigrants were having a deleterious effect on the well-being of the entire Latino community, not just those who are undocumented. • Oregon practitioners believed that CHWs were, in some capacity, responding to the increasing mental health needs of the communities they served, and that they were doing so in culturally appropriate and sensitive ways. This was suspected because CHWs are trusted by these communities, and are a link between health practitioners and the resilient, but marginalized, Latino. • To determine if this was the case, the researchers held a series of focus groups with CHWs who are immersed in the Latino communities in Oregon. Problem • Immigrants tend to present with a range of symptoms that are often misinterpreted and misdiagnosed by medical professionals. The Ulysses Syndrome, as coined by Dr Achetagui, relates physical symptoms with the psychosocial challenges of being an immigrant, encouraging medical practitioners to become familiar with the physical manifestations of unarticulated psychological and emotional suffering. • The current sociopolitical environment and anti-immigrant climate increases the fear and stress experienced by immigrants, which may lead to mental health crises. • The generalized fear and stress reactions are felt by Latino as a whole, as many families are mixed status (immigrant and U.S. citizens), and attacks by White supremacist groups are towards anyone who looks Latino. There are not enough mental health providers to meet the increased hardship. • More important, providers who can adequately respond to the mental health need of the Latino community in culturally and linguistically appropriate ways are even more scarce. A lack of trained professionals limits the support this community receives especially during a time of critical demand. Findings • CHWs are doing the best they can to meet their communities’ emotional needs and have developed culturally appropriate ways of doing so. There is much to be learned from CHWs about what is taking place in Latino communities, and about the creative strategies they use to address these needs. Some of the lessons learned are discussed in the article. Recommendations for how to meet some of the mental health needs of a community marginalized from mainstream resources, and ways administrators can support CHWs, are offered. [End Page 3] • CHWs are charged with great responsibility but often times are not provided with the appropriate supports necessary to adequately do their work. They are impacted by the current anti-immigrant environment, as they are targeted by members of the mainstream community for being allies to undocumented immigrants. They feel undervalued by their employers, as well as colleagues, and medical professionals, who do not realize the breadth and scope of the work they do. • Additionally, CHWs feel they do not receive adequate support from supervisors, which can be due to a lack of knowledge regarding the scope of their work, as well as lack of training for adequate supervision of CHWs. Who Should Care Most • Medical administrators, clinicians, social workers, mental health providers, CHWs, CHW supervisors. • People concerned with meeting the healthcare needs of marginalized Latino and immigrant communities. Recommendations for Action • Provide adequate supervision and training to CHWs so they can offer crisis assistance in the communities they serve. • Adequately train supervisors about the role of CHWs so they understand and properly respond to the breadth and scope of CHWs work as well as the secondary trauma they experience in their crisis-driven work. • Train medical and mental health providers on the CHW model to support culturally appropriate approaches to work with Latino immigrants. • Develop systems to link Latino immigrants with available mental health resources. • Develop methods to effectively employ CHWs, integrating them to the medical team. • Create and sustain educational pipelines and...

Exploring supervision for volunteer community health workers in Mukono District, Uganda: An exploratory mixed-methods study

ABSTRACT Community Health Worker (CHW) supervision is an under-researched area. This mixed-methods study engaged key stakeholders involved in CHW supervision in Mukono District, Uganda including CHWs (n = 14), District Health Office officials (n = 5), NGO programme managers (n = 3) and facility-based health staff (n = 3). Our study aimed to explore how supervision is currently conceptualised and delivered in this setting, the desired qualities of a potential supervisor, as well as the challenges regarding supervision and potential solutions to address these. To understand these concepts, we conducted structured surveys and individual interviews. Survey data were analysed in SPSS using descriptive statistics. Interview transcripts were thematically analysed in NVivo using conventional content analysis. This study revealed current CHW supervision in this context is fragmented. Supervision is perceived both as a means of motivating CHWs and facilitating ongoing training, as well as a way of holding CHWs accountable for their work. Stakeholders identified technical knowledge and expertise, strong interpersonal skills and cultural awareness as desirable qualities for a supervisor. Challenges surrounding supervision included a shortage of funding, a lack of guidelines on supervision, and infrequent supervision. To address these challenges, stakeholders proposed the need for increased funding, creating clearer job descriptions for supervisors, and in-person supervisory meetings.

Developing a district level supportive supervision framework for community health workers through co-production in South Africa

BackgroundOne of the key challenges of community health worker (CHW) programmes across the globe is inadequate supervision. Evidence on effective approaches to CHW supervision is limited and intervention research has up to now focused primarily on outcomes and less on intervention development processes. This paper reports on participatory and iterative research on the supervision of CHWs, conducted in several phases and culminating in a co-produced district level supportive supervision framework for Ward Based Outreach Teams in a South African district.MethodsDrawing on a conceptual framework of domains of co-production, the paper reflects on the implications of the research process adopted for participants, generation of research knowledge and recommendations for practice, as well as lessons for research on the supervision of CHWs.ResultsThrough the research process, participants reflected and engaged meaningfully, honestly and productively across hierarchies, and were able to forge new, dialogic relationships. The iterative, back forth feedback, involving a core group of participants across phases, enabled additions and validations, and informed further data collection. The culmination of the process was consensus on the key issues facing the programme and the generation of a set of recommendations for a local, context-specific framework of supportive supervision. The process of engagement, relationships built and consensus forged proved to be more significant than the framework itself.ConclusionThe co-production approach can enable local impact of research findings by providing a bottom-up collaborative platform of active participation, iterative feedback, knowledge generation and mutual learning that can complement guidance and frameworks from above. Although time consuming and not without its limitations, this approach to research has much to offer in advancing understanding of CHW supervision.

Providers\u2019 perspectives of socio-cultural and health service challenges related to postpartum family planning in Alexandria, Egypt

BackgroundPostpartum family planning (PPFP) focuses on prevention of unintended pregnancy and closely spaced pregnancies through the first 12 months following childbirth. Adoption of family planning during the postpartum period in Egypt faces unique challenges. This study aimed to explore the socio-cultural and health service challenges related to PPFP in Alexandria, Egypt, from perspectives of family planning providers working in public settings.MethodsThree focus group discussions were conducted in the period from May to July 2017. It included 32 family planning physicians working in the family health centers and maternal and child health centers in Alexandria for 3 years or more. A discussion guide was prepared. Analysis of data was done using thematic data analysis using a deductive approach.ResultsThe working experience of participants ranged from 3 to 30 years. The most frequently reported reasons for unmet need for PPFP were cultural norms about the contraceptive effects of lactation and inaccurate knowledge of women about the conditions for appropriate use of the lactation amenorrhea as a contraceptive method. The most commonly cited challenge related to the quality of service was the inadequate health education services about PPFP. Lack of training and supervision of community health workers was one of the underlying causes of the perceived inadequacy of the service.ConclusionsMass media campaigns advocating for family planning are urgently needed with full support from the government. Improvement of health education services is a must. Redistribution of family planning providers with an increase in the staff members is highly recommended.

Impact of Different Levels of Supervision on the Recovery of Severely Malnourished Children Treated by Community Health Workers in Mali.

(1) Background: The Ministry of Health in Mali included the treatment of severe acute malnutrition (SAM) into the package of activities of the integrated community case management (iCCM). This paper evaluates the most effective model of supervision for treating SAM using community health workers (CHWs). Methods (2): This study was a prospective non-randomized community intervention trial with two intervention groups and one control group with different levels of supervision. It was conducted in three districts in rural areas of the Kayes Region. In the high supervision group, CHWs received supportive supervision for the iCCM package and nutrition-specific supervision. In the light supervision group, CHWs received supportive supervision based on the iCCM package. The control group had no specific supervision. (3) Results: A total of 6112 children aged 6–59 months with SAM without medical complications were included in the study. The proportion of cured children was 81.4% in those treated by CHWs in the high supervision group, 86.2% in the light supervision group, and 66.9% in the control group. Children treated by the CHWs who received some supervision had better outcomes than those treated by unsupervised CHWs (p < 0.001). There was no difference between areas with light and high supervision, although those with high supervision performed better in most of the tasks analyzed. (4) Conclusions: Public policies in low-income countries should be adapted, and their model of supervision of CHWs for SAM treatment in the community should be evaluated.

Factors Associated With Workplace and Interpersonal Trust in the Supervisory System of a Community Health Worker Programme in a Rural South African District.

Background: Key to effective supportive supervision, and ultimately performance of community health workers (CHWs), is the nature of relationships in the formal health system at the coal face of programmes. The central character and defining feature of effective relationships, in turn, is the ability to engender trust. This study describes factors associated with workplace and interpersonal trust, the relationship between the two sets of trust factors and how this shaped perceived performance of CHWs in ward-based outreach teams (WBOTs) in a rural South African district. Methods: In the context of a wider study of supportive supervision of CHWs, factors recognised to be associated with trust in the literature were studied qualitatively in Ngaka Modiri Molema district, North West Province. Focus group discussions (FGDs) and individual interviews were conducted by the first author with CHWs (23), team leaders (12), facility managers (10) and middle managers (5). Interviews were recorded, translated and transcribed. Perceptions of trust factors associated with workplace and interpersonal trust were analysed thematically. Results: The interviews revealed a climate of considerable workplace mistrust due to the perceived abandonment of the WBOTs programme by managers at all levels, and this affected support and supervision of WBOTs. However, there was a degree of variability and discretion in expressions of interpersonal trust at the coal face, leading to different perceptions of the competence and functionality of the WBOTs. Mistrust in the workplace and poor interpersonal relationships translated into low confidence in the ability of CHWs, which in turn compromised the performance of these teams. Conclusion: The study contributes empirical evidence on how workplace trust factors impact on interpersonal trust factors and the possible implications of both sets of trust factors on perceived performance of CHWs. Wider trust in the health system have a significant bearing on interpersonal trust between CHWs and other players in the primary healthcare (PHC) system.

Impact of mobile health-enhanced supportive supervision and supply chain management on appropriate integrated community case management of malaria, diarrhoea, and pneumonia in children 2-59 months: A cluster randomised trial in Eastern Province, Zambia.

BackgroundDespite progress made over the past twenty years, child mortality remains high, with 5.3 million children under five years having died in 2018 globally. Pneumonia, diarrhoea, and malaria remain among the commonest causes of under-five mortality; contributing 15%, 8%, and 5% of global mortality respectively. Recent evidence shows that integrated community case management (iCCM) of pneumonia, diarrhoea, and malaria can reduce under-five mortality. However, despite growing evidence of the effectiveness of iCCM, there are implementation challenges, especially stock out of iCCM commodities and inadequate supportive supervision of community health workers (CHWs). This study aimed to address these two key challenges to successful iCCM implementation by using mobile health (mHealth) technology.MethodsThis cluster randomised controlled trial compared health centre catchment areas (clusters) where CHWs and their supervisors implemented mHealth-enhanced iCCM supportive supervision and supply chain management vs clusters implementing iCCM as per current Zambian guidelines. CHWs in intervention clusters used community DHIS2 platform on mobile phones to report on a weekly basis children with iCCM conditions and make requisitions for iCCM commodities. Their supervisors received electronic reports on disease caseloads and monthly automated supervision reminders. The supervisors on receipt of requisitions, organized the medical supplies and notified CHWs for collection. Intention-to-treat analysis on the primary outcome, the percentage of children aged 2-59 months receiving appropriate treatment for malaria, pneumonia, or diarrhoea from an iCCM trained CHW, was performed using a generalized linear model. Prevalence ratios and 95% confidence intervals comparing the prevalence of appropriate treatment in the intervention and control groups were calculated using log binomial regression with an exchangeable correlation matrix, adjusted for clustering by health facility.ResultsIn the intervention clusters, 61.3% (98/160) of expected monthly supervision visits took place vs 52.0% (78/150) in the controls. A total of 3690 children 2-59 months old presented with malaria, diarrhoea, or pneumonia. In the intervention group, 65.9% (1,252/1,899) of children received appropriate care for iCCM conditions, compared to 63.3% (1,134/1,791) in the control group. The mHealth intervention was associated with 18.0% improvement in supportive supervision and 21.0% increase in appropriate treatment for pneumonia; these changes were not statistically significant. There was a 2-3-fold increase in the proportion of CHWs receiving supplies ordered: prevalence ratios ranged from 2.82 (confidence interval (CI) = 1.50, 5.30) to 3.01 (95% CI = 1.29, 7.00) depending on the particular commodity.ConclusionThis study was unable to determine whether using mHealth technology would strengthen supervision and supply chain management of iCCM commodities for community-level workers. There was no statistically significant effect of mHealth enhanced iCCM on appropriate diagnosis and treatment for children with malaria, pneumonia, and diarrhoea in rural Zambia. Longer term longitudinal studies are required to determine the impact of mHealth enhanced iCCM on health outputs and outcomes.Trial registrationClinicalTrials.gov, NCT02866097

Exploring perceptions, barriers, and enablers for delivery of primary ear and hearing care by community health workers: a photovoice study in Mukono District, Uganda

BackgroundHearing loss is a prevalent but neglected disease, especially in low- or middle-income countries. The role of Community Health Workers (CHWs) to deliver primary ear and hearing care has been explored in several studies from a technical standpoint, but understanding perceptions, barriers, and enablers of such an approach from the perspective of CHWs themselves through a health equity lens has been less well documented.MethodsThis qualitative study used photovoice to explore the views and experiences of CHWs in the Seeta Nazigo Parish of Mukono District in the delivery of ear and hearing care in the community. CHWs were trained in ear and hearing care, and provided with digital cameras to capture photographs related to their work in the community over the following 3 months. Individual interviews regarding the photographs were held at the end of each month, in addition to one focus group discussion. A community workshop was convened at the end of the study to display the photos. Thematic analysis of photographs was conducted using Braune and Clarkes six-step framework. We also used the data to explore potential roles for key stakeholders in primary ear and hearing care, and how photovoice may facilitate their engagement.Results13 CHWs participated in the study. Several themes were generated from analysis. CHWs perceived a high burden of ear and hearing disorders in their community and recognised the role they could play in tackling that burden. Potential barriers identified included a lack of equipment, training, and supervision of CHWs; logistical, financial, or psychological barriers to community participation; and the widespread use of traditional medicine. CHWs identified roles for the government and NGO bodies to enable and support delivery of ear and hearing care in the community. The community workshop was a useful method to engage key stakeholders in this topic.ConclusionsPhotovoice is a powerful method to capture issues affecting CHWs. Here it was used to identify a number of perceptions, barriers and enablers to the delivery of ear and hearing care. Our results may inform future strategy in the field of ear and hearing care, and the potential use of photovoice to enact sociocultural change.

The cost of the training and supervision of community health workers to improve exclusive breastfeeding amongst mothers in a cluster randomised controlled trial in South Africa

BackgroundInterventions targeting community health workers (CHWs) aim to optimise the delivery of health services to underserved rural areas. Whilst interventions are evaluated against their objectives, there remains limited evidence on the economic costs of these interventions, and the practicality and value of scale up. The aim of this paper is to undertake a cost analysis on a CHW training and supervision intervention using exclusive breastfeeding rates amongst mothers as an outcome measure.MethodsThis is a retrospective cost analysis, from an implementer’s perspective, of a cluster randomised controlled trial investigating the effectiveness of a continuous quality improvement (CQI) intervention aimed at CHWs providing care and support to pregnant women and women with babies aged < 1 year in South Africa.ResultsOne of the outcomes of the RCT revealed that the prevalence of exclusive breastfeeding (EBF) significantly improved, with the cost per mother EBF in the control and intervention arm calculated at US$760,13 and US$1705,28 respectively. The cost per additional mother practicing EBF was calculated to be US$7647, 88, with the supervision component of the intervention constituting 64% of the trial costs. In addition, women served by the intervention CHWs were more likely to have received a CHW visit and had significantly better knowledge of childcare practices.ConclusionWhilst the cost of this intervention is high, adapted interventions could potentially offer an economical alternative for achieving selected maternal and child health (MCH) outcomes. The results of this study should inform future programmes aimed at providing adapted training and supervision to CHWs with the objective of improving community-level health outcomes.