Mixed method evaluation of a learning from excellence programme for community health workers in Neno, Malawi.

BACKGROUND: Community Health Workers (CHWs) play an essential role in linking communities to facility-based healthcare. However, CHW programmes have often been hampered by low levels of staff motivation, and new tools aimed at improving staff motivation and work environment are needed. One such intervention is the "Learning from Excellence" (LfE) programme. We aimed to assess feasibility, outputs, and impact of a co-designed LfE programme on CHW motivation, in Neno District. METHODS: We conducted a convergent mixed-method evaluation of the LfE programme. Co-design of the programme and forms took place between October 2019 and January 2020. LfE forms submitted between September and November 2020 were analysed using descriptive statistics and memos summarising answers to the open-ended question. To investigate experiences with LfE we conducted in-depth semi-structured interviews with key stakeholders, CHWs, and site supervisors, which were analysed thematically. A pre-post intervention questionnaire was developed to assess the impact of the co-designed LfE intervention on CHW motivation and perceived supervision. Outcomes were triangulated into a logic model. RESULTS: In total 555 LfE forms were submitted, with 34.4% of CHWs in Neno District submitting at least one LfE report. Four themes were identified in the interviews: LfE implementation processes, experience, consequences, and recommendations. A total of 50 CHWs participated in the questionnaire in January 2020 and 46 of them completed the questionnaire in December 2020. No statistically significant differences were identified between pre-and post-LfE measurements for both motivation (Site F: p = 0.86; Site G: p = 0.31) and perceived supervision (Site F: p = 0.95; Site G: p = 0.45). A logic model, explaining how the LfE programme could impact CHWs was developed. CONCLUSIONS: Many CHWs participated in the LfE intervention between September 2020 and November 2020. LfE was welcomed by CHWs and stakeholders as it allowed them to appreciate excellent work in absence of other opportunities to do so. However, no statistically significant differences in CHW motivation and perceived supervision were identified. While the intervention was feasible in Neno District, we identified several barriers and facilitators for implementation. We developed a logic model to explain contextual factors, and mechanisms that could lead to LfE outcomes for CHWs in Neno District. The developed logic model can be used by those designing and implementing interventions like LfE for health workers.

Perspectives of community and facility stakeholders on community health workers in rural Malawi.

BACKGROUND: Community health workers (CHWs) bridge the primary health care (PHC) system and communities by providing care in the household. In Malawi, few studies have examined the perspective of users of household-level CHW services, in remote areas, to understand CHW's role in community-based PHC. AIM: To explore perspectives of community and facility stakeholders on the enablers and challenges of the CHW role in community-based PHC in Neno District. SETTING: The study was conducted in the Neno District health facilities, namely, Ligowe, Dambe, Chifunga, and Zalewa. METHODS: We conducted eight focus group discussions (FGDs) with purposively sampled community members and conveniently sampled facility stakeholders. Data were transcribed and analysed thematically through an adapted COM-B model of behaviour change. RESULTS: Three main themes of perceived behaviour change within the CHW role were identified: (1) capacity - the CHW programme aids health education and promotion within the community; (2) opportunity - the CHW programme facilitates community-based PHC and linkage to the facility; and (3) motivation - the CHW programme enablers and challenges in providing community-based PHC. CONCLUSION: Community health workers enrich community-based PHC delivery through health education, timely access to care, and linking communities to the facility. Optimising workload and programme support is critical for the help of CHWs. Further studies are required to address programme and cultural challenges to enhance positive health-seeking behaviours.Contribution: This study provides contextual knowledge for further research on bringing together spiritual and formal health practices and considering the cultural background when planning for health interventions in remote areas.

A time-motion study of community health workers delivering community-based primary health care in Neno District, Malawi.

INTRODUCTION: Community health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi. METHODS: We conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood's median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks. RESULTS: We observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05). CONCLUSION: This study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.

The role of community health workers in influencing social connectedness using the household model: a qualitative case study from Malawi.

BACKGROUND: Community health workers (CHWs) play a vital role in facilitating social connectedness, building trust, decrease stigma, and link communities to essential healthcare and social support services. More studies are needed to understand the factors facilitating these interactions among CHWs, clients, and community members. OBJECTIVE: This study examined the CHW role and relationships between CHWs, communities, and health facilities that promote trust, positive relationships, and social connectedness. METHODS: In 2016, the CHW program in Neno District, Malawi, was transitioned to a household-level assignment of CHWs to provide screening, linkage to care, and psychosocial and chronic disease support from a disease-based program. We employed an exploratory qualitative study with thematic analysis linked to Fredrickson's broaden-and-build theory of positive emotions through focus group discussions (FGDs) and in-depth interviews (IDIs) to understand the impact of the household assignment. We purposively sampled community stakeholders, CHWs, health service providers, and clients (total N = 180) from October 2018 through March 2020. All interviews were audiotaped, transcribed verbatim, translated, coded, and analyzed. RESULTS: Participants reported decreased stigma and discrimination with increased trust and confidence in CHWs with household-level assignment. Positive relationships between CHWs in their households, community members, and health facility staff fostered health knowledge, individual agency, and personal resources for the community members to access health services. Community members' personal resources of increased health knowledge, trust, gratitude, and social support improved social connectedness and subjective wellbeing. Areas to improve positive relationships include CHWs maintaining confidentiality and caring for pregnant women. CONCLUSION: Our study findings demonstrate that by building solid relationships as a community chosen, well informed, and household-level workforce, CHWs can develop positive relationships with communities and the health-care facility staff through building knowledge, trust, gratitude, and hope. Further work is needed in maintaining CHW confidentiality and new ways to approach culturally sensitive health areas.

Qualitative assessment of community health workers' perspective on their motivation in community-based primary health care in rural Malawi.

BACKGROUND: Community Health Workers (CHWs) have a positive impact on the provision of community-based primary health care through screening, treatment, referral, psychosocial support, and accompaniment. With a broad scope of work, CHW programs must balance the breadth and depth of tasks to maintain CHW motivation for high-quality care delivery. Few studies have described the CHW perspective on intrinsic and extrinsic motivation to enhance their programmatic activities. METHODS: We utilized an exploratory qualitative study design with CHWs employed in the household model in Neno District, Malawi, to explore their perspectives on intrinsic and extrinsic motivators and dissatisfiers in their work. Data was collected in 8 focus group discussions with 90 CHWs in October 2018 and March-April 2019 in seven purposively selected catchment areas. All interviews were audiotaped, transcribed verbatim, coded, and analyzed using Dedoose. RESULTS: Themes of complex intrinsic and extrinsic factors were generated from the perspectives of the CHWs in the focus group discussions. Study results indicate that enabling factors are primarily intrinsic factors such as positive patient outcomes, community respect, and recognition by the formal health care system but can lead to the challenge of increased scope and workload. Extrinsic factors can provide challenges, including an increased scope and workload from original expectations, lack of resources to utilize in their work, and rugged geography. However, a positive work environment through supportive relationships between CHWs and supervisors enables the CHWs. CONCLUSION: This study demonstrated enabling factors and challenges for CHW performance from their perspective within the dual-factor theory. We can mitigate challenges through focused efforts to limit geographical distance, manage workload, and strengthen CHW support to reinforce their recognition and trust. Such programmatic emphasis can  focus on enhancing motivational factors found in this study to improve the CHWs' experience in their role. The engagement of CHWs, the communities, and the formal health care system is critical to improving the care provided to the patients and communities, along with building supportive systems to recognize the work done by CHWs for the primary health care systems.

A household-based community health worker programme for non-communicable disease, malnutrition, tuberculosis, HIV and maternal health: a stepped-wedge cluster randomised controlled trial in Neno District, Malawi.

BACKGROUND: Community health worker (CHW) programmes are a valuable component of primary care in resource-poor settings. The evidence supporting their effectiveness generally shows improvements in disease-specific outcomes relative to the absence of a CHW programme. In this study, we evaluated expanding an existing HIV and tuberculosis (TB) disease-specific CHW programme into a polyvalent, household-based model that subsequently included non-communicable diseases (NCDs), malnutrition and TB screening, as well as family planning and antenatal care (ANC). METHODS: We conducted a stepped-wedge cluster randomised controlled trial in Neno District, Malawi. Six clusters of approximately 20 000 residents were formed from the catchment areas of 11 healthcare facilities. The intervention roll-out was staggered every 3 months over 18 months, with CHWs receiving a 5-day foundational training for their new tasks and assigned 20-40 households for monthly (or more frequent) visits. FINDINGS: The intervention resulted in a decrease of approximately 20% in the rate of patients defaulting from chronic NCD care each month (-0.8 percentage points (pp) (95% credible interval: -2.5 to 0.5)) while maintaining the already low default rates for HIV patients (0.0 pp, 95% CI: -0.6 to 0.5). First trimester ANC attendance increased by approximately 30% (6.5pp (-0.3, 15.8)) and paediatric malnutrition case finding declined by 10% (-0.6 per 1000 (95% CI -2.5 to 0.8)). There were no changes in TB programme outcomes, potentially due to data challenges. INTERPRETATION: CHW programmes can be successfully expanded to more comprehensively address health needs in a population, although programmes should be carefully tailored to CHW and health system capacity.

Early Lessons From Launching an Innovative Community Health Household Model Across 3 Country Contexts.

Community health workers (CHWs) are integrated into health systems through a variety of designs. Partners In Health (PIH), a nongovernmental organization with more than 30 years of experience in over 10 countries, initially followed a vertical approach by assigning CHWs to individual patients with specific conditions, such as HIV, multidrug resistant-TB, diabetes, and other noncommunicable diseases, to provide one-on-one psychosocial and treatment support. Starting in 2015, PIH-Malawi redesigned their CHW assignments to focus on entire households, thereby offering the opportunity to address a wider variety of conditions in any age group, all with a focus on working toward effective universal health coverage. Inspired by this example, PIH-Liberia and then PIH-Mexico engaged in a robust cross-site dialogue on how to adapt these plans for their unique nongovernmental organization-led CHW programs. We describe the structure of this "household model," how these structures were changed to adapt to different country contexts, and early impressions on the effects of these adaptations. Overall, the household model is proving to be a feasible and functional method for organizing CHW programs so that they can contribute toward achieving universal health coverage, but there is no "one-size-fits-all" approach. Other countries planning on adopting this model should plan to analyze and adapt as needed.

Evaluating the impact of a community health worker programme on non-communicable disease, malnutrition, tuberculosis, family planning and antenatal care in Neno, Malawi: protocol for a stepped-wedge, cluster randomised controlled trial.

INTRODUCTION: This protocol concerns the implementation and evaluation of an intervention designed to realign the existing cadre of community health workers (CHWs) in Neno district, Malawi to better support the care needs of the clients they serve. The proposed intervention is a 'Household Model' where CHWs will be reassigned to households, rather than to specific patients with HIV and/or tuberculosis (TB). METHODS AND ANALYSIS: Using a stepped-wedge, cluster-randomised design, this study investigates whether high HIV retention rates can be replicated for non-communicable diseases (NCDs), and the model's impact on TB and paediatric malnutrition case finding, as well as the uptake of family planning and antenatal care. Eleven sites (health centres and hospitals) were arranged into six clusters (average cluster population 21 800). Primary outcomes include retention in care for HIV and chronic NCDs, TB case finding, paediatric malnutrition case finding, and utilisation of early and complete antenatal care. Clinical outcomes are based on routinely collected data from the Ministry of Health's District Health Information System 2 and an OpenMRS electronic medical record supported by Partners In Health. Additionally, semistructured qualitative interviews with various stakeholders will assess community perceptions and context of the Household Model. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Malawian National Health Science Research Committee (#16/11/1694) in Lilongwe, Malawi; Partners Healthcare Human Research Committee (#2017P000548/PHS) in Somerville, Massachusetts; and the Biomedical and Scientific Research Ethics Sub-Committee (REGO-2017-2060) at the University of Warwick in Coventry, UK. Dissemination will include manuscripts for peer-reviewed publication as well as a full report detailing the findings of the intervention for the Malawian Ministry of Health. TRIAL REGISTRATION NUMBER: NCT03106727. PRIMARY SPONSOR: Partners In Health | Abwenzi Pa Za Umoyo P.O. Box 56, Neno, Malawi. Protocol Version 4, March 2018.

Determining whether Community Health Workers are 'Deployment Ready' Using Standard Setting.

BACKGROUND: Community Health Workers (CHWs) provide basic health screening and advice to members of their own communities. Although CHWs are trained, no CHW programmes have used a formal method to identify the level of achievement on post-training assessments that distinguishes "safe" from "unsafe". Objectives: The aim of this study was to use Ebel method of standard setting for a post-training written knowledge assessment for CHWs in Neno, Malawi. METHODS: 12 participants agreed the definitions of a "just-deployment ready" and an "ideal" CHW. Participants rated the importance and difficulty of each question on a three-point scale and also indicated the proportion of "just-deployment ready" CHWs expected to answer each of the nine question types correctly. Mean scores were used to determine the passing standard, which was reduced by one standard error of measurement (SEM) as this was the first time any passing standard had been employed.The level of agreement across participants' ratings of importance and difficulty was calculated using Krippendorf's alpha. The assessment results from the first cohort of CHW trainees were analysed using classical test theory. FINDINGS: There was poor agreement between participants on item ratings of both importance and difficulty (Krippendorf's alphas of 0.064 and 0.074 respectively). The pass mark applied to the assessment, following adjustment using the SEM, was 53.3%. Based on this pass mark, 68% of 129 CHW trainees were 'clear passes', 11% 'borderline passes', 9% 'borderline fails' and 12% 'clear fails'. CONCLUSIONS: Determining whether a CHW is deployment-ready is an important, but difficult exercise, as evidenced by a lack of agreement regarding question importance and difficulty. Future exercises should allow more time for training, discussion and modification of ratings. Based on the assessment, most CHWs trained could be considered deployment-ready, but following-up their performance in the field will be vital to validate the pass mark set.