Success in vaccination programming through community health workers: a qualitative analysis of interviews and focus group discussions from Nepal, Senegal and Zambia.

OBJECTIVES: Community health workers are essential to front-line health outreach throughout low-income and middle-income countries, including programming for early childhood immunisation. Understanding how community health workers are engaged for successful early childhood vaccination among countries who showed success in immunisation coverage would support evidence-based policy guidance across contexts. DESIGN: We employed a multiple case study design using qualitative research methods. SETTING: We conducted research in Nepal, Senegal and Zambia. PARTICIPANTS: We conducted 207 interviews and 71 focus group discussions with 678 participants at the national, regional, district, health facility and community levels of the health systems of Nepal, Senegal and Zambia, from October 2019 to April 2021. We used thematic analysis to investigate contributing factors of community health worker programming that supported early childhood immunisation within each country and across contexts. RESULTS: Implementation of vaccination programming relied principally on the (1) organisation, (2) motivation and (3) trust of community health workers. Organisation was accomplished by expanding cadres of community health workers to carry out their roles and responsibilities related to vaccination. Motivation was supported by intrinsic and extrinsic incentives. Trust was expressed by communities due to community health worker respect and value placed on their work. CONCLUSION: Improvements in immunisation coverage was facilitated by community health worker organisation, motivation and trust. With the continued projection of health worker shortages, especially in low-income countries, community health workers bridged the equity gap in access to vaccination services by enabling wider reach to underserved populations. Although improvements in vaccination programming were seen in all three countries-including government commitment to addressing human resource deficits, training and remuneration; workload, inconsistency in compensation, training duration and scope, and supervision remain major challenges to immunisation programming. Health decision-makers should consider organisation, motivation and trust of community health workers to improve the implementation of immunisation programming.

Public health surveillance through community health workers: a scoping review of evidence from 25 low-income and middle-income countries.

BACKGROUND: The last 3 years have witnessed global health challenges, ranging from the pandemics of COVID-19 and mpox (monkeypox) to the Ebola epidemic in Uganda. Public health surveillance is critical for preventing these outbreaks, yet surveillance systems in resource-constrained contexts struggle to provide timely disease reporting. Although community health workers (CHWs) support health systems in low-income and middle-income countries (LMICs), very little has been written about their role in supporting public health surveillance. This review identified the roles, impacts and challenges CHWs face in public health surveillance in 25 LMICs. METHODS: We conducted a scoping review guided by Arksey and O'Malley's framework. We exported 1,156 peer-reviewed records from Embase, Global Health and PubMed databases. After multiple screenings, 29 articles were included in the final review. RESULTS: CHWs significantly contribute to public health surveillance in LMICs including through contact tracing and patient visitation to control major infectious diseases such as HIV/AIDS, malaria, tuberculosis, Ebola, neglected tropical diseases and COVID-19. Their public health surveillance roles typically fall into four main categories including community engagement; data gathering; screening, testing and treating; and health education and promotion. The use of CHWs in public health surveillance in LMICs has been impactful and often involves incorporation of various technologies leading to improved epidemic control and disease reporting. Nonetheless, use of CHWs can come with four main challenges including lack of education and training, lack of financial and other resources, logistical and infrastructural challenges as well as community engagement challenges. CONCLUSION: CHWs are important stakeholders in surveillance because they are closer to communities than other healthcare workers. Further integration and training of CHWs in public health surveillance would improve public health surveillance because CHWs can provide health data on 'hard-to-reach' populations. CHWs' work in public health surveillance would also be greatly enhanced by infrastructural investments.

Prevalence and factors associated with inadequate work ability among community health workers in Montes Claros, Minas Gerais state, Brazil: a cross-sectional study, 2018.

OBJECTIVE: To estimate the prevalence and analyze factors associated with inadequate work ability among community health workers (CHWs). METHODS: This was a cross-sectional study conducted with CHWs, from July to October 2018, in Montes Claros, state of Minas Gerais, Brazil; work ability, sociodemographic, occupational, and clinical factors were investigated; prevalence ratios (PRs) with 95% confidence intervals (95%CI) were calculated using Poisson regression. RESULTS: Of the 675 CHWs, 25.8% (95%CI 22.7;29.2) showed inadequate work ability; length of service greater than five years (PR = 1.64; 95%CI 1.24;2.18), poor health status (PR = 2.10; 95%CI 1.56;2.83), depressive symptoms (PR = 1.98; 95%CI 1.54;2.55) and voice disorders (PR = 1.85; 95%CI 1.26;2.73) were associated with the event. CONCLUSION: There was a high prevalence of inadequate work ability, associated with occupational and clinical factors. MAIN RESULTS: There was a high prevalence of inadequate work ability among community health workers (CHWs), associated with occupational and clinical factors. IMPLICATIONS FOR SERVICES: This study can contribute to the planning of preventive actions and the promotion of the work ability of CHWs, with repercussions on the quality of service provided by these professionals. PERSPECTIVES: Longitudinal studies are strongly recommended in order to establish cause-and-effect relationships between the variables investigated.

Through the eyes of community health workers: what was needed to increase COVID-19 vaccine uptake in the Missouri Southeast region.

Public health emergencies, such as the COVID-19 pandemic, elucidate the strengths, weaknesses, and significant gaps in infrastructure, compatibility and consistency in communication systems, as well as the quality of collaborative relationships, and provider and workforce capacity. They also expose longstanding patterns of mistrust in the government and healthcare systems, and inadequacy in socio-economic infrastructures. These issues resulted in higher COVID-19 infection and mortality rates, and lower vaccination rates in many rural counties across the nation, including Missouri. In response to these challenges, the COVID-19 Response Network was formed in the Southeast corner of the state. The Network was a community-academic partnership that brought together community and faith-based leaders, academicians, healthcare providers and administrators, public health practitioners, and pharmacists to facilitate collaboration on education and outreach efforts aimed at reducing vaccine inequity in the 16-county project area. Importantly, the Network also included Community Health Workers (CHWs) who worked with these different agencies and organizations and were at the heart of implementing Network activities. The intent of this study was to assess their perspectives on the factors that influenced community engagement and communication strategies, and increased vaccine uptake in rural Missouri. Qualitative methods, including in-depth interviews, were used to explore the professional and personal experiences of CHWs working at the grassroots level during an ongoing pandemic. Narrative analysis revealed effective communication and engagement strategies for increasing vaccine uptake in rural communities. For instance, fear-based messaging was perceived as coercive and met with resistance. In contrast, messages that shared personal experiences and catered to the human need to protect their loved ones were more effective. Trust in the source of information was critical. This study highlights the significance of exploring and leveraging the capacities of trusted community members like CHWs to increase the effectiveness of public health interventions in rural communities.

Community health worker outreach to farmworkers in rural North Carolina: Learning from adaptations to the SARS-CoV-2 pandemic.

BACKGROUND: Community health workers represent a critical part of the health outreach and services for migrant and seasonal farmworkers ('farmworkers') in rural areas of the United States. PURPOSE: We sought to identify adaptations to farmworker patient engagement and health outreach made by community health workers during the first 18 months of the COVID-19 pandemic. METHODS: In this qualitative study, we used semi-structured interviews with community health workers from August 2020 to February 2022 (n = 21). Two coders used thematic analysis to identify three themes related to the experiences of community health workers in conducting health education and outreach to farmworkers prior to and following the onset of the pandemic. FINDINGS: We found themes related to pre-pandemic outreach efforts to provide health education resource sharing with farmworkers and pandemic-related outreach efforts that included adoption of porch drops and distanced delivery of health education, adaptation of modes of health education and communication through technology and the internet, and taking on new roles related to COVID-19. Finally, we identified changes that reverted after the pandemic or will continue as adaptations. CONCLUSIONS: Community health workers created practice-based innovations in outreach in response to the COVID-19 pandemic. These innovations included new COVID-19 related roles and new modes of health education and outreach, including the use of digital resources. The changes developed for emergency use in COVID-19, particularly related to internet and technology, have likely altered how community health workers conduct outreach in North Carolina going forward. Funders, community health worker training programs, and researchers should take note of these innovations. PATIENT OR PUBLIC CONTRIBUTION: Community health workers who typically come from patient populations and provide critical navigation and connection with the health care system advised on the design and creation of this research project, including serving on an advisory board. Two authors have experience working as community health workers.

Enhancing sexual health and empowerment among migrant women sex workers: a community health worker-led intervention in Marseille, France.

Introduction: Given the high infection rate of sexually transmitted infections (STI) among migrant women sex workers (WSWs), it is necessary to understand how to improve prevention, information and care for this vulnerable population. Community health workers (CHWs), by linking community to health services, are positioned to improve health outcomes in migrant communities. This article aims to describe a pilot innovative intervention performed by CHWs to improve sexual health in migrant WSWs. Methods: This one-year intervention study used a respondent-driven sampling (RDS) to recruit a representative cohort of migrant WSWs in Marseille, France. Four CHWs were recruited from different communities and participated in all stages of the research. They performed individual and group interventions of prevention, support in care and empowerment. Data on participant characteristics, type of intervention and adherence to the intervention were reported via questionnaires given to participants. Simultaneously, semi-structured interviews and informal interviews of migrant WSW, CHWs and care providers were carried out. Results: A total of 132 migrant WSWs were included in the cohort. Very few of them knew about PrEP (12%) or already used HIV post-exposure treatment (9%). Migrant WSWs were often victims of rape or racism, 15 and 21%, respectively. In two-thirds of cases the level of health literacy was low. Participants suffered from a combination of vulnerability factors: difficulties with access to social rights, food or housing. Only 13% reported having benefited from medical follow-up or assistance by an NGO in the 3 months prior to the program. By 3 months, more than one third of the participants had been tested for HIV (35%) and 63% knew about PrEP. A total retention rate of 70% was reported in the cohort after 6 months. Conclusion: CHWs enabled to improve care access for migrant WSWs by improving the collaboration between care and social actors at a local level. Through these "bring-back-to" interventions for this hard-to-reach population, CHWs enabled an optimization of the care pathway. Our results also highlight the importance of a population-based approach for individual and group support of empowerment interventions in order to strengthen their capacity for action.

Perceptions of community health workers on teenage pregnancy in rural Limpopo: A qualitative study.

BACKGROUND:  Despite measures put in place to combat teenage pregnancy, the rate remains high. Community health workers (CHWs) are a cadre of health workers that can help put measures in place to reduce teenage pregnancy in the communities in which they live and work. AIM:  This article aims to gain a deeper understanding of CHWs' perceptions regarding teenage pregnancy in the rural districts of Limpopo province. METHODS:  An exploratory qualitative study approach was employed to collect data from CHWs in two rural districts of Limpopo. A non-probability purposive sampling approach was used to choose 81 CHWs. Eight focus group discussions (FGDs) were organised, and audio recorded to collect data from participants. The discussions were 2-3 h long and conducted in English, and data saturation was attained by the fifth FGDs. RESULTS:  An eight-step tech's content analysis approach was employed to deductively code, analyse and summarise data into themes. Three themes emerged: the prevalence of teenage pregnancy in rural villages, factors contributing to teenage pregnancy and challenges faced by CHWs when dealing with teenage pregnancy. CONCLUSION:  The study's findings revealed that CHWs face challenges in their communities when offering appropriate teen pregnancy services and CHWs believe that teen pregnancy numbers remain high. There is a significant barrier in combating teenage pregnancy; if contraceptives are not acceptable to the community, the only solution and option for combating teenage pregnancy is abstinence.Contribution: The CHWs presented their insights of teenage pregnancy in rural communities. The outcomes of this study could help clinical practise, schools, communities, youth-friendly services, policymakers and other non-governmental organisations reduce teenage pregnancy.

On-demand mobile hypertension training for primary health care workers in Nigeria: a pilot study.

BACKGROUND: Only one out of every ten Nigerian adults with hypertension has their blood pressure controlled. Health worker training is essential to improve hypertension diagnosis and treatment. In-person training has limitations that mobile, on-demand training might address. This pilot study evaluated a self-paced, case-based, mobile-optimized online training to diagnose and manage hypertension for Nigerian health workers. METHODS: Twelve hypertension training modules were developed, based on World Health Organization and Nigerian guidelines. After review by local academic and government partners, the course was piloted by Nigerian health workers at government-owned primary health centers. Primary care physician, nurse, and community health worker participants completed the course on their own smartphones. Before and after the course, hypertension knowledge was evaluated with multiple-choice questions. Learners provided feedback by responding to questions on a Likert scale. RESULTS: Out of 748 users who sampled the course, 574 enrolled, of whom 431 (75%) completed the course. The average pre-test score of completers was 65.4%, which increased to 78.2% on the post-test (P < 0.001, paired t-test). Health workers who were not part of existing hypertension control programs had lower pre-test scores and larger score gains. Most participants (96.1%) agreed that the training was applicable to their work, and nearly all (99.8%) agreed that they enjoyed the training. CONCLUSIONS: An on-demand mobile digital hypertension training increases knowledge of hypertension management among Nigerian health workers. If offered at scale, such courses can be a tool to build health workforce capacity through initial and refresher training on current clinical guidelines in hypertension and other chronic diseases in Nigeria as well as other countries.

The impact of accredited social health activists in India on uptake of modern contraception: A nationally representative multilevel modelling study.

The government of India introduced the Accredited Social Health Activist (ASHA) programme in 2006 to connect marginalised communities to the health system. ASHAs are mandated to increase the uptake of modern contraception through the doorstep provision of services. There is currently no evidence on the impact of ASHAs on the uptake of contraception at the national level. This paper examines the impact of ASHAs on the uptake of modern contraception using nationally representative National and Family Health Survey data collected in 2019-21 in India. A multilevel logistic regression analysis was performed to determine the effect of contact with ASHAs on the uptake of modern contraception, controlling for regional variability and socio-demographic variables. The data provide strong evidence that ASHAs have succeeded in increasing modern contraceptive use. Women exposed to ASHAs had twice the odds of being current users of modern contraception compared to those with no contact, even after controlling for household and individual characteristics. However, only 28.1% of women nationally reported recent contact with ASHA workers. The ASHA programme should remain central to the strategy of the government of India and should be strengthened to achieve universal access to modern contraception and meet sustainable development goals by 2030.

Community health worker perspectives on advocacy: design-based research to develop a digital advocacy training course.

Introduction: While community health workers (CHWs) are well-positioned as health advocates, they frequently lack support and feel undervalued. Advocacy training may prepare CHWs to support communities better. Methods: This study uses a design-based research approach to (1) explore how participation in curriculum-development workshops for a digital advocacy course influenced CHWs' (n = 25) perceptions of advocacy and (2) describe how CHW involvement shaped course development. Data were collected via five discussion groups and seven surveys over six months. Results: Initially, the CHWs perceived themselves as community-advocates but not as self-advocates. They increasingly reflected on the merits of advocating for better working conditions and aspired to greater involvement in decision-making. CHWs reflected positively on their advisory role in shaping the course to improve content acceptability and validity. Discussion: Training efforts to engage CHWs in advocacy must overcome systemic barriers and norms internalized by CHWs that deter them from reaching their full potential as advocates.

Community Health Workers Deliver Mental Health Intervention to Uninsured Latinx in Baltimore: Evaluation and Lessons Learned in a Pilot Program.

BACKGROUND: Implementation of evidence-based interventions to reduce depression among uninsured Latinx patients who are at high risk of depression are rare. OBJECTIVES: Our goal was to evaluate Strong Minds, a language and culturally tailored, evidence-based intervention adapted from cognitive behavioral therapy (CBT) for mild-moderate depression and anxiety, delivered by community health workers (CHWs) in Spanish to uninsured Latinx immigrants. METHODS: As part of the pilot, 35 participants, recruited from a free community primary care clinic, completed Strong Minds. Assessments and poststudy interviews were conducted. Paired t-tests were used to assess change of depressive symptoms at 3 and 6 months. LESSONS LEARNED: CHW delivery of depression care to this population was feasible and among those who completed the program, preliminary evidence of depression outcomes suggests potential benefit. CHWs had specific training and support needs related to mental health care delivery. CONCLUSIONS: Further implementation studies of depression care interventions using CHWs for underserved Latinx is needed.

A Model of Community Health Worker Integration into Schools: Community-based Participatory Research in Action.

BACKGROUND: Schools are rich sites for collaborations between health and educational sectors. OBJECTIVES: To identify lessons learned from formation of a community-academic partnership and application of community-based participatory research (CBPR) to develop a model that integrates community health workers into schools. METHODS: Individuals from an academic medical center, a large public school district, and a community-based research institute applied CBPR principles to reimagine schools as a place for improving the health of children. LESSONS LEARNED: Three lessons emerged. Leveraging each team member's expertise centered the partnership on community strengths, co-learning, and stakeholder engagement. Adherence to CBPR's principles of power sharing and equity helped navigate the challenges of collaboration between large institutions. Early focus on sustainability helped address unexpected issues, build capacity, and boost advocacy. CONCLUSIONS: This partnership demonstrates how CBPR fosters conditions in which equitable partnerships between research institutions and public schools can thrive to promote childhood health.

Obesity-Preventive Behaviors and Improvements in Depression among Diverse Utah Women Receiving Coaching from Community Health Workers.

OBJECTIVES: This study evaluated how high versus low-intensity community wellness coaching and health behaviors were associated with changes in depression screen results over one year. METHODS: This was an analysis of secondary data collected in a 12-month obesity-related community health worker (CHW) program for 485 Utah women of color. Depression screen (Patient Health Questionnaire-2 score ³3) and self-reported fruit/vegetable consumption and physical activity (FV/PA) were recorded quarterly. Associations between FV/PA and changes in depression screen over time were evaluated in multivariable models. RESULTS: Positive depression screen prevalence declined over 12 months (21.7% to 9.5%) with no difference between study arms. Overall, FV ³5 times/day (AOR=1.5; 95% CI 1.0-2.2), any PA (AOR=3.1; 95% CI 1.5-6.4), and muscle strengthening activities (AOR=1.13; 95% CI 1.01-1.26) were associated with improved depression screen results over time. CONCLUSION: These results indicate value in addressing and evaluating depression in obesity-related interventions in underserved communities.

A mixed methods evaluation of the impact of ECHO® telementoring model for capacity building of community health workers in India.

INTRODUCTION: India has the largest cohort of community health workers with one million Accredited Social Health Activists (ASHAs). ASHAs play vital role in providing health education and promoting accessible health care services in the community. Despite their potential to improve the health status of people, they remain largely underutilized because of their limited knowledge and skills. Considering this gap, Extension for Community Healthcare Outcomes (ECHO)® India, in collaboration with the National Health System Resource Centre (NHSRC), implemented a 15-h (over 6 months) refresher training for ASHAs using a telementoring interface. The present study intends to assess the impact of the training program for improving the knowledge and skills of ASHA workers. METHODS: We conducted a pre-post quasi-experimental study using a convergent parallel mixed-method approach. The quantitative survey (n = 490) assessed learning competence, performance, and satisfaction of the ASHAs. In addition to the above, in-depth interviews with ASHAs (n = 12) and key informant interviews with other stakeholders (n = 9) examined the experience and practical applications of the training. Inferences from the quantitative and qualitative approaches were integrated during the reporting stage and presented using an adapted Moore's Expanded Outcomes Framework. RESULTS: There was a statistically significant improvement in learning (p = 0.038) and competence (p = 0.01) after attending the training. Participants were satisfied with the opportunity provided by the teleECHO™ sessions to upgrade their knowledge. However, internet connectivity, duration and number of participants in the sessions were identified as areas that needed improvement for future training programs. An improvement in confidence to communicate more effectively with the community was reported. Positive changes in the attitudes of ASHAs towards patient and community members were also reported after attending the training. The peer-to-peer learning through case-based discussion approach helped ensure that the training was relevant to the needs and work of the ASHAs. CONCLUSIONS: The ECHO Model ™ was found effective in improving and updating the knowledge and skills of ASHAs across different geographies in India. Efforts directed towards knowledge upgradation of ASHAs are crucial for strengthening the health system at the community level. The findings of this study can be used to guide future training programs. Trial registration The study has been registered at the Clinical Trials Registry, India (CTRI/2021/10/037189) dated 08/10/2021.

Community perceptions of community health worker effectiveness: Contributions to health behaviour change in an urban health district in South Africa.

BACKGROUND: Community health worker (CHW) programmes contribute towards strengthening adherence support, improving maternal and child health outcomes and providing support for social services. They play a valuable role in health behaviour change in vulnerable communities. Large-scale, comprehensive CHW programmes at health district level are part of a South African (SA) strategy to re-engineer primary healthcare and take health directly into communities and households, contributing to universal health coverage. OBJECTIVE: These CHW programmes across health districts were introduced in SA in 2010 - 11. Their overall purpose is to improve access to healthcare and encourage healthy behaviour in vulnerable communities, through community and family engagements, leading to less disease and better population health. Communities therefore need to accept and support these initiatives. There is, however, inadequate local evidence on community perceptions of the effectiveness of such programmes. METHODS: A cross-sectional descriptive study to determine community perceptions of the role and contributions of the CHW programme was conducted in the Ekurhuleni health district, an urban metropolis in SA. Members from 417 households supported by CHWs were interviewed in May 2019 by retired nurses used as fieldworkers. Frequencies and descriptive analyses were used to report on the main study outcomes of community acceptance and satisfaction. RESULTS: Nearly all the study households were poor and had at least one vulnerable member, either a child under 5, an elderly person, a pregnant woman or someone with a chronic condition. CHWs had supported these households for 2 years or longer. More than 90% of households were extremely satisfied with their CHW; they found it easy to talk to them within the privacy of their homes and to follow the health education and advice given by the CHWs. The community members highly rated care for chronic conditions (82%), indicated that children were healthier (41%) and had safer pregnancies (6%). CONCLUSION: As important stakeholders in CHW programmes, exploring community acceptance, appreciation and support is critical in understanding the drivers of programme performance. Community acceptance of the CHWs in the Ekurhuleni health district was high. The perspective of the community was that the CHWs were quite effective. This was demonstrated when they reported changes in household behaviour with regard to improved access to care through early screening, referrals and improved management of chronic and other conditions.

Community health workers for health systems resilience during COVID-19: protocol for qualitative evidence synthesis.

INTRODUCTION: COVID-19 exposed the fragility of health systems, where even the most basic health services in high-income and low-income and middle-income nations could not withstand the health systems shock due to the pandemic. Community health workers (CHWs) can contribute to improving the resilience of health systems, specifically to withstand shocks and emergencies and to avoid disruptions of routine service delivery. We aim to explore and understand the 'individual' and 'systems-level' resilience factors that shaped the involvement of CHWs in the COVID-19 response. METHODS AND ANALYSIS: We will search five electronic databases (PubMed, Cochrane Library, EMBASE, CINAHL and SciELO (Spanish)) and conduct citation screening to identify studies on CHWs' response during the COVID-19 pandemic. Two review authors will independently screen the studies for inclusion and to extract data. The software Rayyan will be used to assist in screening the relevant literature. A thematic analysis approach will be followed to analyse and synthesise the qualitative evidence. The quality of the included studies will be critically assessed using the Critical Skills Appraisal Programme Tool. We will use the GRADE CERQual(Grading of Recommendations, Assessment, Development, and Evaluations - Confidence in the Evidence from Reviews of Qualitative Research) approach to assess certainty in the synthesised findings of the qualitative evidence. ETHICS AND DISSEMINATION: This study will be conducted on published evidence, with no living participants; thus, no ethical approval is required. The final review will be submitted and published in a peer-reviewed journal. We will also develop a policy brief to communicate the review findings to the stakeholders.

Importance of Utilizing Non-Communicable Disease Screening Tools; Ward-Based Community Health Care Workers of South Africa Explain.

The screening of patients in the community is important and is a commonly used indicator to detect, prevent, and treat abnormal health changes. As such, the South African Department of Health following the initiative of the World Health Organization has appointed ward-based community health care workers through a primary health care reengineering program. The main objective of their appointment was to screen household members to reduce the burden of diseases such as diabetes mellitus and hypertension. As such, the study investigated the importance of using non-communicable disease screening tools by ward-based community health care workers in South Africa. A qualitative, exploratory, and descriptive design was used. A non-probability purposive sampling method was used to select forty participants from primary health care facilities. Four focus group discussions were held with ten participants in each group. Semi-structured focus group discussions were held with participants in their workplaces. Content data analysis was applied to come up with one theme and six subthemes. The study findings revealed that the use of screening tools facilitated comprehensive household assessments, helped identify risk factors and symptoms, and facilitated health education and patient referrals. The continuous supply of screening tools and updates on their use was recommended to reduce the rate and burden caused by non-communicable diseases to society at large.

Knowledge, Attitudes, and Practices of Community Health Workers in Relation to Environmental Health Hazards in the Nelson Mandela Bay.

BACKGROUND: Community health workers (CHWs) cover extensive areas observing the environmental conditions in which community members live. However, current CHW training modules do not have modules focusing specifically on environmental health. CHWs appear to lack knowledge of environmental health hazards, and little is known of their attitudes and practices regarding environmental health hazards. The purpose of this study was to determine the knowledge, attitudes, and practices of CHWs in relation to environmental health hazards in the Nelson Mandela Bay (NMB). METHODS: This study used a quantitative, cross-sectional research design. A sample of 110 respondents completed the questionnaire. The questionnaire was based on the literature, consisting of 36 items in four sections. Data analysis consisted of descriptive and inferential statistics. Reliability and validity were enhanced by utilizing a pre-test study. RESULTS: There were significant differences in attitudes (t = -2.308, df = 91.107, p = 0.023) and practices (t = -2.936, df = 62.491, p = 0.005). Those trained in environmental health had a significantly lower mean attitudes score (m = 3.2365, sd = 1.113) compared to those not trained in environmental health (m = 3.694, sd = 0.894). In addition, those trained in environmental health had a significantly lower mean practice score (practiced more frequently) (m = 1.231, sd = 0.327) compared to those not trained in environmental health (m = 1.4605, sd = 0.4162). Regarding training, 62% (n = 67) of CHWs felt they needed additional training in environmental health. CONCLUSION: Most of the CHWs had a moderate knowledge of environmental health hazards. Furthermore, most of the CHWs had a very positive or positive attitude towards environmental health hazards. However, there is a need for CHWs to receive very specific training in environmental health. In addition, the scope of work of CHWs, as well as their role in relation to environmental health, needs to be further explored.

The role of a community health worker-delivered preconception and pregnancy intervention in achieving a more positive pregnancy experience: the Bukhali trial in Soweto, South Africa.

BACKGROUND: A patient-centered, human-rights based approach to maternal care moves past merely reducing maternal mortality and morbidity, towards achieving a positive pregnancy experience. When evaluating an intervention, particularly in the context of the complex challenges facing maternal care in South Africa, it is therefore important to understand how intervention components are experienced by women. We aimed to qualitatively explore (i) factors influencing the pregnancy and postpartum experience amongst young women in Soweto, South Africa, and (ii) the influence of Bukhali, a preconception, pregnancy, and early childhood intervention delivered by community health workers (CHWs), on these experiences. METHODS: Semi-structured, in-depth interviews were conducted with 15 purposively sampled participants. Participants were 18-28-year-old women who (i) were enrolled in the intervention arm of the Bukhali randomized controlled trial; (ii) were pregnant and delivered a child while being enrolled in the trial; and (iii) had at least one previous pregnancy prior to participation in the trial. Thematic analysis, informed by the positive pregnancy experiences framework and drawing on a codebook analysis approach, was used. RESULTS: The themes influencing participants' pregnancy experiences (aim 1) were participants' feelings about being pregnant, the responsibilities of motherhood, physical and mental health challenges, unstable social support and traumatic experiences, and the pressures of socioeconomic circumstances. In terms of how support, information, and care practices influenced these factors (aim 2), four themes were generated: acceptance and mother/child bonding, growing and adapting in their role as mothers, receiving tools for their health, and having ways to cope in difficult circumstances. These processes were found to be complementary and closely linked to participant context and needs. CONCLUSION: Our findings suggest that, among women aged 18-28, a CHW-delivered intervention combining support, information, and care practices has the potential to positively influence women's pregnancy experience in South Africa. In particular, emotional support and relevant information were key to better meeting participant needs. These findings can help define critical elements of CHW roles in maternal care and highlight the importance of patient-centred solutions to challenges within antenatal care. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201903750173871, 27/03/2019.

Cost-effectiveness of severe acute malnutrition treatment delivered by community health workers in the district of Mayahi, Niger.

BACKGROUND: A non-randomized controlled trial, conducted from June 2018 to March 2019 in two rural communes in the health district of Mayahi in Niger, showed that including community health workers (CHWs) in the treatment of severe acute malnutrition (SAM) resulted in a better recovery rate (77.2% vs. 72.1%) compared with the standard treatment provided solely at the health centers. The present study aims to assess the cost and cost-effectiveness of the CHWs led treatment of uncomplicated SAM in children 6-59 months compared to the standard national protocol. METHODS: To account for all relevant costs, the cost analysis included activity-based costing and bottom-up approaches from a societal perspective and on a within-trial time horizon. The cost-effectiveness analysis was conducted through a decision analysis network built with OpenMarkov and evaluated under two approaches: (1) with recovery rate and cost per child admitted for treatment as measures of effectiveness and cost, respectively; and (2) assessing the total number of children recovered and the total cost incurred. In addition, a multivariate probabilistic sensitivity analysis was carried out to evaluate the effect of uncertainty around the base case input data. RESULTS: For the base case data, the average cost per child recovered was 116.52 USD in the standard treatment and 107.22 USD in the CHWs-led treatment. Based on the first approach, the CHWs-led treatment was more cost-effective than the standard treatment with an average cost per child admitted for treatment of 82.81 USD vs. 84.01 USD. Based on the second approach, the incremental cost-effectiveness ratio of the transition from the standard to the CHWs-led treatment amounted to 98.01 USD per additional SAM case recovered. CONCLUSIONS: In the district of Mayahi in Niger, the CHWs-led SAM treatment was found to be cost-effective when compared to the standard protocol and provided additional advantages such as the reduction of costs for households. TRIAL REGISTRATION: ISRCTN with ID 31143316. https://doi.org/10.1186/ISRCTN31143316.