What do Accredited Social Health Activists need to provide comprehensive care that incorporates non-communicable diseases? Findings from a qualitative study in Andhra Pradesh, India.

BACKGROUND: The Indian National Program for Cardiovascular Disease, Diabetes, Cancer and Stroke (NPCDCS) was introduced to provide non-communicable disease (NCD) care through primary healthcare teams including Accredited Social Health Activists (ASHAs). Since ASHAs are being deployed to provide NCD care on top of their regular work for the first time, there is a need to understand the current capacity and challenges faced by them. METHODS: A desktop review of NPCDCS and ASHA policy documents was conducted. This was followed by group discussions with ASHAs, in-depth interviews with their supervisors and medical officers and group discussions with community members in Guntur, Andhra Pradesh, India. The multi-stakeholder data were analysed for themes related to needs, capacity, and challenges of ASHAs in providing NCD services. RESULTS: This study identified three key themes-first, ASHAs are unrecognised as part of the formal NPCDCS service delivery team. Second, they are overburdened, since they deliver several NPCDCS activities without receiving training or remuneration. Third, they aspire to be formally recognised as employees of the health system. However, ASHAs are enthusiastic about the services they provide and remain an essential link between the health system and the community. CONCLUSION: ASHAs play a key role in providing comprehensive and culturally appropriate care to communities; however, they are unrecognised and overburdened and aspire to be part of the health system. ASHAs have the potential to deliver a broad range of services, if supported by the health system appropriately. TRIAL REGISTRATION: The study was registered with "Clinical Trials Registry - India" (identifier CTRI/2018/03/012425 ).

Evaluation of a training program of hypertension for accredited social health activists (ASHA) in rural India.

BACKGROUND: Hypertension is a major risk factor for cardiovascular disease, a leading cause of premature death and disability in India. Since access to health services is poor in rural India and Accredited Social Health Activists (ASHAs) are available throughout India for maternal and child health, a potential solution for improving hypertension control is by utilising this available workforce. We aimed to develop and implement a training package for ASHAs to identify and control hypertension in the community, and evaluate the effectiveness of the training program using the Kirkpatrick Evaluation Model. METHODS: The training program was part of a cluster randomised feasibility trial of a 3-month intervention to improve hypertension outcomes in South India. Training materials incorporated details on managing hypertension, goal setting, facilitating group meetings, and how to measure blood pressure and weight. The 15 ASHAs attended a five-day training workshop that was delivered using interactive instructional strategies. ASHAs then led community-based education support groups for 3 months. Training was evaluated using Kirkpatrick's evaluation model for measuring reactions, learning, behaviour and results using tests on knowledge at baseline, post-training and post-intervention, observation of performance during meetings and post-intervention interviews. RESULTS: The ASHAs' knowledge of hypertension improved from a mean score of 64% at baseline to 76% post-training and 84% after the 3-month intervention. Research officers, who observed the community meetings, reported that ASHAs delivered the self-management content effectively without additional assistance. The ASHAs reported that the training materials were easy to understand and useful in educating community members. CONCLUSION: ASHAs can be trained to lead community-based group educational discussions and support individuals for the management of high blood pressure. TRIAL REGISTRATION: The feasibility trial is registered with the Clinical Trials Registry - India (CTRI) CTRI/2016/02/006678 (25/02/2016).

The development of an Android platform to undertake a discrete choice experiment in a low resource setting.

BACKGROUND: Discrete choice experiment (DCE) is a quantitative technique which helps determine preferences from a definite set of choices. DCEs have been widely used to inform health services in high-income country settings and is gradually being used in low and middle-income countries (LMICs). There are challenges in deploying this method in LMIC settings due to the contextual, cultural and language related barriers. Most DCEs are conducted using paper-based tools. With mobile technology readily accessible across LMICs, we developed an Android-based platform to conduct a DCE among community health workers (CHWs) in rural India. METHODS: This paper describes the development of a DCE for low-literacy community health workers (CHWs) in low-resourced setting on an Android platform. We illustrate the process of identifying realistic and locally relevant attributes, finalising the tool and cognitively testing it among respondents with an average of 10 years of education using 'think aloud' and 'verbal probing' techniques. The Android application was tested in two rounds, first by the research team and second, by the CHWs. The 'think aloud' and 'verbal probing' techniques were essential in assessing the comprehension of the CHWs to the DCE choices. RESULTS: The CHWs did not take much time to familiarize themselves with the Android application. Compared to the paper based DCE, the time required for data collection using the Android application was reduced by 50%. We found the Android-based app to be more efficient and time saving as it reduced errors in data collection, eliminated the process of data entry and presented the data for analysis in real time. CONCLUSION: Electronic administration of DCE on Android computer tablets to CHWs with basic education is more efficient, time-saving than paper-based survey designs once the application is provided. It is feasible to use technology to develop and implement DCEs among participants with basic education in resource poor settings.

What do community health workers want? Findings of a discrete choice experiment among Accredited Social Health Activists (ASHAs) in India.

INTRODUCTION: A number of factors contribute to the performance and motivation of India's Accredited Social Health Activists (ASHAs). This study aims to identify the key motivational factors (and their relative importance) that may help retain ASHAs in service. METHODS: A discrete choice experiment (DCE) survey presented ASHAs with eight unlabelled choice sets, each describing two hypothetical jobs that varied based on five attributes, specifically salary, workload, travel allowance, supervision and other job benefits. Multinomial logit and latent class (LC) models were used to estimate stated preferences for the attributes. RESULT: We invited 318 ASHAs from 53 primary health centres of Guntur, a district in south India. The DCE was completed by 299 ASHAs using Android tablets. ASHAs were found to exhibit a strong preference for jobs that incorporated training leading to promotion, a fixed salary and free family healthcare. ASHAs were willing to sacrifice 2530 Indian rupee (INR) from their monthly salary, for a job offering training leading to promotion opportunity and 879 INR for a free family health-check. However, there was significant heterogeneity in preferences across the respondents. The LC model identified three distinct groups (comprising 51%, 35% and 13% of our cohort, respectively). Group 1 and 2 preferences were dominated by the training and salary attributes with group 2 having higher preference for free family health-check while group 3 preferences were dominated by workload. Relative to group 3, ASHAs in groups 1 and 2 were more likely to have a higher level of education and less likely to be the main income earners for their families. CONCLUSION: ASHAs are motivated by both non-financial and financial factors and there is significant heterogeneity between workers. Policy decisions aimed at overcoming workforce attrition should target those areas that are most valued by ASHAs to maximise the value of investments into these workers. TRIAL REGISTRATION NUMBER: CTRI/2018/03/012425.

Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region.

INTRODUCTION: This paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region. METHODS: We developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify 'what works' to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions. RESULTS: From an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a 'systems' lens or adequately considered long-term costs or implementation challenges. CONCLUSION: Based on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems.

Effectiveness of community health worker training programmes for cardiovascular disease management in low-income and middle-income countries: a systematic review.

INTRODUCTION: Community health workers (CHWs) are increasingly being tasked to prevent and manage cardiovascular disease (CVD) and its risk factors in underserved populations in low-income and middle-income countries (LMICs); however, little is known about the required training necessary for them to accomplish their role. This review aimed to evaluate the training of CHWs for the prevention and management of CVD and its risk factors in LMICs. METHODS: A search strategy was developed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and five electronic databases (Medline, Global Health, ERIC, EMBASE and CINAHL) were searched to identify peer-reviewed studies published until December 2016 on the training of CHWs for prevention or control of CVD and its risk factors in LMICs. Study characteristics were extracted using a Microsoft Excel spreadsheet and quality assessed using Effective Public Health Practice Project's Quality Assessment Tool. The search, data extraction and quality assessment were performed independently by two researchers. RESULTS: The search generated 928 articles of which 8 were included in the review. One study was a randomised controlled trial, while the remaining were before-after intervention studies. The training methods included classroom lectures, interactive lessons, e-learning and online support and group discussions or a mix of two or more. All the studies showed improved knowledge level post-training, and two studies demonstrated knowledge retention 6 months after the intervention. CONCLUSION: The results of the eight included studies suggest that CHWs can be trained effectively for CVD prevention and management. However, the effectiveness of CHW trainings would likely vary depending on context given the differences between studies (eg, CHW demographics, settings and training programmes) and the weak quality of six of the eight studies. Well-conducted mixed-methods studies are needed to provide reliable evidence about the effectiveness and cost-effectiveness of training programmes for CHWs.