Female health workers at the doorstep: a pilot of community-based maternal, newborn, and child health service delivery in northern Nigeria.

INTRODUCTION: Nigeria has one of the highest maternal mortality ratios in the world. Poor health outcomes are linked to weak health infrastructure, barriers to service access, and consequent low rates of service utilization. In the northern state of Jigawa, a pilot study was conducted to explore the feasibility of deploying resident female Community Health Extension Workers (CHEWs) to rural areas to provide essential maternal, newborn, and child health services. METHODS: Between February and August 2011, a quasi-experimental design compared service utilization in the pilot community of Kadawawa, which deployed female resident CHEWs to provide health post services, 24/7 emergency access, and home visits, with the control community of Kafin Baka. In addition, we analyzed data from the preceding year in Kadawawa, and also compared service utilization data in Kadawawa from 2008-2010 (before introduction of the pilot) with data from 2011-2013 (during and after the pilot) to gauge sustainability of the model. RESULTS: Following deployment of female CHEWs to Kadawawa in 2011, there was more than a 500% increase in rates of health post visits compared with 2010, from about 1.5 monthly visits per 100 population to about 8 monthly visits per 100. Health post visit rates were between 1.4 and 5.5 times higher in the intervention community than in the control community. Monthly antenatal care coverage in Kadawawa during the pilot period ranged from 11.9% to 21.3%, up from 0.9% to 5.8% in the preceding year. Coverage in Kafin Baka ranged from 0% to 3%. Facility-based deliveries by a skilled birth attendant more than doubled in Kadawawa compared with the preceding year (105 vs. 43 deliveries total, respectively). There was evidence of sustainability of these changes over the 2 subsequent years. CONCLUSION: Community-based service delivery through a resident female community health worker can increase health service utilization in rural, hard-to-reach areas.

Community Health Worker Interventions to Improve Glycemic Control in People with Diabetes: A Systematic Review and Meta-Analysis.

OBJECTIVES: We set out to review the efficacy of Community Health Worker (CHW) interventions to improve glycemia in people with diabetes. METHODS: Data sources included the Cochrane Central Register of Controlled Trials, Medline, clinicaltrials.gov, Google Scholar, and reference lists of previous publications. We reviewed randomized controlled trials (RCTs) that assessed the efficacy of CHW interventions, as compared to usual care, to lower hemoglobin A1c (A1c). Two investigators independently reviewed the RCTs and assessed their quality. Only RCTs with a follow-up of at least 12 months were meta-analyzed. A random effects model was used to estimate, from unadjusted within-group mean reductions, the standardized mean difference (SMD) in A1c achieved by the CHW intervention, beyond usual care. RESULTS: Thirteen RCTs were included in the narrative review, and nine of them, which had at least 12 months of follow-up, were included in the meta-analysis. Publication bias could not be ruled-out due to the small number of trials. Outcome heterogeneity was moderate (I(2)= 37%). The SMD in A1c (95% confidence interval) was 0.21 (0.11-0.32). Meta-regression showed an association between higher baseline A1c and a larger effect size. CONCLUSIONS: CHW interventions showed a modest reduction in A1c compared to usual care. A1c reduction was larger in studies with higher mean baseline A1c. Caution is warranted, given the small number of studies.

Failure to return: parental, practice, and social factors affecting missed immunization visits for urban children.

OBJECTIVE: To assess parental, practice, and social factors associated with missed immunization visits by young, urban children. STUDY DESIGN: Parents of children ≤ 36 months(n = 705) were surveyed. The primary outcome was missed immunization visit, by parental report. Key parent, practice, and social factors were assessed using hierarchical logistical regression. Results. Families were predominantly Latino and publicly insured. Parents who rescheduled (adjusted odds ratio [AOR] = 3.27; 95% confidence interval [95% CI] = 1.76-6.09) or had problems scheduling appointments (AOR = 4.00; 95% CI = 1.49-10.75) were more likely to miss an immunization visit, as were those with vaccine safety fears (AOR = 3.76; 95% CI = 1.23-11.5) or more limited communication with their provider (AOR = 2.38; 95% CI = 1.05-5.36). Having friends and families with positive immunization views was protective (AOR = 0.030; 95% CI = 0.002-0.41). CONCLUSION: This study highlights factors that may help urban families keep immunization visits: open communication with providers, flexibility in scheduling appointments, and individual and community education.

Awareness, use, and unmet need for family planning in rural northern Nigeria.

Access to quality reproductive health and family planning services remain poor in Nigeria. We present results on family planning awareness and use from a survey of 3,080 women (age 15-49 years) in Jigawa, Katsina, Yobe, and Zamfara States. About 43.0% had heard of any method of contraception whereas 36.6% had heard of any modern method. Overall, 7.0% of all currently married women reported ever using a method of contraception; 4.4% used a modern method and 2.9% used a traditional method. Only 1.3% of women in union (currently married or cohabiting) used modern contraception methods at the time of the survey; 1.3% of women in union used traditional methods. Unmet need for family planning was 10.3%. Low family planning use in the presence of low awareness and low felt need suggests, among other things, a need to increase awareness and uptake and make family planning commodities available.

Using community-based research to shape the design and delivery of maternal health services in Northern Nigeria.

Maternal mortality ratios in northern Nigeria are among the worst in the world, over 1,000 per 100,000 live births in 2008, with a very low level and quality of maternity services. In 2009, we carried out a study of the reasons for low utilisation of antenatal and delivery care among women with recent pregnancies, and the socio-cultural beliefs and practices that influenced them. The study included a quantitative survey of 6,882 married women, 119 interviews and 95 focus group discussions with community and local government leaders, traditional birth attendants, women who had attended maternity services and health care providers. Only 26% of the women surveyed had received any antenatal care and only 13% delivered in a facility with a skilled birth attendant for their most recent pregnancy. However, those who had had at least one antenatal consultation were 7.6 times more likely to deliver with a skilled birth attendant. Most pregnant women had little or no contact with the health care system for reasons of custom, lack of perceived need, distance, lack of transport, lack of permission, cost and/or unwillingness to see a male doctor. Based on these findings, we designed and implemented an integrated package of interventions that included upgrading antenatal, delivery and emergency obstetric care; providing training, supervision and support for new midwives in primary health centres and hospitals; and providing information to the community about safe pregnancy and delivery and the use of these services.

Change in parental reasons for use of an urban pediatric emergency department in the past decade.

OBJECTIVE: To assess changes over the past decade in parental reasons associated with nonurgent visits to pediatric emergency departments (PEDs) during regular primary care office hours. METHODS: Secondary analysis of cross-sectional surveys of families of children younger than 3 years visiting a PED in a low-socioeconomic area in New York City conducted in 1997 and 2006. We performed multivariable analyses to assess differences in parental reported reasons for PED use over the period, controlling for sociodemographic factors. RESULTS: Most children (95.6%) had a usual source of care across both periods. Compared with those seen in 1997, children seen in 2006 were far less likely to be brought to the PED during regular primary care office hours for parental perceived urgency (adjusted odds ratio [AOR], 0.076; 95% confidence interval [CI], 0.024-0.24; P < 0.001). At the same time, these children were more likely to be brought to the PED for limited access to their usual source of care (AOR, 3.35; 95% CI, 1.24-9.02; P < 0.05) and greater trust in the medical expertise of the PED (AOR, 5.95 95% CI, 1.20-29.45; P < 0.05). CONCLUSIONS: Over the last decade, despite the presence of a usual source of care, a greater number of parents report visiting this urban PED during regular office hours for reasons unrelated to parental perceived urgency. Limited access to care and greater trust in the medical expertise available in PEDs have played important roles. Approaches to decreasing nonurgent visits must take into account all of these factors.

Effective strategies for integrating immunization promotion into community programs.

Most immunization coalitions have originated with health care providers, potentially excluding families without medical homes. This study focused on a community-based approach to providing timely vaccinations. A coalition of 23 organizations developed an immunization program in a low-income community in New York City. Nearly 1,000 community health workers incorporated immunization promotion into social service and educational programs. Outcomes were coverage rates for the 4:3:1:3:3 series at 19 to 35 months, which were compared with national data by ethnicity, as reported in the National Immunization Survey 2002-2006. Parents (n = 10,251) of children <5 years received immunization education and reminders. The 2003-2007 rates of 80% equaled or exceeded the national rates for 19- to 35-month-olds, and the 2007 rate of 96.8% far surpassed the national average. Coalitions can effectively integrate immunization promotion activities into community programs. Immunization rate improvements maintained for a 5-year period, suggesting this approach to be sustainable.

Changes in childhood immunization disparities between central cities and their respective states, 2000 versus 2006.

Central cities have lower childhood immunization coverage rates than states in which they are located. We conducted a secondary analysis of the National Immunization Survey (NIS) 2000 and 2006 of children 19-35 months old for 26 NIS-defined central cities and the rest of their respective states in order to examine patterns in early childhood immunization disparities between central cities and their respective states and the contextual factors associated with these disparities. We examined three measures of immunization disparities (absolute, difference, and ratio of change) and the patterns of disparity change with regard to selected contextual factors derived from the census. In 2000, immunization coverage in central cities was 68.3% and 74.7% in the rest of their states, a 6.4% disparity (t = 3.82, p < 0.000). Between 2000 and 2006, the overall city/state disparity narrowed to 3.5%, with the central city coverage up to 78.7% vs. 82.5% for the rest of state (t = 2.48, p = 0.017). However, changes in immunization disparities were not uniform: six cities narrowed, 14 had minimal change, and six widened. Central cities with a larger share of Hispanics experienced less reduction in disparities than other cities (beta = -4.2, t = -2.11, p = 0.047). Despite overall progress in childhood immunization coverage, most central cities still show significant disparities with respect to the rest of their states. Cities with larger Hispanic populations may need extra help in narrowing their disparities.

Community health worker insights on their training and certification.

BACKGROUND: In recent years, the community health worker (CHW) field has grown significantly in the United States, with increasing numbers, roles, and visibility of CHWs. State health department regulators, health program administrators, and community health advocates have observed this growth with uncertainty about the definition of a CHW, how CHW roles differ from those of other health professionals, CHW training needs, and the potential impact of the growing certification and accreditation regulations. OBJECTIVE: Despite the proliferation of regulatory policies, few studies have examined how regulation can most effectively support CHWs in the field. Our objective is to define CHW, identify training needs, and examine possibilities for credentialing from the perspective of CHWs in New York City. METHODS: Community-based participatory research (CBPR) was used to engage CHW leadership and gather input from CHWs in the design and conduct of the study. The academic-community-state partnership designed focus group topic guides, and conducted fifteen focus groups with CHWs in New York City. The focus group responses were analyzed using HyperResearch and formed the basis for policy recommendations to the participating partners. RESULTS: We developed a consensus definition of CHW and its fundamental qualities. We identified unmet training needs in the area of core competencies. We outlined the characteristics of a credentialing process that would support and advance the work of CHWs. CONCLUSIONS: CBPR enabled CHWs to have a direct voice in defining their description, roles, training, and certification preferences. This informed policy recommendations to the state, university, and CHWs through a collaborative process.

Effectiveness of a community coalition for improving child vaccination rates in New York City.

We used a retrospective, matching, birth cohort design to evaluate a comprehensive, coalition-led childhood immunization program of outreach, education, and reminders in a Latino, urban community. After we controlled for Latino ethnicity and Medicaid, we found that children enrolled in the program were 53% more likely to be up-to-date (adjusted odds ratio = 1.53; 95% confidence interval = 1.33, 1.75) and to receive timely immunizations than were children in the control group (t = 3.91). The coalition-led, community-based immunization program was effective in improving on-time childhood immunization coverage.

Community-based strategies to reduce childhood immunization disparities.

This study demonstrates how community-based immunization promotion reduced immunization disparities. In 2002 to 2004, the coalition enrolled 3,748 children younger than 5, with 1,502 aged 19 to 35 months in April 2004. Disparity reduction was assessed by comparing coalition immunization coverage rates (4:3:1:3:3) to the National Immunization Survey 2003 rates. Logistic regression was used to assess factors contributing to up-to-date immunizations. Coverage increased from 46.0% at enrollment to 80.5%, matching nationwide rates for all (t = 0.87) or White (t = 1.99) children. The 78% for African Americans was higher than 73% for U.S. African American children (t = 2.90); 84% for Latinos was higher than 77% for U.S. Latinos (t = 2.32). Being current with age-appropriate immunizations at enrollment (OR = 9.8), being Latino (OR = 1.6), and participating through child health insurance enrollment (OR = 4.9), Women, Infants, and Children (OR = 3.1), or child care or parenting (OR = 1.9) programs increased immunization coverage. Embedding immunization promotion into existing community programs was successful in eliminating immunization disparities. Most effective programs were those with direct linkages to health care systems or that targeted young children.

The impact of community health worker training and programs in NYC.

The Northern Manhattan Community Voices Collaborative is committed to improving health care in Harlem, Washington Heights, Inwood, and low-income communities in New York City, large parts of which are home to many immigrants to the U.S. The collaborative developed a program to train and integrate community health workers (CHWs) into ongoing programs at partner community organizations. We report on our 2000-2005 experiences with CHWs for health insurance, child immunizations, and asthma management. A total of 1,504 CHWs were trained, with 16%-200% increase in CHW competency for selected skills. The CHWs facilitated health insurance enrollment for about 30,000 individuals, assisted 8,000 children to become completely immunized, and supported 4,000 families improving asthma management. Integration of CHW training into community programs is effective for empowering health promotion in underserved communities.

Impact of the Advisory Committee on Immunization Practices' 4-day grace period in a low-income community.

BACKGROUND: In 2002, the Advisory Committee on Immunization Practices (ACIP) recommended vaccine doses administered < or = 4 days before the minimum age or interval be counted as valid. The study objective was to assess the impact of the 4-day grace period on the need for revaccination and associated costs in a low-income community, compared to standard practice (i.e., repeating all doses that fall outside current ACIP guidelines). METHODS: From 1999 to 2001, semi-annual immunization assessments of 8293 randomly selected children, aged 19-35 months, were conducted at a 16-practice network serving an underserved community in New York City. Outcome measures were rates of antigen-specific invalid doses and number of children needing revaccination, with and without the 4-day grace period. Revaccination costs were based on the Vaccines for Children (VFC) price list. RESULTS: The 4-day grace period reduced the number of children needing revaccination from 17.1% to 12.0%, a drop of 30%. The rates of invalid doses decreased from 1.9% to 1.3%, a drop of 33%. Invalid doses for hepatitis B (HepB)-2 decreased by two thirds (69.7%); for diphtheria-tetanus-acellular pertussis (DTaP)-1, Haemophilus influenzae type b (Hib)-1 and Hib-3 by half (44.9%-50.0%); for Polio-1, Polio-2, Polio-3, and measles-mumps-rubella (MMR) by one third (31.6%-33.3%); and for DTaP-2, DTaP-3, HepB-3, and varicella by nearly one quarter (20.0%-24.0%). At these rates, revaccinating 100,000 children younger than age 3 years would cost 213,588 dollars per year, compared to 152,539 dollars with the 4-day grace period, in vaccine costs alone. CONCLUSIONS: In a low-income community, ACIP's 4-day grace period made a significant impact on the number of children requiring revaccination and on revaccination costs. However, the number of children needing revaccination remains high.

Community-provider partnerships to reduce immunization disparities: field report from northern Manhattan.

In 1996 we launched a community-provider partnership to raise immunization coverage for children aged younger than 3 years in Northern Manhattan, New York City. The partnership was aimed at fostering provider knowledge and accountability, practice improvements, and community outreach. By 1999 the partnership included 26 practices and 20 community groups. Between 1996 and 1999, immunization coverage rates increased in Northern Manhattan 5 times faster than in New York City and 8 times faster than in the United States (respectively, 3.4% vs 0.4% [t = 6.05, p < 0.001] and vs 0.6% [t = 5.65, p < 0.001]). The coverage rate for Northern Manhattan stayed constant through 2000, although it declined during this period for the United States and New York City. We attribute the success at reducing the gap to the effectiveness of our partnership.