Exploring health provider's knowledge on the home-based maternal and neonatal health care package in Rwanda.

BACKGROUND: Rwanda implemented post-natal care home visits by maternal community health workers (M-CHWs) in charge of maternal and newborn health care in 2010 as a component of a home-based maternal and neonatal health care package (HB-MNHCP), this being a complementary strategy to facility-based postnatal care to improve survival. The country has not met its Sustainable Development Goal (SDG) 3 target of less than 70 maternal mortalities per 100,000 live births and less than 12 neonatal deaths per 1,000 live births. This study therefore aimed to establish the knowledge of the health providers, providing HB-MNHC services as part of their antenatal, delivery and postnatal care program, specifically the M-CHWs services. METHODS: The cross-sectional descriptive study included 79 purposively sampled health care providers who were directly involved in the various components of the HB-MNHCP, namely: professional nurses, midwives, M-CHW, social workers, supervisors and data managers. The Kibogora, Muhima and Nyamata District Hospitals and two rural, semi-urban and urban health facility were included. Data was collected using questionnaires from April to July 2018. This study followed the STROBE checklist form: Cross -sectional studies. RESULTS: Overall, 88.6% (n=70/79) of participants knew about the M-CHW three home visits scheduled during pregnancy, 73.4% (n=58/79) about the three postnatal home visits after birth when the weight was normal, and 64.6% (n=51/79) about the five PNC home visits for low birth weights. Most (97.5%, n=77/79) knew that the mother and newborn should be screened during the same M-CHW home visits, and 87.2% (n= 68/79) were aware of the seven postnatal core competencies of delivering key maternal and newborn interventions during PNC home visits. CONCLUSIONS: There were varying levels of knowledge among the HB-MNHCP staff, indicating the need for ongoing monitoring and training to ensure that the correct information is provided to the mothers throughout the antenatal and postnatal periods. While most of the M-CHWs appear to have had the correct knowledge, their executing of some activities needs to be monitored to ensure that they provide the required services, as this is an important step in lowering the maternal and infant mortality and enabling Rwanda to meet its SDG 3. Home visits by the M-CHWs could increase referrals and reduce maternal and newborn mortality.

Cost-effectiveness analysis of integrated community case management delivery models utilizing drug sellers and community health workers for treatment of under-five febrile cases of malaria, pneumonia, diarrhoea in rural Uganda.

BACKGROUND: Malaria, pneumonia and diarrhoea continue to be the leading causes of death in children under the age of five years (U5) in Uganda. To combat these febrile illnesses, integrated community case management (iCCM) delivery models utilizing community health workers (CHWs) or drug sellers have been implemented. The purpose of this study is to compare the cost-effectiveness of delivering iCCM interventions via drug sellers versus CHWs in rural Uganda. METHODS: This study was a cost-effectiveness analysis to compare the iCCM delivery model utilizing drug sellers against the model using CHWs. The effect measure was the number of appropriately treated U5 children, and data on effectiveness came from a quasi-experimental study in Southwestern Uganda and the inSCALE cross-sectional household survey in eight districts of mid-Western Uganda. The iCCM interventions were costed using the micro-costing (ingredients) approach, with costs expressed in US dollars. Cost and effect data were linked together using a decision tree model and analysed using the Amua modelling software. RESULTS: The costs per 100 treated U5 children were US$591.20 and US$298.42 for the iCCM trained-drug seller and iCCM trained-CHW models, respectively, with 30 and 21 appropriately treated children in the iCCM trained-drug seller and iCCM trained-CHW models. When the drug seller arm (intervention) was compared to the CHW arm (control), an incremental effect of 9 per 100 appropriately treated U5 children was observed, as well as an incremental cost of US$292.78 per 100 appropriately treated children, resulting in an incremental cost-effectiveness ratio (ICER) of US$33.86 per appropriately treated U5 patient. CONCLUSION: Since both models were cost-effective compared to the do-nothing option, the iCCM trained-drug seller model could complement the iCCM trained-CHW intervention as a strategy to increase access to quality treatment.

Instructive roles and supportive relationships: client perspectives of their engagement with community health workers in a rural south African home visiting program.

BACKGROUND: Community health worker (CHW) programs have been positioned as a way to meet the needs of those who experience marginalization and inequitable access to health care, and current global health narratives also emphasize their adaptable nature to meet growing health burdens in low-income settings. However, as CHW programs adopt more technical roles, the value of CHWs in building relationships with clients tends to be overlooked. More importantly, these programs are often reframed and redeployed without attending to the interests and needs of program clients themselves. We set out to gather perspectives of program and CHW engagement from clients of a maternal and child health program in rural South Africa. METHODS: We conducted 26 interviews with pregnant or recently-delivered clients of the Enable Mentor Mother program between February-March 2018. After obtaining informed consent, a trained research assistant conducted all interviews in the clients' home language, isiXhosa. Interviews, translated and transcribed into English, were organized and coded using ATLAS.ti software and thematically analyzed. RESULTS: We found that clients' home-based interactions with Mentor Mothers were generally positive, and that these engagements were characterized by two core themes, instructive roles and supportive relationships.. Instructive roles facilitated the transfer of knowledge and uptake of new information for behavior change. Relationships were developed within the home visit setting, but also extended beyond routine visits, especially when clients required further instrumental support. Clients further discussed a sense of agency gained through these interactions, even in cases where they chose not to, or were unable to, heed their Mentor Mother's advice. CONCLUSIONS: These findings highlight the important roles that CHWs can assume in providing both instructive and supportive care to clients; as deepening relationships may be key for encouraging behavior change, these findings pinpoint the need to bolster training and support for CHWs in similar programs. They also emphasize the importance of integrating more channels for client feedback into existing programs, to ensure that clients' voices are heard and accounted for in shaping ongoing engagement within the communities in which these programs operate.

Accredited Social Health Activist (ASHA) and Her Role in District Mental Health Program: Learnings from the COVID 19 Pandemic.

COVID 19 pandemic has posed challenges for public mental healthcare delivery, particularly in LAMI countries such as India. However, this unique situation has also brought in opportunities to revisit the health system and optimally utilize the available resources. In this brief report, we report one such new initiative in which existing community health workers (CHWs), known as ASHAs (Accredited Social Health Activist) acted as a bridge between patients with mental illness and the District Mental Health Program (DMHP) of Ramanagara district of Karnataka State, India. They maintained continuity of care of 76 patients by delivering mental healthcare services to the patients' doorstep. This has paved the way to rethink and revisit their role in public mental healthcare delivery not only during COVID 19 times, but also beyond.

Development assistance for community health workers in 114 low- and middle-income countries, 2007-2017.

OBJECTIVE: To estimate the level and trend of development assistance for community health worker-related projects in low- and middle-income countries between 2007 and 2017. METHODS: We extracted data from the Organisation for Economic Co-operation and Development's creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries over 2007-2017. We produced estimates for projects specifically described by relevant keywords and for projects which could include components on CHWs. We analysed the pattern of development assistance by purpose, donors, recipient regions and countries, and trends over time. FINDINGS: Between 2007 and 2017, total development assistance targeting CHW projects was around United States dollars (US$) 5 298.02 million, accounting for 2.5% of the US$ 209 277.99 million total development assistance for health. The top three donors (Global Fund to Fight AIDS, Tuberculosis and Malaria, the government of Canada and the government of the United States of America) provided a total of US$ 4 350.08 million (82.1%) of development assistance for these projects. Sub-Saharan Africa received a total US$ 3 717.93 million, the largest per capita assistance over 11 years (US$ 0.39; total population: 9 426.25 million). Development assistance to projects that focused on infectious diseases and child and maternal health received most funds during the study period. CONCLUSION: The share of development assistance invested in the CHW projects was small, unstable and decreasing in recent years. More research is needed on tracking government investments in CHW-related projects and assessing the impact of investments on programme effectiveness.

Coverage of community case management for malaria through CHWs: a quantitative assessment using primary household surveys of high-burden areas in Chhattisgarh state of India.

BACKGROUND: Community Case Management of Malaria (CCMM) has been implemented through community health workers (CHWs) in many countries. Existing studies have shown that CHWs can be viable means of implementing CCMM. However, not many studies have examined the coverage under large-scale CCMM programmes. India is a big contributor to global malaria burden. Chhattisgarh is a leading state in India in terms of malaria incidence and mortality. CCMM was implemented on a large scale through the 'mitanin' CHWs in rural Chhattisgarh from 2015. Under CCMM, 37,696 CHWs in 84 high-burden administrative blocks of the state were trained and equipped with rapid diagnostic tests (RDT), artemisinin-based combination therapy (ACT) and chloroquine. METHODS: This descriptive quantitative study assesses coverage of CCMM in detection and treatment of Malaria over three rounds of household surveys-2015, 2016 and 2018. Household-interviews covered more than 15,000 individuals in each round, using multi-stage random sampling across the 84 blocks. The main objectives were to find out the coverage in identification and treatment of malaria and the share of CHWs in them. A 15-days recall was used to find out cases of fever and healthcare sought by them. RESULTS: In 2018, 62% of febrile cases in rural population contacted CHWs. RDT, ACT and chloroquine were available with 96%, 80% and 95% of CHWs, respectively. From 2015 to 2018, the share of CHWs in testing of febrile cases increased from 34 to 70%, while it increased from 28 to 69% in treatment of malaria cases. CHWs performed better than other providers in treatment-completion and administered medication under direct observation to 72% of cases they treated. CONCLUSION: This study adds to one of the most crucial but relatively less reported area of CCMM programmes, i.e. the extent of coverage of the total febrile population by CHWs, which subsequently determines the actual coverage of case-management in malaria. Mitanin-CHWs achieved high coverage and treatment-completion rates that were rarely reported in context of large-scale CCMM elsewhere. Close to community, well-trained CHWs with sufficient supplies of rapid tests and anti-malarial drugs can play a key role in achieving the desired coverage in malaria-management.

Epilepsy knowledge, attitudes, and practices among primary healthcare providers in an Indian district.

INTRODUCTION: Scaling up the involvement of primary care providers in epilepsy management in low- and middle-income countries (LMICs) requires an understanding of their epilepsy knowledge, attitudes, and practices (KAP). AIM: The aim of the study was to document levels of knowledge about, attitudes towards, and practices regarding epilepsy among different ranks of primary healthcare providers in a North-Western Indian district. METHODS: The survey included government medical officers (MOs), auxiliary nurse midwives (ANMs), and accredited social health activists (ASHAs). They were administered a specially designed KAP questionnaire. Responses were analyzed according to rank. RESULTS: The survey showed that nearly 10% of ANMs and almost a fifth of ASHAs had never heard about epilepsy. A quarter of MOs and over two-thirds of ANMs and ASHAs had never provided care to someone with epilepsy. There were significant differences in the levels of knowledge between the three groups of workers. CONCLUSIONS: Closing the huge gaps in KAP by educating primary care and community health workers about epilepsy should be a priority before engaging them in the epilepsy care delivery.

Establishing voluntary certification of community health workers in Arizona: a policy case study of building a unified workforce.

BACKGROUND: Community health workers (CHWs) are widely recognized as essential to addressing disparities in health care delivery and outcomes in US vulnerable populations. In the state of Arizona, the sustainability of the workforce is threatened by low wages, poor job security, and limited opportunities for training and advancement within the profession. CHW voluntary certification offers an avenue to increase the recognition, compensation, training, and standardization of the workforce. However, passing voluntary certification legislation in an anti-regulatory state such as Arizona posed a major challenge that required a robust advocacy effort. CASE PRESENTATION: In this article, we describe the process of unifying the two major CHW workforces in Arizona, promotoras de salud in US-Mexico border communities and community health representatives (CHRs) serving American Indian communities. Differences in the origins, financing, and even language of the population-served contributed to historically divergent interests between CHRs and promotoras. In order to move forward as a collective workforce, it was imperative to integrate the perspectives of CHRs, who have a regular funding stream and work closely through the Indian Health Services, with those of promotoras, who are more likely to be grant-funded in community-based efforts. As a unified workforce, CHWs were better positioned to gain advocacy support from key health care providers and health insurance companies with policy influence. We seek to elucidate the lessons learned in our process that may be relevant to CHWs representing diverse communities across the US and internationally. CONCLUSIONS: Legislated voluntary certification provides a pathway for further professionalization of the CHW workforce by establishing a standard definition and set of core competencies. Voluntary certification also provides guidance to organizations in developing appropriate training and job activities, as well as ongoing professional development opportunities. In developing certification with CHWs representing different populations, and in particular Tribal Nations, it is essential to assure that the CHW definition is in alignment with all groups and that the scope of practice reflects CHW roles in both clinic and community-based settings. The Arizona experience underscores the benefits of a flexible approach that leverages existing strengths in organizations and the population served.

Operability, Usefulness, and Task-Technology Fit of an mHealth App for Delivering Primary Health Care Services by Community Health Workers in Underserved Areas of Pakistan and Afghanistan: Qualitative Study.

BACKGROUND: The recent proliferation of digital health technology in low- and middle-income countries has made it possible for community health workers (CHWs) to use mobile health (mHealth) to perform tasks such as data collection and training. Although most studies focus on the prospect of digital apps to motivate and connect CHW, only a few have captured end-user experiences with mobile-based apps. We examined the experience of frontline health workers with a move towards digitalized real-time data to record maternal and childcare services in remote areas of Afghanistan and Pakistan. OBJECTIVE: Our study aimed to explore CHW perceptions on the operability of the mHealth app in a community setting, usefulness of the app in the delivery of assigned maternal and childcare functions, and the task-technology fit with monitoring information systems. METHODS: The Hayat app, designed to digitalize and facilitate electronic record keeping, was evaluated to be embedded into mainstream health systems. The app had 2 components: smartphone app for data entry and web dashboard for visualization of the maternal, newborn, and child health reports. Using a qualitative exploratory study design, we conducted a total of 8 focus group discussions with purposively selected lady health workers (LHWs) and CHWs in 3 districts of Pakistan and 3 hamlets of Afghanistan, respectively. Focus group discussions were conducted in the local language, audio recorded, and converted into expanded notes for thematic analysis. RESULTS: Although a majority of LHWs used the app with ease, some initially faced difficulties in operating it and requested a longer duration of training. Contrary to LHWs, the CHWs were able to use the app without difficulty, as they were using it only to register clients. Overall, use of the mHealth app in both countries resulted in a positive impact on health education sessions, easier communication with parents or clients, tracking of routine immunization defaulters and follow-ups, improved data validity, easily accessible vaccination schedules, and faster registration. In addition to building up their image in the community and personal development, the improved reporting and monitoring mechanisms also set the stage for the LHWs to get recognized for their hard work. CHWs in Afghanistan also reported the app provided immediate access to information when requested by their supervisor. Although the Hayat app eliminates the need to carry multiple registers and helps in recalling client information at the touch of a button, technical issues around connectivity and data inputting tabs were highlighted by the participants. CONCLUSIONS: The digitization of records not only provided CHWs support in their daily routine but also strengthened monitoring mechanisms and improved motivation. We recommend conducting end user experience studies before embedding apps into mainstream health systems as high acceptability does not always result in high uptake of digital technology.

The home visit communication skills inventory: Piloting a tool to measure community health worker fidelity to training in rural South Africa.

Community-based home visiting programs using community health workers (CHWs) have become popular modes of delivering health care services, especially in settings where health workers are overburdened and resources are limited. Yet, little is known about the processes that shape effective implementation in low-resource settings, and whether these processes adhere to home visitors' training. This study used the newly-developed Home Visit Communication Skills Inventory (HCSI) to explore the delivery of a CHW program in rural South Africa. Routine home visits from CHWs to their maternal care clients were audio-recorded with consent, and later transcribed and translated into English. The HCSI, devised and piloted using existing frameworks and program-specific training components, consisted of 21 items covering domains related to active listening, active delivery, and active connecting, and was used to score English transcripts of the home visits. The HCSI was used to generate general frequencies and aggregate scores for each CHW. Eighty-four home visits by 14 CHWs showed a diverse application of communication skills. Active listening and active delivery were common, with fewer instances of active connecting observed. Practices disaggregated by CHW showcased varying strengths by an individual. In reviewing visit characteristics, longer average visit duration was significantly correlated with the presence of multiple types of active connecting skills. While technical skills were widely observed, fewer CHWs engaged in more complex "connecting" skills. The HCSI is a feasible, low-cost, and practical way to describe home visit fidelity among CHWs. Audio-based checklists can be used to describe fidelity to a model in the absence of additional supervisory resources.

Translating Workforce Development Policy Interventions for Community Health Workers: Application of a Policy Research Continuum.

CONTEXT: There is a need for knowledge translation to advance health equity in the prevention and control of cardiovascular disease and type 2 diabetes. One recommended strategy is engaging community health workers (CHWs) to have a central role in related interventions. Despite strong evidence of effectiveness for CHWs, there is limited information examining the impact of state CHW policy interventions. This article describes the application of a policy research continuum to enhance knowledge translation of CHW workforce development policy in the United States. METHODS: During 2016-2019, a team of public health researchers and practitioners applied the policy research continuum, a multiphased systematic assessment approach that incorporates legal epidemiology to enhance knowledge translation of CHW workforce development policy interventions in the United States. The continuum consists of 5 discrete, yet interconnected, phases including early evidence assessments, policy surveillance, implementation studies, policy ratings, and impact studies. RESULTS: Application of the first 3 phases of the continuum demonstrated (1) how CHW workforce development policy interventions are linked to strong evidence bases, (2) whether existing state CHW laws are evidence-informed, and (3) how different state approaches were implemented. DISCUSSION: As a knowledge translation tool, the continuum enhances dissemination of timely, useful information to inform decision making and supports the effective implementation and scale-up of science-based policy interventions. When fully implemented, it assists public health practitioners in examining the utility of different policy intervention approaches, the effects of adaptation, and the linkages between policy interventions and more distal public health outcomes.

Community preparedness for COVID-19 and frontline health workers in Chhattisgarh.

At the end of April 2020, there had already been three million cases of COVID-19 in the world pandemic. Chhattisgarh might expect 90,000 diagnosed cases of COVID-19 in the end. The first step taken in March was to ensure a simple checklist of activities that needed to continue. Handbills were given with the basic information on the symptoms and what to do in the community. In urban areas, the lockdown affected the poorer section of the society, especially who are not having BPL card and no other means of availing necessary eatables. Issues that arose affecting regular activities such as tuberculosis and immunization. Residents of informal settlements are also vulnerable during any COVID-19 responses. Frontline workers such as Mitanins in the community are an important asset in the capacity building and preparedness strategies.

Adolescent Mothers' Experiences With Community Health Assistants in Rural Zambia.

Adolescent health demands specific attention because adolescents have the lowest levels of health-care coverage of any age-group globally. The main objective as addressed in this article was to explore the lived experience of adolescent mothers and the services provided to them by community health assistants (CHAs) in rural Zambia. Because the number of adolescent mothers in rural Zambia is so high, it is even more critical to describe the lived experiences of health care among these young women with particular emphasis on primary health care as delivered by CHAs in rural Zambia. We used a mixed-methods design to address our research questions. Data were collected from nine focus groups, which were conducted with young mothers from four provinces and 10 districts (n = 60). To support our effort to better understand the delivery of maternal and child health care in rural Zambia, key informant interviews were conducted with adolescent mothers (n = 12). We also conducted surveys (n = 44) and one-on-one interviews (n = 22) with CHAs. To the best of our knowledge, this is the largest study focused on the intersection of adolescents, maternal child health, and CHA delivery of care in Zambia. The results of our study suggest opportunities for change to operational practices within the rural health-care setting and the need to develop structured and age-appropriate services that focus on adolescents. This work addresses the gap in research for adolescents in health care in rural Zambia and brings attention to the unique health-care needs of adolescent mothers within the rural health-care setting.

Evaluating the impact of community health volunteer home visits on child diarrhea and fever in the Volta Region, Ghana: A cluster-randomized controlled trial.

BACKGROUND: Although there is mounting evidence demonstrating beneficial effects of community health workers (CHWs), few studies have examined the impact of CHW programs focused on preventing infectious diseases in children through behavior changes. We assessed the preventive effects of community health volunteers (CHVs), who receive no financial incentive, on child diarrhea and fever prevalence in Ghana. METHODS AND FINDINGS: We conducted a cluster-randomized controlled trial in 40 communities in the Volta Region, Ghana. Twenty communities were randomly allocated to the intervention arm, and 20 to the control arm, using a computer-generated block randomization list. In the intervention arm, CHVs were deployed in their own community with the key task of conducting home visits for health education and community mobilization. The primary outcomes of the trial were diarrhea and fever prevalence at 6 and 12 months among under-5 children based on caregivers' recall. Secondary outcomes included oral rehydration treatment and rapid diagnostic testing for malaria among under-5 children, and family planning practices of caregivers. Generalized estimating equations (GEEs) with a log link and exchangeable correlation matrix were used to determine the relative risk (RR) and 95% confidence intervals (CIs) for diarrhea, fever, and secondary outcomes adjusted for clustering and stratification. Between April 18 and May 4, 2015, 1,956 children were recruited and followed up until September 20, 2016. At 6 and 12 months post-randomization, 1,660 (85%) and 1,609 (82%) participants, respectively, had outcomes assessed. CHVs' home visits had no statistically significant effect on diarrhea or fever prevalence at either time point. After a follow-up of 12 months, the prevalence of diarrhea and fever was 7.0% (55/784) and 18.4% (144/784), respectively, in the control communities and 4.5% (37/825) and 14.7% (121/825), respectively, in the intervention communities (12-month RR adjusted for clustering and stratification: diarrhea, RR 0.73, 95% CI 0.37-1.45, p = 0.37; fever, RR 0.76, 95% CI 0.51-1.14, p = 0.20). However, the following were observed: improved hand hygiene practices, increased utilization of insecticide-treated bed nets, and greater participation in community outreach programs (p-values < 0.05) in the intervention group. In a post hoc subgroup analysis, the prevalence of diarrhea and fever at 6 months was 3.2% (2/62) and 17.7% (11/62), respectively, in the intervention communities with ≥70% coverage and a ≥30-minute visit duration, and 14.4% (116/806) and 30.2% (243/806) in the control communities (RR adjusted for clustering, stratification, baseline prevalence, and covariates: diarrhea, RR 0.23, 95% CI 0.09-0.60, p = 0.003; fever, RR 0.69, 95% CI 0.52-0.92, p = 0.01). The main limitations were the following: We were unable to investigate the longer-term effects of CHVs; the trial may have been underpowered to detect small to moderate effects due to the large decline in diarrheal and fever prevalence in both the intervention and control group; and caregivers' practices were based on self-report, and the possibility of caregivers providing socially desirable responses cannot be excluded. CONCLUSIONS: We found no effect of CHVs' home visits on the prevalence of child diarrhea or fever. However, CHV programs with high community coverage and regular household contacts of effective duration may reduce childhood infectious disease prevalence. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Registry, ISRCTN49236178.

Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania.

BACKGROUND: Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home. METHODS AND FINDINGS: As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82-1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30-0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified. CONCLUSIONS: A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC. TRIAL REGISTRATION: ClinicalTrials.gov NCT01932138.

Core Competencies and a Workforce Framework for Community Health Workers: A Model for Advancing the Profession.

OBJECTIVES: To establish a validated, standardized set of core competencies for community health workers (CHWs) and a linked workforce framework. METHODS: We conducted a review of the literature on CHW competency development (August 2015), completed a structured analysis of literature sources to develop a workforce framework, convened an expert panel to review the framework and write measurable competencies, and validated the competencies (August 2017) by using a 5-point Likert scale survey with 58 participants in person in Biloxi, Mississippi, and electronically across the United States. RESULTS: The workforce framework delineates 3 categories of CHWs based upon training, workplace, and scope of practice. Each of the 27 competencies was validated with a mean of less than 3 (range = 1.12-2.27) and a simple majority of participants rated all competencies as "extremely important" or "very important." CONCLUSIONS: Writing measurable competencies and linking the competencies to a workforce framework are significant advances for CHW workforce development. Public Health Implications. The standardized core competencies and workforce framework are important for addressing health disparities and maximizing CHW effectiveness.

Enabling Community Health Worker Recognition and Referral of Surgical Diseases: Pilot Study Results of a Pictorial Guide.

BACKGROUND: Access to surgical care is a pressing challenge, particularly for vulnerable populations. Informal and formal community health workers (CHWs), including lay people, increasingly function in pivotal roles in primary care, however, remain disconnected from surgical care in most environments. This study examined the degree to which CHW understanding of surgical conditions could be improved through the use of a pictorially based manual. METHODS: A manual and associated situational problem-solving questionnaire instrument were developed and contextualized through focus groups in Central America. A baseline assessment was obtained. In the program implementation, cohorts of formal and informal CHWs were introduced and trained to use the manual through a short curriculum. Assessment was repeated in program implementation, first with access to relevant manual content only, and then after the teaching session. Participants were also surveyed about manual scheme, usability, and utility. RESULTS: A total of 100 subjects (67% female) participated in baseline assessment, and 403 subjects (68% female) were assessed through the program implementation. Baseline problem-solving averaged 11.8 (SD 2.46) out of a possible 20 points. Mean score increased to 15.4 (SD 3.10) when participants had access to relevant surgical manual content and again to 15.9 (SD 3.09, p < 0.0001) following participation with an instructive curriculum. Participant score while utilizing the manual correlated with amount of education completed (r = 0.26), but baseline score did not. High readability 389 (96%) and high self-reported willingness for use 398 (96%) were noted. CONCLUSION: Baseline familiarity with surgically treatable conditions appears modest among rural Central American populations, and improves with access to a contextualized, pictorial manual focused on recognizing and appropriately referring surgical conditions.

A conceptual framework for measuring community health workforce performance within primary health care systems.

BACKGROUND: With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. METHODS: A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. RESULTS: Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. CONCLUSIONS: Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

National guidance and district-level practices in the supervision of community health workers in South Africa: a qualitative study.

BACKGROUND: Supportive supervision is considered critical to community health worker programme performance, but there is relatively little understanding of how it can be sustainably done at scale. Supportive supervision is a holistic concept that encompasses three key functions: management (ensuring performance), education (promoting development) and support (responding to needs and problems). Drawing on the experiences of the ward-based outreach team (WBOT) strategy, South Africa's national community health worker (CHW) programme, this paper explores and describes approaches to supportive supervision in policy and programme guidelines and how these are implemented in supervision practices in the North West Province, an early adopter of the WBOT strategy. Outreach teams typically consist of six CHWs plus a nurse outreach team leader (OTL). METHODS: A qualitative, descriptive study that combined a document review of national policy and guidelines with key informant interviews in two districts of the North West Province was conducted. An overall WBOT policy statement and four guidelines on aspects of the strategy, spanning the period 2011-2017, were reviewed for statements on the three core facets of supervision outlined above. Eight focus group discussions, involving facility managers, team leaders and community health workers (total 40 respondents), purposively selected from four sub-districts in two districts, assessed local-level supervision practices. Alignment across policy and guidance documents and between policy/guidance and practice was examined. FINDINGS: While all the official policy documents and guidelines reviewed acknowledged the need for supervision and support, these elements were inadequately developed and poorly aligned, both in terms of scope and in providing firm guidance on the supervision of WBOTs. The practices of supervision entailed a variety of reporting lines, while development and support processes were informal and often lacking, and teams poorly resourced. There was internal cohesion and support within teams amongst CHWs and between CHWs and OTLs. However, primary health care clinic managers, who were supposed to supervise the WBOTs, struggled to fulfil this role amidst the high workloads in facilities, and relationships between WBOTs and facility staff often remained strained. CONCLUSION: This study identified weaknesses in both the design and implementation of the supervision system of WBOTs. The lack of explicit, coherent and holistic guidance in policy and the failure to address constraints to supervision at local level undermine the performance and sustainability of the WBOT strategy in South Africa.

Competency building for lay health workers is an intangible force driving basic public health services in Southwest China.

BACKGROUND: Providing universal basic public health services (BPHS) for residents is the main goal of the new health reform in China. Lay health workers (LHWs) in primary health care (PHC) sectors play key roles in BPHS delivery. The competency of LHWs is critical to quality BPHS. This study assessed LHWs' competency to deliver BPHS and related training in resource-limited Southwest China. METHODS: A mixed research method combining in-depth interviews with secondary data collection was used to collect data in this cross-sectional study. Fifty-four LHWs and 16 leaders in 16 PHC sectors were recruited for in-depth interviews. Secondary data on 198 LHWs were collected through standard forms. RESULTS: Both the interviews and secondary data suggested that all PHC sectors did not have sufficient LHWs and lacked qualified LHWs to deliver BPHS overall, particularly in relatively low economic rural areas in Guizhou province. Furthermore, PHC sectors had difficulties retaining existing LHWs due to low incomes and fewer opportunities for self-development. In-depth interviews discovered that, although numerous training opportunities have been provided for LHWs since 2009, the trainings did not achieve the expected outcome in LHW competency building, as LHWs actually did not have access to the trainings and the training design was unresponsive to the actual needs of LHWs. Both LHWs and leaders expressed an urgent need for effective training for LHWs based on systematic needs assessments and the use of qualified trainers and materials. CONCLUSIONS: The shortage of qualified LHWs in PHC sectors became the bottleneck for BPHS delivery in Southwest China. Recent trainings for LHWs were less effective with regard to LHW competency building. A need-based professional training programme for LHWs by qualified trainers was expected by both LHWs and leaders in PHC sectors.