Community Health Workers: Improving Home Visiting Engagement of High-Risk Birthing People in Segregated Neighborhoods.

CONTEXT: Racial and ethnic disparities in perinatal health remain a public health crisis. Despite improved outcomes from home visiting (HV) participation during pregnancy, most eligible individuals of color do not engage. Neighborhood segregation, a manifestation of structural racism, may impose constraints on engaging eligible individuals in HV. OBJECTIVE: To examine whether race, ethnicity, and/or language-concordant community health workers (CHWs) increased HV engagement for birthing people in segregated neighborhoods. DESIGN: Program evaluation using administrative linked data from birth records, Medicaid claims, and HV program participation. Strong Beginnings (SB), a program with HV provided by CHWs working with nurses and social workers, was compared with the Maternal Infant Health Program (MIHP), a state Medicaid-sponsored HV program without CHW involvement. Data were analyzed using χ 2 tests and Poisson regressions. PARTICIPANTS: A total of 4560 individuals with a Medicaid-eligible birth between 2016 and 2019, including 1172 from SB and 3388 from the MIHP. MAIN OUTCOME MEASURES: Penetration (percentage of participants in HV among all Medicaid-eligible individuals across quintiles of neighborhood segregation) and dosage (the total number of home visits from both CHWs and nurses/social workers, and then restricted to those from nurses/social workers). RESULTS: SB penetrated more segregated neighborhoods than the MIHP (58.4% vs 48.3%; P < .001). SB participants received a higher dosage of home visits (mean [SD]: 11.9 [6.1]) than MIHP participants (mean [SD]: 4.4 [2.8], P < .001). Importantly, CHWs did not replace but moderately increased home visits from nurses and social workers (51.1% vs 35.2% with ≥5 intervention visits, P < .001), especially in more segregated neighborhoods. POLICY IMPLICATION: Community-informed HV models intentionally designed for people facing disparities may help facilitate program outreach to segregated neighborhoods with concentrated deprivation and reduce racial and ethnic disparities. CONCLUSIONS: An HV program provided by CHWs working with nurses and social workers was associated with an increase in penetration and dosage in segregated neighborhoods, compared with HV without CHW involvement. This underscores the value of CHWs partnering with licensed professional workers in improving HV engagement in disadvantaged communities.

The potential of task-shifting in scaling up services for prevention of mother-to-child transmission of HIV: a time and motion study in Dar es Salaam, Tanzania.

BACKGROUND: In many African countries, prevention of mother-to-child transmission of HIV (PMTCT) services are predominantly delivered by nurses. Although task-shifting is not yet well established, community health workers (CHWs) are often informally used as part of PMTCT delivery. According to the 2008 World Health Organization (WHO) Task-shifting Guidelines, many PMTCT tasks can be shifted from nurses to CHWs. METHODS: The aim of this time and motion study in Dar es Salaam, Tanzania, was to estimate the potential of task-shifting in PMTCT service delivery to reduce nurses' workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to CHWs in the Tanzanian public-sector health system. RESULTS: A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 (95% confidence interval (CI) 42-65) min, followed by the first PNC visit which took 29 (95% CI 26-32) minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 (95% CI 14-17) and 13 (95% CI 11-16) minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses' time could be shifted to CHWs, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on CHW salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit). CONCLUSIONS: Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to CHWs. Such task-shifting could allow nurses to spend more time on specialized PMTCT tasks and can substantially reduce the average cost per PMTCT patient.

The impact of HIV/SRH service integration on workload: analysis from the Integra Initiative in two African settings.

BACKGROUND: There is growing interest in integration of HIV and sexual and reproductive health (SRH) services as a way to improve the efficiency of human resources (HR) for health in low- and middle-income countries. Although this is supported by a wealth of evidence on the acceptability and clinical effectiveness of service integration, there is little evidence on whether staff in general health services can easily absorb HIV services. METHODS: We conducted a descriptive analysis of HR integration through task shifting/sharing and staff workload in the context of the Integra Initiative - a large-scale five-year evaluation of HIV/SRH integration. We describe the level, characteristics and changes in HR integration in the context of wider efforts to integrate HIV/SRH, and explore the impact of HR integration on staff workload. RESULTS: Improvements in the range of services provided by staff (HR integration) were more likely to be achieved in facilities which also improved other elements of integration. While there was no overall relationship between integration and workload at the facility level, HIV/SRH integration may be most influential on staff workload for provider-initiated HIV testing and counselling (PITC) and postnatal care (PNC) services, particularly where HIV care and treatment services are being supported with extra SRH/HIV staffing. Our findings therefore suggest that there may be potential for further efficiency gains through integration, but overall the pace of improvement is slow. CONCLUSIONS: This descriptive analysis explores the effect of HIV/SRH integration on staff workload through economies of scale and scope in high- and medium-HIV prevalence settings. We find some evidence to suggest that there is potential to improve productivity through integration, but, at the same time, significant challenges are being faced, with the pace of productivity gain slow. We recommend that efforts to implement integration are assessed in the broader context of HR planning to ensure that neither staff nor patients are negatively impacted by integration policy.

Perfil de los servicios de partería en las Américas: modelos de atención del parto / Profiling midwifery services in the Americas: models of childbirth care

La partería profesional se considera la "parte esencial" del equipo obstétrico y la espina dorsal de la atención moderna prenatal y de parto. La experiencia en la historia (Suecia y Holanda) así como las pruebas contemporáneas (Chile y Sri Lanka) han indicado que el desarrollo de la cobertura de la partería nacional es la medida más importante para reducir la mortalidad materna y perinatal. Es por otro lado, más notable aún, que tales mejoras tuvieron lugar en países todavía clasificados como países de bajos ingresos. (AU)

Profiling midwifery services in the Americas: models of childbirth care

The actual document is the first of three steps, i) a literature study, ii) a questionnaire study and iii) selected case studies, in an effort by Pan American Health Organization (PAHO) to profile midwifery services and practices in the Americas. A variety of collaborating partners are involved, among these regional, national and local universities and nursing associations. The World Health Organization (WHO) has voiced concern about continued high maternal and perinatal mortality rates, which to a great extent is blamed on slow progress in introducing skilled attendants during pregnancy and childbirth. A five + five strategy, which focus on assisting the nations in providing skilled care to pregnant and women in labor, was launched in 2000. One of many efforts related to the strategy is a worldwide profiling of midwifery presently conducted by WHO in Geneva. (AU)