Learning from the universal, proactive outreach of the Brazilian Community Health Worker model: impact of a Community Health and Wellbeing Worker initiative on vaccination, cancer screening and NHS health check uptake in a deprived community in the UK.

BACKGROUND: Delays in preventative service uptake are increasing in the UK. Universal, comprehensive monthly outreach by Community Health and Wellbeing Workers (CHW), who are integrated at the GP practice and local authority, offer a promising alternative to general public health campaigns as it personalises health promotion and prevention of disease holistically at the household level. We sought to test the ability of this model, which is based on the Brazilian Family Health Strategy, to increase prevention uptake in the UK. METHODS: Analysis of primary care patient records for 662 households that were allocated to five CHWWs from July 2021. Primary outcome was the Composite Referral Completion Indicator (CRCI), a measure of how many health promotion activities were received by members of a household relative to the ones that they were eligible for during the period July 2021-April 2022. The CRCI was compared between the intervention group (those who had received at least one visit) and the control group (allocated households that were yet to receive a visit). A secondary outcome was the number of GP visits in the intervention and control groups during the study period and compared to a year prior. RESULTS: Intervention and control groups were largely comparable in terms of household occupancy and service eligibilities. A total of 2251 patients in 662 corresponding households were allocated to 5 CHWs and 160 households had received at least one visit during the intervention period. The remaining households were included in the control group. Overall service uptake was 40% higher in the intervention group compared to control group (CRCI: 0.21 ± 0.15 and 0.15 ± 0.19 respectively). Likelihood of immunisation uptake specifically was 47% higher and cancer screening and NHS Health Checks was 82% higher. The average number of GP consultations per household decreased by 7.4% in the intervention group over the first 10 months of the pilot compared to the 10 months preceding its start, compared with a 0.6% decrease in the control group. CONCLUSIONS: Despite the short study period these are promising findings in this deprived, traditionally hard to reach community and demonstrates potential for the Brazilian community health worker model to be impactful in the UK. Further analysis is needed to examine if this approach can reduce health inequalities and increase cost effectiveness of health promotion approaches.

Village doctors' dilemma in China: A systematic evaluation of job burnout and turnover intention.

Background: Village doctors (VDs) in China undertook arduous primary healthcare missions. However, they received little attention in comparison to doctors in urban public secondary and tertiary hospitals. There is an urgent need to explore the overall situation of turnover intention and job burnout among VDs to evaluate and adjust current health manpower policy. Methods: In this study, seven databases like PubMed, EMBASE, Web of Science (WOS), WanFang, China Science and Technology Journal Database (VIP), Chinese BioMedical Literature Database (CBM), and China National Knowledge Infrastructure (CNKI) were systematically searched, relevant experts were consulted, and empirical research on job burnout and turnover intention among VDs in international publications was evaluated. Therefore, we evaluated the prevalence of job burnout among VDs in general, across all dimensions and different severity levels, as well as the scores of each category. For turnover intention, we assessed the prevalence of different groups and their overall situation and also identified significant contributors. Results: In this study, we integrated 20 research evidences on job burnout and turnover intention among 23,284 VDs from almost all provinces in China, and the prevalence of turnover intention among VDs in China was as high as 44.1% [95% confidence interval (CI): 34.1-54.2], which was two to four times that of primary health workers in high-income countries, but not much different from some developing countries. Simultaneously, VDs with the highest risk of turnover intention were men [odds ratio (OR): 1.22 (1.05-1.43)], those with a monthly income below USD 163.4 [OR: 0.88 (0.78-0.98)], those with a high educational level [OR: 0.88 (0.78-0.98)], and those <40 years old [OR: 1.27 (1.16-1.40)]. Similarly, the detection rate of job burnout toward them was 59.8% (95% CI: 38.7-79.1) with the MBI-GS score being 44.44 (95% CI: 37.02-51.86) in a total of 90, while the detection rate of job burnout in moderate and above almost reached 20%. The most significant contributor that affects job burnout was low personal accomplishment (LPA), and the detection rate for moderate and higher severity was 65.2% (95% CI: 58.7-71.7). Conclusion: Attention should be paid to the high turnover intention and severe job burnout of primary health workers in rural areas of developing countries, and targeted measures should be taken to improve the situation. Health policymakers should increase financial subsidies for VDs, set a reasonable workload, improve various health policies such as pension insurance for VDs, and encourage "targeted training" for medical students to enrich and expand their team. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021289139.

Análise do perfil sociodemográfico, laboral e dos riscos ocupacionais de agentes comunitários de saúde / Analysis of the sociodemographic, work profile and occupational risks of community health agents / Análisis del perfil sociodemográfico, laboral y riesgos ocupacionales de los agentes de salud comunitarios

Objetivo: delinear o perfil sociodemográfico e laboral de Agentes Comunitários de Saúde bem como investigar os riscos ocupacionais aos quais estão expostos em um município da Região Nordeste. Método: realizado por meio de um questionário autoaplicado com 64 sujeitos, constituído por duas seções: uma relativa aos dados sociodemográficos e laborais e outra com questões acerca dos riscos ocupacionais. Resultados: a maioria dos participantes é do gênero feminino, casada, com o ensino médio completo, fez curso de qualificação, reside na microárea que trabalha e cumpre 40 horas semanais. Elencou-se 5 variáveis como riscos ocupacionais, sendo elas: contato com pessoas infectantes, agressão física, desgaste emocional, problemas interpessoais e ataques de animais. Conclusão: é imperativo que tal profissional seja reconhecido pelo seu potencial. Ademais, que possa ter as suas demandas atendidas e compreendidas, especialmente no que concerne ao modo de enfrentamento às adversidades laborais, o que o faz ser tão suscetível ao adoecimento, comprovado nessa pesquisa

Objective: to outline the sociodemographic and work profile of Community Health Agents as well as to investigate the occupational risks to which they are exposed in a municipality in the Northeast Region. Method: conducted by means of a self-administered questionnaire with 64 subjects, consisting of two sections: one related to sociodemographic and work data and the other with questions about occupational risks. Results: most of the participants are female, married, with complete high school, took a qualification course, live in the micro area that works and work 40 hours a week. Five variables were listed as occupational risks, namely: contact with infectious people, physical aggression, emotional exhaustion, interpersonal problems and attacks by animals. Conclusion: it is imperative that such a professional is recognized for his potential. Furthermore, that he can have his demands met and understood, especially with regard to coping with adversity at work, which makes him so susceptible to illness, as evidenced in this research

Objetivo: esbozar el perfil sociodemográfico y laboral de los Agentes Comunitarios de Salud así como investigar los riesgos laborales a los que están expuestos. Método: realizado mediante un cuestionario autoadministrado con 64 sujetos, que consta de dos apartados: uno relacionado con datos sociodemográficos y laborales y otro con preguntas sobre riesgos laborales. Resultados: la mayoría de los participantes son mujeres, casadas, con bachillerato completo, cursaron un curso de calificación, viven en el área micro que trabaja y trabajan 40 horas semanales. Se enumeraron cinco variables como riesgos laborales, a saber: contacto con personas infecciosas, agresión física, agotamiento emocional, problemas interpersonales y ataques de animales. Conclusión: es imperativo que dicho profesional sea reconocido por su potencial. Además, que sus demandas sean atendidas y comprendidas, especialmente en lo que respecta al afrontamiento de las adversidades laborales, que lo hacen tan susceptible a la enfermedad, como se evidencia en esta investigación

The Use of Community Health Workers in Community Health Centers.

BACKGROUND: Until 2016, community health centers (CHCs) reported community health workers (CHWs) as part of their overall enabling services workforce, making analyses of CHW use over time infeasible in the annual Uniform Data System (UDS). OBJECTIVE: The objective of this study was to examine changes in the CHW workforce among CHCs from 2016 to 2018 and factors associated with the use of CHWs. RESEARCH DESIGN, SUBJECTS, MEASURES: The two-part model estimated separate effects for the probability of using any CHW and extent of CHW full-time equivalents (FTEs) reported in those CHCs, using a total of 4102 CHC-year observations from 2016 to 2018. To estimate the extent to which increases in CHW workforce are attributable to real growth or rather are a consequence of a change in reporting category, we also conducted a difference-in-differences analysis to compare non-CHW enabling services FTEs between CHCs with and without CHWs before (2013-2015) and after (2016-2018) the reporting change in 2016. RESULTS: The rate of CHCs that employed CHWs rose from 20.04% in 2016 to 28.34% in 2018, while average FTEs stayed relatively flat (3.32 FTEs). Patient visit volume (larger CHCs) and grant funding (less reliant on federal but more reliant on private funding) were significant factors associated with CHW use. However, we found that a substantial portion of this growth was attributable to a change in UDS reporting categories. CONCLUSION: While we do not address the reasons why CHCs have been slow to use CHWs, our results point to substantial financial barriers associated with CHCs' expanding the use of CHWs.

Evaluation of a Community Health Worker Social Prescribing Program Among UK Patients With Type 2 Diabetes.

Importance: Despite lacking robust evidence of effectiveness, health care systems in developed countries are funding holistic community health worker (CHW) social prescribing programs that address social needs and health behaviors as adjuncts to clinical care. Objective: To determine whether a UK National Health Service (NHS) CHW social prescribing program was associated with improved hemoglobin A1c (HbA1c) levels among patients with type 2 diabetes. Design, Setting, and Participants: This cohort study with difference-in-differences analysis was conducted among 8086 patients (4752 in the referral program, 3334 in the control group) in 24 NHS primary care practices in a city in North East England. Patients aged 40 to 74 years with a diagnosis of type 2 diabetes were observed for 8 years, from 2011 through 2019. The statistical analysis was conducted between June 1, 2019, and January 31, 2021. Interventions: A social prescribing program, launched in April 2015, enabling primary care staff to refer patients to CHW support to identify condition management and social needs goals and access voluntary and community sector support to address these goals. Intervention referral was only available in primary care practices in the city's west. The control group included patients in the city's east where referral was unavailable. Main Outcomes and Measures: HbA1c level, a marker of glycemic control. Results: A total of 8086 patients were included in the analysis (mean [SD] age, 57.8 [8.78] years; 3477 women [43%]; 6631 White patients [82%]). Mean (SD) baseline HbA1c levels were 7.56% (1.47%) in the referral program group and 7.44% (1.43%) in the control group. Following introduction of the social prescribing referral program, the referral group experienced an HbA1c reduction of -0.10 percentage points (95% CI, -0.17 to -0.03 percentage points) compared with the control group. The association increased over time: after 3 years the estimated association was -0.14 percentage points (95% CI, -0.24 to -0.03 percentage points). The association was stronger for White patients compared with non-White patients (-0.15 percentage points [95% CI, -0.26 to -0.04 percentage points] after 3 years), those with fewer additional comorbidities (-0.16 percentage points [95% CI, -0.29 to -0.04 percentage points] after 3 years), and those living in the most socioeconomically deprived areas (-0.19 percentage points [95% CI, -0.32 to -0.07 percentage points] after 3 years). Conclusions and Relevance: In this study of UK adults with type 2 diabetes, a social prescribing program with referral to CHWs targeting patients' social needs and health behaviors was associated with improved HbA1c levels, suggesting that holistic CHW interventions may help to reduce the public health burden of type 2 diabetes.

'It was hell in the community': a qualitative study of maternal and child health care during health care worker strikes in Kenya.

BACKGROUND: Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers. METHODS: We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women's pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches. RESULTS: Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care. CONCLUSION: We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.

Prevalence of latent tuberculosis infection among health workers in Afghanistan: A cross-sectional study.

BACKGROUND: About 26% of the world's population may have latent tuberculosis infection (LTBI). Health care workers are a high-risk category because of their professional exposure. METHODS: This cross-sectional study assessed the LTBI burden among health care workers in Afghanistan, a high-TB-burden country. We selected health facilities using a systematic sampling technique and invited all workers at the targeted health facilities to participate. Participants were interviewed about sociodemographic and exposure variables and received tuberculin skin tests for LTBI. RESULTS: Of the 4,648 health care workers invited to participate, 3,686 had tuberculin skin tests. The prevalence of LTBI was found to be 47.2% (1,738 workers). Multivariate analysis showed that a body mass index of ≥ 30 and marriage were associated with an increased risk of LTBI. Underweight (body mass index of ≤ 18 and below) and normal body mass index had no association with increased risk of LTBI. CONCLUSION: LTBI is high among health care workers in Afghanistan. We recommend instituting infection control measures in health facilities and screening workers for timely TB diagnosis.

Effect of Community Health Workers on 30-Day Hospital Readmissions in an Accountable Care Organization Population: A Randomized Clinical Trial.

Importance: Value-based care within accountable care organizations (ACOs) has magnified the importance of reducing preventable hospital readmissions. Community health worker (CHW) interventions may address patients' unmet psychosocial and clinical care needs but have been underused in inpatient and postdischarge care. Objective: To determine if pairing hospitalized patients with ACO insurance with CHWs would reduce 30-day readmission rates. Design, Setting, and Participants: This randomized clinical trial was conducted in 6 general medicine hospital units within 1 academic medical center in Boston, Massachusetts. Participants included adults hospitalized from April 1, 2017, through March 31, 2019, who had ACO insurance and were at risk for 30-day readmission based on a hospital readmission algorithm. The main inclusion criterion was frequency of prior nonelective hospitalizations (≥2 in the past 3 months or ≥3 in the 12 months prior to enrollment). Data were analyzed from February 1, 2018, through March 3, 2021. Intervention: CHWs met with intervention participants prior to discharge and maintained contact for 30 days postdischarge to assist participants with clinical access and social resources via telephone calls, text messages, and field visits. CHWs additionally provided psychosocial support and health coaching, using motivational interviewing, goal-setting, and other behavioral strategies. The control group received usual care, which included routine care from primary care clinics and any outpatient referrals made by hospital case management or social work at the time of discharge. Main Outcomes and Measures: The primary outcome was 30-day hospital readmissions. Secondary outcomes included 30-day missed primary care physician or specialty appointments. Results: A total of 573 participants were enrolled, and 550 participants (mean [SD] age, 70.1 [15.7] years; 266 [48.4%] women) were included in analysis, with 277 participants randomized to the intervention group and 273 participants randomized to the control group. At baseline, participants had a mean (SD) of 3 (0.8) hospitalizations in the prior 12 months. There were 432 participants (78.5%) discharged home and 127 participants (23.1%) discharged to a short rehabilitation stay prior to returning home. Compared with participants in the control group, participants in the intervention group were less likely to be readmitted within 30 days (odds ratio [OR], 0.44; 95% CI, 0.28-0.90) and to miss clinic appointments within 30 days (OR, 0.56; 95% CI, 0.38-0.81). A post hoc subgroup analysis showed that compared with control participants, intervention participants discharged to rehabilitation had a reduction in readmissions (OR, 0.09; 95% CI, 0.03-0.31), but there was no significant reduction for those discharged home (OR, 0.68; 95% CI, 0.41-1.12). Conclusions and Relevance: This randomized clinical trial found that pairing ACO-insured inpatient adults with CHWs reduced readmissions and missed outpatient visits 30 days postdischarge. The effect was significant for those discharged to short-term rehabilitation but not for those discharged home. Trial Registration: ClinicalTrials.gov Identifier: NCT03085264.

Satisfaction of Malaria Patients with Care by Community Health Workers Trained in Microscopy: A Mixed-Methods Study in Palawan, the Philippines.

Palawan is the malaria-endemic province with the highest prevalence of malaria in the Philippines, and microscopists (community health workers) have been allowed to deliver early diagnosis and prompt treatment of malaria throughout the province since 1999. To improve the quality of care, the present mixed-methods study attempted to identify the factors associated with satisfaction of patients in Palawan with their microscopists by analyzing the patients' perspectives. First, a quantitative cross-sectional study was conducted among 48 ex-patients and their nine microscopists. Ex-patients were asked about their satisfaction with care, and microscopists were asked about their job satisfaction and ability. Structural equation modeling was conducted for data analysis. Second, a qualitative cross-sectional study was performed using narrative interviews. Data were analyzed using the NVivo 10 software program. As a result, both studies revealed high patient satisfaction with microscopists. The quantitative study showed that ex-patients' satisfaction with their microscopists was independently enhanced by two factors: high ability in malaria microscopic observation and low household wealth of the patients. Particularly, specific subpopulations (those with lower household wealth, relatively old people, and ethnic minorities) were more satisfied with the microscopists' care. The qualitative study strengthens this finding by showing that their microscopists offered prompt and precise diagnosis and effective treatment for free. In conclusion, microscopists were shown to have an important role in narrowing the disparities in malaria care in Palawan. It is important to maintain/enhance the ability of microscopists in malaria microscopy to satisfy their patients.

Evaluation of the mental health status of community healthcare workers during the COVID-19 outbreak.

ABSTRACT: Coronavirus disease 2019 (COVID-19) has rapidly spread across China and many countries worldwide, and community healthcare workers at the front lines of disease control are under high physical and mental pressure. This study investigated the mental health status of community healthcare workers during the COVID-19 outbreak in Sichuan Province, China. This cross-sectional study, which was conducted from February 8 to 18, 2020, involved 450 healthcare workers in 18 community hospitals who had worked for more than 1 year. A self-designed demographic data questionnaire and Symptom Checklist 90 (SCL-90) were provided to the participants through links and quick response codes. The respondents completed and submitted the questionnaires online. Binary logistic regression was used to analyze multiple factors related to the SCL-90 scores of these community healthcare workers in China. For the 450 community healthcare workers who completed the study, the median scores in each SCL-90 factor were lower than the Chinese norms, and 119 (26.4%) participants were SCL-90 positive. Among them, 178 participants were doctors and had the highest scores on most SCL-90 factors except for obsessive compulsiveness, hostility, phobic anxiety, and psychoticism (P < 0.05). The top 3 positive items for doctors working in the community were obsessive compulsiveness, others, and somatization, and those among nurses were obsessive compulsiveness, others, and hostility. Sex, type of workers, and occupational exposure risk to COVID-19 were independent risk factors for the mental health status of the community healthcare workers. Overall, the community healthcare workers experienced psychological problems during the COVID-19 outbreak in Sichuan Province, China. More attention should be paid to the mental health of these workers, and their mental status should be regularly assessed. Psychological interventions should be provided to those with serious mental problems through networks or telephone visits.

Needs assessment of community health workers to enhance efficient delivery of their services for community case management of malaria in Kenya.

BACKGROUND: Malaria continues to be the leading cause of morbidity and mortality in Africa. Community Case Management of malaria (CCMm) which is undertaken by engaging Community Health Workers (CHWs) to effectively address management of malaria cases in some endemic communities was explored in this study. The aim was to assess the needs of CHWs that would help sustain and retain their services to enhance the efficient delivery of CCMm. METHODS: Using semi-structured questionnaires, data on the needs of CHWs was gathered through a qualitative study consisting of in-depth interviews and focus group discussions (FGDs) conducted among study participants in five districts in western Kenya. The study participants comprised of 100 CHWs, 100 mothers of children under five years and 25 key informants made up of public health officers and clinicians involved in the CCMm. The interviews were conducted in English and Swahili or Dholuo, the local language. The recorded audio interviews were transcribed later. The analysis was done using NVivo version 7 software and transcripts were coded after which themes related to the objectives of the study were identified. RESULTS: All the study participants recognized the need to train and update CHWs on their work as well as remunerating them for their services to enhance efficient delivery of services. The CHWs on their part perceived the provision of gloves, rapid diagnostic test kits (RDTs), lancets, cotton wool and ethanol, bins (to dispose of RDTs and lancets), together with drugs for treating clients as the essential needs to undertake CCMm in the communities. Other logistical needs and incentives mentioned by CHWs and key informants for the successful delivery of CCMm included: gumboots, raincoats, torch lights, mobile phones, means of transportation (bicycles and motorbikes), uniforms and ID cards for identification. CONCLUSIONS: CHWs would perform tasks better and their services retained for a sustainable CCMm if: properly incentivized; offered refresher trainings (and updates) on malaria; and equipped with the requisite tools identified in this study.

Viewpoints of pregnant mothers and community health workers on antenatal care in Lweza village, Uganda.

BACKGROUND: Uganda is a low-income country with high fertility, adolescent birth, and maternal mortality rates. How Ugandan Ministry of Health antenatal education guidelines have been implemented into standardized health education and how pregnant women utilize health facilities remains unclear. OBJECTIVE: We aimed to determine how women obtain education during pregnancy, what guidelines health educators follow, and what barriers exist to receiving antenatal care in Lweza Village, Uganda. METHODS: Household surveys were conducted with women in Lweza who were or had previously been pregnant. Focus group discussions were conducted with community members and Lweza Primary School teachers. Interviews were conducted with key informants, including midwives, a traditional birth attendant, a community leader, and a Village Health Team member. Data collection was done in English along with a Luganda translator. RESULTS: Of the 100 household surveys conducted, 86% of women did not meet the WHO recommendation of 8 antenatal appointments during their pregnancies. Reasons cited for inadequate visits included facing long wait times (>7 h) at health facilities, getting education from family or traditional healers, or being told to delay antenatal care until 6 months pregnant. Informant interviews revealed that no standardized antenatal education program exists. Respondents felt least educated on family planning and postpartum depression, despite 37% of them reporting symptoms consistent with postpartum depression. Education was also lacking on the use of traditional herbs, although most women (60%) reported using them during pregnancy. CONCLUSIONS: Most women in Lweza do not receive 8 antenatal appointments during their pregnancies or any standardized antenatal education. Educational opportunities on family planning, postpartum depression, and the safety of traditional herbs during pregnancy exist. Future studies should focus on ways to overcome barriers to antenatal care, which could include implementing community-based education programs to improve health outcomes for women in Lweza Village.

Optimizing Myanmar's community-delivered malaria volunteer model: a qualitative study of stakeholders' perspectives.

BACKGROUND: In parallel with the change of malaria policy from control to elimination and declines in the malaria burden in Greater Mekong Sub-region, the motivation and social role of malaria volunteers has declined. To address this public health problem, in Myanmar, the role and responsibilities of malaria volunteers have been transformed into integrated community malaria volunteers (ICMV), that includes the integration of activities for five additional diseases (dengue, lymphatic filariasis, tuberculosis, HIV/AIDS and leprosy) into their current activities. However, this transformation was not evidence-based and did not consider inputs of different stakeholders. Therefore, qualitative stakeholder consultations were performed to optimize future malaria volunteer models in Myanmar. METHODS: Semi-structured interviews were conducted with key health stakeholders from the Myanmar Ministry of Health and Sports (MoHS) and malaria implementing partners to obtain their perspectives on community-delivered malaria models. A qualitative descriptive approach was used to explore the experiences of the stakeholders in policymaking and programme implementation. Interview topic guides were used during the interviews and inductive thematic data analysis was performed. RESULTS: While ICMVs successfully provided malaria services in the community, the stakeholders considered the ICMV model as not optimal and suggested that many aspects needed to be improved including better training, supervision, support, and basic health staff's recognition for ICMVs. Stakeholders believe that the upgraded ICMV model could contribute significantly to achieving malaria elimination and universal health care in Myanmar. DISCUSSION AND CONCLUSION: In the context of high community demand for non-malaria treatment services from volunteers, the integrated volunteer service package must be developed carefully in order to make it effective in malaria elimination programme and to contribute in Myanmar's pathway to universal health coverage (UHC), but without harming the community. An evidenced-based, community-delivered and preferred model, that is also accepted by the MoHS, is yet to be developed to effectively contribute to achieving malaria elimination and UHC goals in Myanmar by 2030.

Effectiveness of screening and treatment of children with severe acute malnutrition by community health workers in Simiyu region, Tanzania: a quasi-experimental pilot study.

Health system constraints hamper treatment of children with severe acute malnutrition (SAM) in Tanzania. This non-inferiority quasi-experimental study in Bariadi (intervention) and Maswa (control) districts assessed the effectiveness, coverage, and cost-effectiveness of SAM treatment by community health workers (CHWs) compared with outpatient therapeutic care (OTC). We included 154 and 210 children aged 6-59 months with SAM [mid-upper arm circumference (MUAC) < 11.5 cm] without medical complications in the control and intervention districts, respectively. The primary treatment outcome was cure (MUAC ≥ 12.5 cm). We performed costing analysis from the provider's perspective. The probability of cure was higher in the intervention group (90.5%) than in the control group (75.3%); risk ratio (RR) 1.17; 95% CI 1.05, 1.31 and risk difference (RD) 0.13; 95% CI 0.04, 0.23. SAM treatment coverage was higher in the intervention area (80.9%) than in the control area (41.7%). The cost per child treated was US$146.50 in the intervention group and US$161.62 in the control group and that per child cured was US$161.77 and US$215.49 in the intervention and control groups, respectively. The additional costs per an additional child treated and cured were US$134.40 and US$130.92, respectively. Compared with OTC, treatment of children with uncomplicated SAM by CHWs was effective, increased treatment coverage and was cost-effective.

Significance of training, monitoring and assessment of malaria workers in achieving malaria elimination goal of Malaria Elimination Demonstration Project.

BACKGROUND: The Malaria Elimination Demonstration Project (MEDP) maintained a workforce of 235 Village Malaria Workers (VMWs) and 25 Malaria Field Coordinators (MFCs) to conduct disease surveillance, case management, IEC/BCC activities, capacity building, and monitoring of vector control activities in 1233 villages of Mandla, a high malaria endemic district of Madhya Pradesh in central India. METHODS: The induction training was conducted for 3 days on malaria diagnosis, treatment, prevention, and ethics. All trainings were assessed using a pre and post-training assessment questionnaire, with 70% marks as qualifying threshold. The questionnaire was divided into three thematic areas viz. general knowledge related to malaria (KAP), diagnosis and treatment (DXRX), and vector control (PVC). RESULTS: In 2017, the project trained 330 candidates, followed by 243 and 247 candidates in 2018 and 2019, respectively. 94.3% candidates passed after a single training session. Almost all (95%) candidates showed improvement in knowledge after the training with 4% showing no effect and 1% showing deterioration. Progressive improvement in scores of 2017 cohort was seen along with significant improvement in performance of candidates in 2019 after the introduction of systematic monitoring and 'shadowing' training exercises. CONCLUSION: The project has successfully demonstrated the value of recruitment of workers from the study area, outcome of training, and performance evaluation of field staff in malaria elimination programme. This careful strategy of recruitment and training resulted in a work-force that was capable of independently conducting surveillance, case management, vector control, and Information Education Communication/Behaviour Change Communication (IEC/BCC). The learnings of this study, including the training modules and monitoring processes, can be used to train the health delivery staff for achieving national goal for malaria elimination by 2030. Similar training and monitoring programmes could also be used for other public health delivery programmes.

Community demand for comprehensive primary health care from malaria volunteers in South-East Myanmar: a qualitative study.

BACKGROUND: Malaria volunteers have contributed significantly to malaria control achieving a reduction of annual parasite incidence to pre-elimination levels in several townships across Myanmar. However, the volunteers' role is changing as Myanmar transitions from a malaria control to elimination programme and towards the goal of universal health coverage. The aim of the study is to explore the perspectives of community leaders, members and malaria volunteers in South-East Myanmar on community-delivered models to inform an optimal design that targets malaria elimination in the context of primary health care in Myanmar. METHODS: Qualitative methods including focus group discussions (FGDs) with community members and current or ex-malaria volunteers, and participatory workshops with community leaders were conducted. All data collection tools were pilot tested with similar participants. The FGDs were stratified into male and female participants in consideration of diverse gender roles among the ethnic groups of Myanmar. Data saturation was the key cut-off point to cease recruitment of participants. Inductive thematic analysis was used. RESULTS: Community members were willing to be tested for malaria because they were concerned about the consequences of malaria although they were aware that malaria prevalence is low in their villages. Malaria volunteers were the main service providers for malaria and other infectious diseases in the community. Apart from malaria, the community identified common health problems such as the flu (fever, sneezing and coughing), diarrhoea, skin infections and tuberculosis as priority diseases in this order. Incorporating preventive, and whenever possible curative, services for those diseases into the current malaria volunteer model was recommended. DISCUSSION AND CONCLUSION: There was a gap between the communities' expectations of health services and the health services currently being delivered by volunteers in the community that highlights the need for reassessment and reform of the volunteer model in the changing context. An evidence-based, community preferred, pragmatic community-delivered integrated model should be constructed based on the context of malaria elimination and progressing towards universal health coverage in Myanmar.

Using Implementation Science to Disseminate a Lung Cancer Screening Education Intervention Through Community Health Workers.

National lung cancer screening with low dose computed tomography (LDCT) uptake is suboptimal. One factor contributing to slow uptake is lack of awareness. Trained Community Health Workers (CHWs) may be effective in increasing lung cancer screening awareness among disparate populations, however little is known about the processes necessary to scale an intervention for implementation by CHWs in a new area. We examined implementation processes with the RE-AIM framework and pilot tested a CHW-delivered lung cancer education intervention based on the Health Belief Model. We measured pre-post participant knowledge, attitudes and beliefs regarding cancer screening, lung cancer stigma, and intent to obtain LDCT screening. We used community-engaged strategies to collaborate with a local health system, to identify CHWs. CHWs were trained to recruit participants and deliver the one-session lung cancer education intervention. Seven CHWs and eight community sites participated. Participants (n = 77) were female (53%) primarily low income (62.9%); tobacco use was high (36.9%). Post intervention changes in lung cancer screening knowledge (p = < .0001), attitudes regarding lung cancer screening benefit (p = .034) and lung cancer stigma. (p = .024) We learned important lessons that will be useful in subsequent scaling. Collaborating with a local health system is a promising method to disseminate a lung cancer screening education intervention.

A Cross-Sectional Survey Analyzing Community Perception and Utilization of Village Health Workers Stratified by the Urban-Rural Divide Within the Kingdom of Bhutan.

Village health workers (VHWs) serve as an integral health resource for many resource limited nations, including the Kingdom of Bhutan. As such, we aimed to identify community perceptions as well as utilization rates and types with relation to VHWs based on the urban-rural divide. Our team conducted a randomized survey of 429 community members in 14 villages within the Western region of Bhutan. Our findings indicate VHWs in rural communities are requested for their services twice as much as their urban counterparts. More specifically, urban VHWs are utilized 2.5 times more for general community services, while rural VHWs are utilized more for accessing medications. Additionally, our research indicates a need to increase training of VHWs as well as overall program promotion relating to the specific services that VHWs can provide. These investigations indicate the importance of differentially allocating resources, programming, and training based on the urban-rural divide.

Community Health Workers and Disease Surveillance in Tanzania: Promoting the Use of Mobile Technologies in Detecting and Reporting Health Events.

This cross-sectional study was conducted in the Kilosa, Morogoro Urban, Ngorongoro, and Ulanga districts of Tanzania to investigate the practices of community health workers (CHWs) related to disease surveillance functions and to establish their needs and technology capacities. We also established the strength of mobile phone networks and internet connections in the study areas to inform the feasibility of using mobile-based applications in community-based disease surveillance. A total of 135 CHWs from 85 villages participated in the study. Health events captured at the community level were entirely paper-based. CHWs submitted reports to higher-level health authorities mainly on foot (100%), but they also used public transport (65%) and telephone calls (56%). The median number of days between the onset of a suspected disease outbreak at the community level and reporting to a primary healthcare facility was 10 days (interquartile range [IQR] 2-30). The median number of days between submitting a report and receiving a response was 7 days (IQR 2-30). Of the 53 CHWs who reported the most recent health events to a higher-level health authority, 39 (74%) never received feedback. All 85 villages had a reliable mobile phone network and 74 (87%) had a mobile phone internet connection that was strong enough to support data transmission using digital technology. Almost all (n = 132, 98%) of the CHWs owned mobile phones. The practices related to detection and reporting of health events could be improved to enhance early warning disease surveillance. Reliable mobile networks and internet connections and the ownership of mobile phones among CHWs in the study areas present opportunities to strengthen community event-based surveillance using mobile-based solutions.

Integração do agente de combate às endemias na Estratégia Saúde da Família, Campo Grande, Mato Grosso do Sul, 2017* / Integración del agente de combate a las endemias en la Estrategia Salud Familiar, Campo Grande, Mato Grosso do Sul, Brasil, 2017 / Integration of endemic disease control workers in the Family Health Strategy, Campo Grande, Mato Grosso do Sul, Brazil, 2017

Objetivo: Descrever o processo de integração do agente de combate às endemias (ACE) na Estratégia Saúde da Família (ESF). Métodos: Estudo transversal descritivo. Os dados foram coletados por questionário semiestruturado autoaplicável, de fevereiro a maio de 2017, em quatro unidades de Saúde da Família na região urbana de Campo Grande, Mato Grosso do Sul, Brasil. Resultados: Participaram 57 agentes comunitários de saúde (ACS) e 8 ACEs. Todos os participantes informaram realizar orientações ao morador e 58 realizavam controle mecânico durante a vistoria de imóveis, visando evitar e eliminar possíveis criadouros do Aedes aegypti. Quanto à integração dos ACEs na ESF, 18 participantes destacaram o trabalho em equipe como aspecto positivo, enquanto 15 referiram falta de autonomia para intervenções legais como aspecto negativo. Conclusão: A integração do ACE na ESF é viável; contudo, ajustes devem ser realizados para potencializar as atividades, na perspectiva do trabalho compartilhado em uma mesma base territorial.

Objetivo: Describir el proceso de integración del Agente de Combate a las Endemias (ACE) en la Estrategia de Salud Familiar (ESF). Métodos: Estudio descriptivo transversal. Los datos se recopilaron por un cuestionario semiestructurado autoadministrado, de febrero a mayo de 2017, en cuatro Unidades de Salud Familiar en la región urbana de Campo Grande, Mato Grosso do Sul, Brasil. Resultados: Participaran 57 Agentes de Salud Comunitaria (ACS) y 8 ACE. Todos informaron que proporcionaron orientación a los habitantes y 58 realizaron control mecánico durante la inspección de las propiedades, buscando evitar y eliminar posibles sitios de reproducción para Aedes aegypti. En cuanto a la integración de los ACE en la ESF, 18 participantes destacaron el trabajo en equipo como un aspecto positivo, y 15, la falta de autonomía para las intervenciones legales como un aspecto negativo. Conclusión: La integración de los ACE en la ESF es factible, sin embargo, son necesarios ajustes para mejorar las actividades en la perspectiva del trabajo compartido sobre la misma base territorial.

Objective: To describe the process of Endemic Disease Control Worker (EDCW) integration into the Family Health Strategy. Methods: This was a descriptive cross-sectional study. Data were collected through a self-administered semi-structured questionnaire, from February to May 2017, in four Family Health centers in the urban region of Campo Grande, Mato Grosso do Sul, Brazil. Results: 57 Community Health Agents (CHW) and eight EDCWs participated. All participants reported providing guidance to property dwellers and 58 carried out mechanical vector control during the inspection of properties, in order to avoid and eliminate possible Aedes aegypti breeding sites. With regard to EDCW integration in the Family Health Strategy, 18 participants highlighted teamwork as a positive aspect; while 15 highlighted lack of autonomy to undertake legal interventions as a negative aspect. Conclusion: EDCW integration in the Family Health Strategy is feasible, however, adjustments need to be made to optimize activities within the perspective of shared work in the same territorial area.