Community Health Toolkit

Community Health Research Round-Up, Issue 029

Hi all,

Today, in recognition that strengthening care delivery will save lives–not just in a pandemic, but every day --we return to our standard format. This issue covers papers indexed (largely!) since March 10. Please feel free to reply to tthis with anything we may have missed.

Community Health Research Round-Up, Issue 029

March 10, 2020 - March 23, 2020

  1. Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program.
  • Comments: From our friends at Integrate Health - applying lessons from Togo to NYC! Explores the integration of social needs screening and CHW referral assistance as part of the Community Linkage to Care (CLC) program at a Federally Qualified Health Center in the Bronx, NY (USA)
  • Methods: Prospective data collection over ~12 months
  • Takeaway: Among households with at least one self-reported, unmet social need, only 29% requested referral to a CHW for assistance (further investigation needed to understand low rate); where CHW referrals did occur, 43% resulted in household obtaining resources as a result
  1. The fidelity of implementation of recommended care for children with malaria by community health workers in Nigeria.
  • Comments: A rare but important assessment of fidelity of implementation (FOI) of CHW-led malaria interventions
  • Methods: Trainers computed performance scores using a standardized checklist for 35 CHWs under one-time hospital-based observation
  • Takeaway: Adherence to malaria diagnostic and treatment protocol by trained CHWs was higher than adherence by comparative medical personnel; notably, these CHWs received training, refresher training, and close supervision (visits 2x per week); differences were observed for CHWs with vs. without prior healthcare experience
  1. ‘Our village is dependent on us. That’s why we can’t leave our work’. Characterizing mechanisms of motivation to perform among Accredited Social Health Activists (ASHA) in Bihar.
  • Comments: Discusses opportunities to leverage sources of intrinsic motivation for CHWs (e.g., enhanced social standing, pride in serving community) but also highlights challenges with extrinsic motivators like pay and support mechanisms
  • Methods: Case study
  • Takeaway: Highlights issues with the ASHA program’s financial arrangements that may be relevant for other programs; ASHAs feel that pay is low relative to workload, financial incentives are linked to customer behaviors that are often out of ASHA’s direct control, and public sector priorities that influence ASHA workload are unpredictable. These findings are another tool in our arsenal calling for fair pay for CHWs! Findings also identify the need to develop more managerial skills for CHW supervisors.
  1. Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India.
  • Comments: Assesses impact of an integrated intervention (comprising team-based coverage goals and targets, provision of non-monetary incentives, and team-building initiatives) on CHW performance and motivation
  • Methods: C-RCT (May 2012 - November 2014, published 2019)
  • Takeaway: The intervention resulted in more antenatal home visits and more mothers receiving iron folic acid tablets - but did not result in significant improvements on other health behaviors related to the goals of the trial
  1. ‘We need other men to stand up and start the journey’ engaging men as HIV community health workers - a gender transformative approach?.
  • Comments: Provides insights into what it will take to address the gendered nature of the HIV epidemic (in terms of disease burden and caregiving burden) - specifically, how can we get more men involved as CHWs?
  • Methods: Qualitative
  • Takeaway: Acknowledges difficulties in achieving a more gender-balanced approach; male CHW perspectives are shaped by the fact that CHW work is “poorly paid” with insecure tenure. Findings point to the need to address issues of financial compensation for CHW caregivers (male and female) and to revisit wider constructions of masculinity
  1. Role of home visits by volunteer community health workers: to improve the coverage of micronutrient powders in rural Bangladesh.
  • Comments: Examines BRAC program in which CHWs sell micronutrient powder (MNP) to caregivers and provide advice (in contrast to other programs which tend to rely on free distribution). (N.B. The WHO recommends against volunteer CHWs and has long recommended against point-of-care user fees, given the equity and access implications)
  • Methods: Cross-sectional
  • Takeaway: Home visits are an important driver of coverage of MNP, along with child’s age: coverage was higher among younger children (who also tend to need MNP most); selling MNP is believed to contribute to higher coverage; authors note that a market-based approach raises questions around affordability and may require government intervention to monitor/regulate the market-based approach
  1. Observational stepped-wedge analysis of a community health worker-led intervention for diabetes and hypertension in rural Mexico.
  • Comments: From our friends at Partners in Health! Evidence from rural Mexico that CHWs can effectively deliver interventions targeting diabetes and hypertension
  • Methods: Prospective observational stepped-wedge study
  • Takeaway: CHWs in rural Mexico achieved clinically-meaningful improvements in disease markers for controlled and uncontrolled patients with diabetes and hypertension (note: wide confidence intervals; effect was most pronounced for patients with poor control at baseline)
  1. Comparison of 3 Days Amoxicillin Versus 5 Days Co-Trimoxazole for Treatment of Fast-breathing Pneumonia by Community Health Workers in Children Aged 2-59 Months in Pakistan: A Cluster-randomized Trial.
  • Comments: Current WHO/Unicef iCCM guidelines recommend five days of treatment with oral amoxicillin for fast-breathing pneumonia. This trial examines whether amoxi treatment duration could be reduced to three days (thereby reducing higher cost of amoxi relative to co-trimoxazole); trial funded by WHO/USAID
  • Methods: C-RCT (intervention = 3 days oral amoxi, control = 5 days oral cotrimoxazole)
  • Takeaway: Higher treatment failure rate was seen among control clusters; confirms that three-day course of amoxi, administered by Lady Health Worker, is safe and effective
  1. Performance of community health workers and associated factors in a rural community in Wakiso district, Uganda.
  • Comments: We encourage researchers and implementers to consider equity issues at the heart of any discussion on selecting for specific CHW characteristics such as marital status; with that caveat in place, here is a study providing more data on factors that may be associated with CHW performance
  • Methods: Cross-sectional - questionnaire administered to 201 CHWs
  • Takeaway: Refresher training was associated with higher CHW performance; level of education and marital status were also linked to CHW performance; stock-outs of essential medicines and low motivation of CHWs need to be addressed
  1. Evaluation of the effectiveness of community health workers in the fight against malaria in the Central African Republic (2012-2017).
  • Comments: Evaluates effectiveness of a ten-year CHW program in the CAR; focuses on malaria case management
  • Methods: Mixed methods
  • Takeaway: More evidence that CHWs can effectively deliver curative and preventive services for malaria case management; nearly fifty percent of CHWs reported receiving at least four training sessions per month
  1. Depression, social support, and stigma as predictors of quality of life over time: results from an ASHA-based HIV/AIDS intervention in India.
  • Comments: Interesting study on quality of life (QOL) for women living with HIV/AIDS in India, conducted under a larger nurse-led-ASHA-support RCT
  • Methods: Pre/post, 6 month follow up
  • Takeaway: An ASHA-supported approach may help improve QOL for women living with HIV/AIDS in India; results hold across different social classes
  1. The Feasibility and Effectiveness of PASS Plus, A Lay Health Worker Delivered Comprehensive Intervention for Autism Spectrum Disorders: Pilot RCT in a Rural Low and Middle Income Country Setting.
  • Comments: Promising findings from a pilot RCT funded by Grand Challenges Canada; assesses feasibility and effectiveness of a community-delivered intervention for young children with autism
  • Methods: RCT
  • Takeaway: The intervention can be delivered by CHWs, providing a potentially feasible and effective option for autism care in countries facing a shortage of specialist health workers
  1. Evaluating community health worker education policy through a National Certificate (Vocational) Primary Health qualification lens.
  • Comments: An important contribution to the discourse around CHW training and education programs using a case study of formalized training in South Africa
  • Methods: Qualitative enquiry
  • Takeaway: South Africa launched a formal vocational training curriculum and three-year certified qualification program for CHWs in 2013. The program was abruptly terminated in 2016. This retrospective enquiry assesses the curriculum against the 2018 WHO Guidelines for optimizing CHW systems and finds that the curriculum matched and aligned with WHO recommendations
  1. Advocating for the Health Worker.
  • Comments: Published in January 2019, this piece makes the case for health worker protection
  • Methods: Reviews reports from development agencies and public health agencies in the aftermath of the 2014 Ebola outbreak
  • Takeaway: Somewhat dated, but may be relevant for CHIC position paper and related content on COVID-19 as we continue to make the case for protecting valuable cadres of CHWs
  1. PROTOCOL: The roles, responsibilities and perceptions of community health workers and ward-based primary health care outreach teams (WBPHCOTs) in South Africa: a scoping review protocol.
  • Comments: Review will look at factors that undermine or enable effectiveness of WBPHCOTs in KwaZulu-Natal, South Africa
  • Methods: Scoping review
  • Takeaway: Findings are intended to inform South Africa’s National Health Insurance Program about the impact of WBPHCOTs on the national healthcare system and population health

BONUS : Coalition White Paper on Investment Priorities for the Global COVID-19 Response

FINAL GRAPHIC - Priorities for COVID Response .png


Thank you for continuing to post these research round ups @mballard!

If I can just further emphasize the last item: the Coalition White Paper on Investment Priorities for the Global COVID-19 Response is a great resource and well worth reviewing for anyone on the CHT forum getting involved in covid response.