Community Health Toolkit

Community Health Research Round-Up, Issue 033 & 034

Hi All -

We are doubling up on Research Round-Ups this week. Below are the articles from Issue 033 (May 5 - May 18, 2020) and Issue 034 (May 19 - June 1, 2020).

Especially relevant for this audience: Check out Issue 033 - Article #6, which covers CHW-based hearing screening via mobile platform in Haiti. And Issue 034 - Article #1, which assesses a mobile platform-based algorithm for CHW identification of surgical site infections for patients who have undergone a C-section in Rwanda.


1 & 2. To Strengthen The Public Health Response To COVID-19, We Need Community Health Workers & Prioritizing Community Partners and Community HIV Workers in the COVID‑19 Pandemic

  • Comments: Two great new pieces on the role of CHWs in COVID-19. Complement with this BMJ blog (RR 028), and this white paper forthcoming in BMJ GH.
  • Methods: Opinion/notes from the field
  • Takeaway: The Health Affairs article argues CHWs are being underused in the [US] nationwide fight against the pandemic, noting many states have opted to lay off CHWs. They note CHWs have critical communications skills and community connections that can be leveraged to boost public health and safety-net provider capacity, but that additional efforts are needed to protect CHW wellbeing. The second article argues HIV researchers have a particular responsibility to acknowledge the challenges and develop interventions to support the health and well-being of community partners, including CHWs.

3. Community-Based Interventions for Stroke Provided by Nurses and Community Health Workers: A Review of the Literature

  • Comments: Although nurses and community health workers (CHWs) are commonly involved in community-based interventions, less is known about their roles relative to other poststroke rehabilitation professionals (physical therapists, occupational therapists, and speech-language pathologists), hence this review
  • Method: Systematic review
  • Takeaway: Details regarding nurses’ and CHWs’ roles were limited, but suggest a critical role for these actors. Data from this review illustrate a continued need for comprehensive programs designed to address the complex needs of stroke survivors and families when they return to their homes and communities.
  1. Where Is the Break-even Point for Community Health Workers? Using National Data and Local Programmatic Costs to Find the Break-even Point for a Metropolitan Community Health Worker Program
  • Comments: This study estimates the number of hospitalizations and emergency department visits that would need to be avoided to recoup program costs for a CHW program that addressed both medical and social needs. A potentially useful model for other systems wanting to do this analysis.
  • Method: Programmatic cost analysis
  • Takeaway: Estimates of avoided visits needed to reach the break-even point for Metropolitan are consistent with the literature.

5. Exploring perceptions, barriers, and enablers for delivery of primary ear and hearing care by community health workers: a photovoice study in Mukono District, Uganda

  • Comments: The latest from our friends at Oxford - complement with other photovoice findings on gender & workflow (RR 007) and CHW challenges (RR 018). Barriers identified here are as you would expect.
  • Method: Photovoice, a participatory visual method which involves the capture of photographic images related to issues of social importance, to explore the perceptions, barriers, and enablers of CHWs delivering primary ear and hearing care
  • Takeaway: Potential barriers identified included a lack of equipment, training, and supervision of CHWs; logistical, financial, or psychological barriers to community participation; and the widespread use of traditional medicine.

6. Community health worker‐based hearing screening on a mobile platform: A scalable protocol piloted in Haiti

  • Comments: Compare w/earlier articles on CHWs supporting hearing health using mHealth technologies (RR 016) + cell-phone based hearing screening tools (RR 018)
  • Method: cross‐sectional study
  • Takeaway: CHWs using a cell phone app can significantly reduce the burden of hearing healthcare specialists while simultaneously facilitating early diagnosis and management of disabling hearing loss in low‐resourced settings

7. Feasibility, Acceptability, and Efficacy of a Community Health Worker–Driven Approach to Screen Hard-to-Reach Periurban Women Using Self-Sampled HPV Detection Test in India

  • Comments: Detection of high-risk HPV in self-collected vaginal samples can significantly improve participation of hard-to-reach women, but these women still need to be reached! In this study Women age 30 to 65 years from low socioeconomic periurban areas who had never been screened before were motivated by CHWs to attend local community centers and provide self-collected vaginal samples for careHPV testing.
  • Methods: Cross-sectional
  • Takeaways: Women readily accepted to provide self-collected samples after counseling by CHWs. Screen positivity was 6.4%, and CHWs successfully navigated 65% of HPV-positive women to colposcopy. CHW-driven self-sampling for HPV testing is feasible, well-accepted, and effective for screening unscreened hard-to-reach women.

8. Integrating Community Health Workers into Safety-Net Primary Care for Diabetes Prevention: Qualitative Analysis of Clinicians’ Perspectives

  • Comments: More interesting research from the USA on what it will take for doctors to work w/CHWs
  • Methods: Semi-structured interviews
  • Takeaways: Clinicians found CHWs appropriate for diabetes prevention in safety-net settings. However, disseminating high-quality evidence about CHWs’ effectiveness (clinicians expressed concerns about the adequacy of CHWs’ training) and operations (clinicians expressed concern re: added workload and communication with CHWs) is needed to overcome concerns about integrating CHWs in primary care.

9. BONUS: Health for the People: National Community Health Worker Programs from Afghanistan to Zimbabwe

  • Comments: The latest update to the most comprehensive collection of CHW country-level case studies has just been released. Featuring nearly 30 countries and 500 pages of analysis, this has always been a fantastic resource.

1. Diagnosing Post-Cesarean Surgical Site Infections in Rural Rwanda: Development, Validation, and Field Testing of a Screening Algorithm for Use by Community Health Workers

  • Comments: From our friends at Partners in Health. This study evaluates a mobile phone-based screening algorithm to assist CHWs in identifying & referring surgical site infections (SSI) after c-section in rural Rwanda.
  • Methods: Developed & validated screening tool; then randomized c-section patients to 1 of 3 arms: (1) CHW performs SSI screening post-op at patient’s home, (2) CHW administers screening via phone, and (3) standard of care (no special follow-up)
  • Takeaway: The SSI screening tool had high accuracy in clinical setting but performed poorly when administered by CHWs in the field. Methods to improve diagnostic ability (i.e., training or telemedicine), must be explored.

2. Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique’s community health workforce

  • Comments: Mozambique’s community health workforce (APEs) is 70% male. This study examines recruitment & retention through a gender lens.
  • Methods: Interviews + focus group discussions
  • Takeaway: Responsive policies to support gender equity within APE recruitment processes are required to support & retain a gender-equitable APE cadre. This includes remuneration for APEs commensurate w/ working hours & skills, along w/ selection criteria to promote gender equity.

3 & 4. Two new systematic scoping reviews: CHWs in palliative care provision in low-income and middle-income countries and CHWs and early detection of breast cancer

  • Comments: The latest from friends at Oxford, these reviews examine where & how CHWs are currently deployed in palliative care delivery & breast cancer detection, methods used to train & support CHWs, evidence on costs, & challenges/barriers.
  • Methods: Systematic scoping review
  • Takeaway: Evidence suggests CHWs can play important roles in breast cancer early detection & palliative care. For both palliative care & breast cancer detection, training & support varied and/or was poorly reported, and formal cost analyses were nonexistent.

5. Meeting the challenges posed by per diem in development projects in southern countries: a scoping review

  • Comments: This review explores possible levers of action to address per diem practices in the Global South. The issues w/ per diem are well-documented, but reforms efforts are stifled by inaction.
  • Methods: Scoping review (26 documents included) & interviews w/ original authors to see if any of their original recommendations had been implemented
  • Takeaway: Addressing inaction on proposed per diem reforms (e.g., reduction of daily allowance rates, pay per diems only in exchange for actual work, harmonize rates, reduce instances of abuse, avoid paying advances) will take a collaborative approach & open dialogue.

6. Perinatal Health Outcomes Following a Community Health Worker-Supported Home-Visiting Program in Rochester, New York, 2015-2018.

  • Comments: More evidence on the role of CHWs in perinatal care (see RR024 and RR032 for studies from Malawi & USA, respectively).
  • Methods: Compared perinatal outcomes of 455 at-risk pregnant women w/ program data merged w/ electronic medical records
  • Takeaway: Participants in a CHW-supported home visitor program had fewer adverse outcomes vs. nonparticipants, including lower rates of preterm birth & low birth weight. The program was effective at achieving improved perinatal outcomes.

7. Social Determinants of Health and Community Health Agent Work

  • Comments: CHWs experience social determinants of health (SDH) as residents of the community & professionals at the local level; this study sought perspectives from CHWs in Brazil.
  • Methods: Qualitative (interviews & focus groups w/ 25 community health agents)
  • Takeaway: The study revealed a complex relationship between the work of community health agents and the social determinants of health, especially as it relates to violence, drug trafficking, lack of sanitation, waste w/ improper disposal, illiteracy, and people living w/ chronic disease.

8 & 9. Two related papers examining the Lazos Hispanos program, designed to reach Latinx communities in Southeastern USA

10. Implementing without guidelines, learning at the coalface: a case study of health promoters in an era of community health workers in South Africa.

  • Comments: Amidst a flurry of interest in primary healthcare (PHC) and health promotion, an oft-overlooked question is who is responsible for health promotion activities. Unclear policy guidelines in South Africa have created tensions between the country’s health promotion practitioners and CHWs.
  • Methods: Qualitative case study
  • Takeaway: Absent clear policy and process guidance, health workers are “‘working it out’ on the ground” and finding ways to realign their roles in ways that support both impacted cadres & the communities they serve.