Issue 037 - some good stuff on PPE for CHWs, online vs. in-person training, new costing analysis
June 30 - July 12, 2020
1. & 2. Two articles on the role of CHWs: (i) Community Health Workers as Influential Health System Actors and not “Just Another Pair Of Hands” (ii) The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability
- Comments: Two complementary articles on the role of CHWs. Compare w/classics like Lackey or Liberator? and more recent offerings like this GHD Online case study. The latter is interesting in that it breaks with the liberator/lackey dichotomy and suggest CHWs play three roles - see the takeaway.
- Methods: (i) qualitative case study (India); (ii) critical interpretive synthesis (CIS) of CHWs and accountability in LMICs
Takeaway: (i) A narrow and instrumentalist view of CHWs as merely
an ‘extra pair of hands’ to be called upon to provide ‘technical
fixes,’ ignores the vast social capital many CHWs accumulate & their emergence as influential social actors in the communities they serve. (ii) CHWs are intended to comprise a ‘bridge’ between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. These three roles can be seen as existing on a continuum from extending the reach of the current health system, to effecting change in the health system and in other social determinants of health; though many CHW job descriptions contain elements of more than one of these roles.
- Comments: A damning (self-) assessment: “Another research team described differing goals between academic and community partners (including CHWs), where academic partners prioritized data and community partners prioritized funding and policy.” Complement with Prioritizing Competencies for Research paper from RR 031
- Methods: Scoping review including 130 studies
- Takeaway: CHW positionality as research partners varied greatly across studies, and they are not uniformly integrated within all stages of research. Community based participatory research (CBPR) approach, and CBPR studies included CHWs as research partners in more phases of research relative to non-CBPR studies. CHWs were least involved in identifying the research question, data analysis, and research dissemination. Advantages of CHW involvement include: informing study design to consider contextual factors, improving the content and delivery of health interventions, and validating and explaining research findings.
- Comments: Many previous CHW interventions have been shown to ameliorate MNCH. This study looks at less often evaluated but potentially protective factors, such as obtaining a child support grant (CSG), avoiding traditional healers, and attending a minimum of four antenatal care visits
- Methods: Longitudinal prospective cohort study
- Takeaway: Compared to mothers receiving standard care, mothers who also received home visits by CHWs were more likely to attend the recommended four antenatal care visits, to exclusively breastfeed at 3 months, and were less likely to consult traditional healers at 3 months. CHW home visits resulted in better maternal caretaking, but did not have direct benefits for infants in the domains assessed (infant growth and achievement of developmental milestones were similar at 2 years for both groups)
- Comments: Multiple RCTs indicate that CHW-delivered interventions have a substantial impact on exclusive breastfeeding (EBF) up to six months postpartum. This trial is interesting because it offers evidence from Kenya on both EBF and early breastfeeding initiation (EBI) in a setting where very low EBF rates (2% to 12%) have been documented.
- Methods: Randomized trial (6 mo)
- Takeaway: CHWs had potential effectiveness in promoting EBF but not EBI: the prevalence of EBF at 24 weeks was 45.3% in the CHW group compared with 15.0% in the control group (p < .001). The difference was not statistically significant in EBI prevalence between the CHW (58.2%) and control (60.3%; χ 2 = 0.008, p = .928).
- Comments: Hot off the press from Coalition member, Possible. Context for this costing: in 2017, the Nepal Ministry of Health and Population partnered w/Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. (CHWs (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees) The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization.
- Methods: Retrospective costing analysis (Both for the pilot and three alternative scenarios: (1) CHW salaries decreased (2) Administrative functions of the program are absorbed into municipal health care unit governance structures (3) CHW program incorporated directly into existing primary health care infrastructure)
- Takeaway: The average per capita annual cost of a pilot CHW program in rural Nepal is US$3.05. Personnel costs, the largest cost driver, contribute 74% of the total implementation costs and are affected by the number of households covered, population distribution, geographical terrain, and supervision structure.
- Comments: Some relevant considerations for online learning - particularly relevant in the age of COVID-19 where everything is moving to digital. (N.B. previous studies for different disease areas have found online-trained CHWs produced similar health outcomes as in-person-trained CHWs) - context matters!
- Methods: C-RCT & cost analysis
- Takeaway: CHWs who attended live training outperformed their online-trained colleagues. Elements of the didactic approach or practice with peers in the live session may have contributed to the superior training effectiveness and, ultimately, improved cost-effectiveness of the in-person approach.
- Given the convenience of online training (no geographic or time limitations) future such training should better facilitate the interactions among CHWs and seek to improve CHW’s skills in building rapport with participants and facilitating discussion among participants.
- Comments: Similar findings as Kok’s 2015 systematic review of contextual determinants of CHW effectiveness in LMIC. This single study also identified community factors (particularly the fear of stigma) as an important determinant and found that the organisational context was the most noteworthy impediment to the potential effectiveness of the CHWs.
- Methods: In-depth interviews and focus group discussions (grounded theory)
- Takeaway: Six critical contexts affecting the implementation of the CHW program: geographic, social and economic, community, local governance and authority, and organisational (e.g. tensions between the NDoH and NGOs responsible for paying CHWs, staff shortages, the overburdening of CHWs in terms of their reporting requirements etc.)
- Comments: As noted in the Coalition’s COVID priorities paper (RR 035) CHWs require personal protective equipment (PPE) to safely support COVID-19 response efforts and maintain essential health services.
- Methods: Rapid literature review w/partial country validation in nine countries were used to verify CHW estimates. Evidence-based assumptions regarding CHW workflow and PPE use were used to calculate the annual PPE needs for CHWs.
Takeaway: In order to provide one year of protection to one million CHWs serving over 400 million people across 24 countries (40% of the continent), 448 million pieces of PPE (masks, gloves, goggles, gowns, biohazard bags) are required annually. Based on current, fluctuating commodity prices, this would require an outlay of circa 100