Community Health Research Round-Up, Issue 040

Community Health Research Round-Up, Issue 040
August 11 - August 24, 2020

1. SARS-CoV-2 Infection Among Community Health Workers in India Before and After Use of Face Shields

  • Comments: New study outlining the importance of COMPLETE personal protective equipment (PPE), including eye protection, for CHWs. Limitations include the before-after design; however, the unique living circumstances of the workers (alone in catered rooms) minimized other sources of transmission.
  • Methods: Before and after on the use of face shields
  • Takeaway: This study found no SARS-CoV-2 infections among community health workers after the addition of face shields to their PPE. Before face shields, 19% of CHWs were infected after routine home visits, after face shields 0%.

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

  • Comments: Good case study of aligning w/ the existing health system and its priorities. Would have been nice to measure uptake of screening
  • Methods: Pre-post (RE-AIM)
  • Takeaway: CHWs were trained to recruit participants and deliver the one-session lung cancer education intervention. Post intervention changes in lung cancer screening knowledge (p = < .0001), attitudes regarding lung cancer screening benefit (p = .034) and lung cancer stigma. (p = .024)

3. Severe acute malnutrition treatment delivered by low-literate community health workers in South Sudan: A prospective cohort study

  • Comments: Cohort results from this study of a simplified SAM treatment protocol and a set of low‐literacy‐adapted tools developed by IRC featured in RR 006.
  • Methods: Prospective cohort study
  • Takeaway: The recovery rate for SAM children enrolled in acute malnutrition treatment by low-literate CHWs shows promise that deploying CHWs to treat SAM in areas with high prevalence and low treatment access may lead to higher recovery, better continuity of care in the transition between SAM and MAM, and shorter treatment time. The recovery rate from the severe to the moderate acute malnutrition (MAM) cut-off of MUAC 115 mm was 91% (95% confidence interval (CI) = 88%-95%). The median length of treatment was five weeks. The recovery rate of children from SAM to full recovery was 75% (95% CI = 69%-81%). The median time to full recovery was eight weeks. When the data were compared against routine monitoring and evaluation data from nearby static clinics, children treated by CHWs appeared to have improved continuity of care and shorter time to recovery.

4. Opportunities for and Perceptions of Integrating Community Health Workers Via the Affordable Care Act: Medicaid Health Homes

  • Comments: Of interest to colleagues in the US: how CHWs have been integrated into the relatively novel Medicaid Health Home (MHH) virtual health care network system.
  • Methods: Semistructured qualitative interviews
  • Takeaway: CHWs were compatible with MHHs by enrolling patients, helping coordinate patient care, and providing social support. The complexities of CHW integration into MHHs included barriers to CHW integration, no direct reimbursement for their services, lack of clarity for CHW roles and responsibilities, and no explicit external policy for their use in MHHs.

5. From Policy Statement to Practice: Integrating Social Needs Screening and Referral Assistance With Community Health Workers in an Urban Academic Health Center

  • Comments: The Community Linkage to Care (CLC) pilot program integrates social needs screening and referral support using CHWs as part of routine primary care visits.
  • Methods: Mixed: Iterative process to define key components, measures adapted based on RE-AIM
  • Takeaway: Social needs screens were conducted at 65% of eligible well-child visits over one year; 19.7% of screens had one or more positive responses. Screening for social needs at well-child visits is feasible as part of routine primary care. Authors attribute progress to leveraging resources, obtaining provider buy-in, and defining program components to sustain activities.
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A post was split to a new topic: Community Health Research Round-Up, Issue 041

Community Health Research Round-Up, Issue 042
September 8 - September 21, 2020

1. When information is not power: Community-elected health facility committees and health facility performance indicators

  • Comments: Community-elected health facility committees (HFCs) are often promoted - especially in performance-based financing (PBF) programs - as a viable mechanism for holding primary care facilities accountable to the communities and patients they serve. This study from Burundi, where PBF is implemented nationally, takes a closer look with surprising results.
  • Methods: RCT (n = 251 health facilities w/ 168 receiving intervention which consisted of HFCs receiving training on roles, rights, and PBF) + nested qualitative follow up
  • Takeaway: The intervention led to better organized HFCs but had no impact on health facility management and service delivery; intervention sites saw higher turnover of chief nurses and qualitative exploration uncovered tensions between intervention HFCs and health facility staff. These results call into question the purported watchdog role of HFCs in PBF.

2. Community-level interventions for pre-eclampsia (CLIP) in Pakistan: A cluster randomised controlled trial

  • Comments: CHWs do not operate in a vacuum! This study provides an example of how CHWs’ impact can be negatively attenuated by “incomplete implementation or weak in-facility care.”
  • Methods: C-RCT with 39,446 women in intervention (n = 20,264) and control clusters (n = 19,182); primary outcome was a composite of maternal + fetal + newborn mortality & major morbidity
  • Takeaway: Task-sharing activities related to pre-eclampsia can be achieved by CHWs. However, the primary outcome did not differ between intervention and control clusters, suggesting that investments community-level interventions must be accompanied by corresponding investments in strengthening health facilities.

3. Can people-centered community-oriented interventions improve skilled birth attendance? Evidence from a quasi-experimental study in rural communities of Cambodia, Kenya, and Zambia

  • Comments: A closer look at how CHW service delivery impacts maternal care-seeking behavior at World Vision sites in three countries (Cambodia, Kenya, Zambia).
  • Methods: Quasi-experimental w/ matched comparison groups; intervention groups received timed, targeted CHW visits and other community-oriented interventions including use of community scorecards
  • Takeaway: Over 80% of women in all three countries reported SBA at delivery. In Cambodia, SBA during delivery was significantly higher for intervention areas (p < 0.001); in Kenya and Zambia, the difference between intervention & control sites was not statistically significant. Study also looked at CHW home visitation practices. We were initially surprised that in Zambia, >75% of women did NOT receive any visit from a CHW (76% in intervention sites and 89.9% in comparison sites, p < 0.001) - until we read that in Zambia, the CHWs were volunteers who lacked transport to reach remote households, therefore suffering from high attrition and low satisfaction levels. PSA: WHO guidelines recommend paying CHWs commensurate w/ job demands & providing necessary support!

4. Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care

  • Comments: The litany of design and implementation challenges uncovered in this qualitative analysis of Ghana’s CHPS+ program means we just can’t help ourselves from sharing the CHW AIM tool, specifically the updated Program Functionality Matrix which is a practitioner-friendly tool for improving program design and implementation.
  • Methods: Qualitative (4 focus group discussions + 2 general discussions with 60+ CHPS+ stakeholders)
  • Takeaway: The authors uncover a multitude of challenges that inhibit the implementation of CHPS in Ghana, including but not limited to: high attrition among staff at health posts, lack of proper community entry and engagement, non-availability of essential logistics, lack of funding, and lack of community ownership.

5. Filling the human resource gap through public-private partnership: can private, community-based skilled birth attendants improve maternal health service utilization and health outcomes in a remote region of Bangladesh?

  • Comments: An example of how public-private collaboration can help countries close gaps in service utilization and health outcomes. While significant efforts are made to involve local community and take an equitable approach towards charging for services, the model nonetheless relies on user fees which stifle access, especially for the poor (N.B. OOP expenditures were already high in the region where this study was implemented).
  • Methods: Pre-post x-sectional w/ n = 1800 respondents at baseline at n = 1755 respondents three years post-baseline in the same project area
  • Takeaway: In Sunamganj District, Bangladesh where presence of a skilled birth attendant (SBA) at delivery is an abysmally low 27%, GSK and CARE achieved a dramatic increase in self-reported SBA at birth (and other MNCH outcomes) after introducing private - community skilled birth attendants (P-CSBA) linked to communities and the public health system. P-CSBAs charged for services according to a sliding scale where the extremely poor received services free of charge.

6. Resource requirements for community-based care in rural, deep-rural and peri-urban communities in South Africa: a comparative analysis in 2 South African provinces

  • Comments: Robust analysis from SAMRC and RHAP exploring how CHWs in rural vs. urban areas spend their time, and what this might mean for program costs associated with travel and service delivery.
  • Methods: Economic analysis
  • Takeaway: CHWs in both rural and urban settings spent most of their time performing home visits, although the % was higher in rural settings due to shorter travel times. Median time per home visit was 50% longer for CHWs in deep-rural areas compared to those in urban areas. Planners should assume a higher number of CHWs required to serve rural areas given the longer travel times and longer time spent per home visit.

7. Community health workers impact on maternal and child health outcomes in rural South Africa – a non-randomized two-group comparison study

  • Comments: Takes a successful model implemented in peri-urban settings in Cape Town and implements it in rural areas of Eastern Cape to assess differences in maternal and child outcomes over ~2.5 year period
  • Methods: Non-randomized, two-group comparison study of 1310 mother-infant pairs
  • Takeaway: While the intervention group did show marked improvements in targeted indicators (e.g., ANC attendance, exclusive breast-feeding, and treatment adherence), “the impact of CHWs in a rural area was less pronounced than in peri-urban areas. CHWs are likely to need enhanced support and supervision in the challenging rural context.”

8. Evaluating the effect of village health workers on hospital admission rates and their economic impact in the Kingdom of Bhutan

  • Comments: CHWs have long been touted as a way to reduce the burden on health facilities and thereby save costs, while extending healthcare services closer to communities. This paper models both outcomes using Ministry of Health data in Bhutan and focusing on the country’s unpaid cadre of Village Health Workers (VHWs). We hope future investments will also address the key ingredients that make VHWs successful - like fair pay, supervision, and other supports - and that come with their own costs!
  • Methods: Quantitative modeling (hospital admission rates and the potential disease cases averted when the average number of VHWs per health center is increased by one unit) + costing analysis
  • Takeaway: VHWs serve as a source of cost-savings for the Kingdom of Bhutan and also act as an economic buffer for more vulnerable communities, which the authors claim as rationale for increasing investments in the country’s struggling (and shrinking) VHW cadre.

9. Task sharing in family planning in Burkina Faso: quality of services delivered by the delegate [Article in French]

  • Comments: The purpose of this study was to assess the quality of family planning (FP) services offered by primary health care workers (PHCWs) and CHWs to whom tasks had been delegated (known as “delegatees”) by higher level providers (“delegators”). PHCWs were trained in IUD insertion and implants, while CHWs were trained in injectable contraceptives.
  • Methods: X-sectional w/ mixed methods (observation, document review, interviews)
  • Takeaway: There was no statistically significant difference in quality scores for delegators vs. delegatees. The authors conclude it is possible to transfer skills for (a) long-acting contraceptive methods to PHCWs as well as (b) the provision of injectable contraceptives to CHWs, while maintaining a satisfactory level of FP service quality.

10. Article processing charges are stalling the progress of African researchers: a call for urgent reforms

  • Comments: An important take on structural barriers that critically limit African researchers’ ability to contribute to research publication output (currently a shocking 1.3%!), placing much of the blame on the unintended consequences of hefty article processing charges by open access journals.
  • Methods: Commentary
  • Takeaway: Publication fees severely limit the publication and citation potential of African researchers. The authors call for urgent reforms to remove the constraints impacting African researchers’ ability to publish in high-impact journals, with takeaways for governments, donors & funders, and the international publishing industry.

Awesome, thanks for sharing @Carey_Westgate!

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