Community Health Toolkit

Fortnightly Community Health Research Round-Ups (2020)

Hi all,

Happy new year! I know there has been some engagement w/theCommunity Health Research Round-up in the past on this forum so I wanted to share the latest issue and start a thread to share new issues as they’re released. Hopefully some of this sparks some dialogue and, at the very least, it’s nice to have everything in one easy-to-access thread.

The issue below covers papers indexed (largely!) since December 17. Please feel free to reply to the list with anything we may have missed.

  • Should you have colleagues who’d like to receive these updates via email, please have them sign up here
  • An abridged version of the round-up is also available on twitter—please follow the Coalition’s handle, @CHW_impact, and tag relevant colleagues!
  • As always, previous editions of the round-up are available in our archive here

All the best,


Community Health Research Round-Up, Issue 023

Dec 17, 2019 - January 13, 2020

  1. Development assistance for community health workers in 114 low- and middle-income countries, 2007–2017
  • Comments: Helpful estimate of the level and trend of development assistance for CHW-related projects in LMICs over ~last decade by our very own CHIC member, Dan Palazuelos + company. Conclusion particularly of interest to colleagues at Financing Alliance, GFF ++

  • Methods: Analysis of OECD’s creditor reporting system database

  • Takeaway: The share of development assistance invested in the CHW projects was small, unstable and decreasing in recent years.

  1. The relative importance of material and non-material incentives for community health workers: Evidence from a discrete choice experiment in Western Kenya
  • Comments: Important data on how to optimize crumbs.

  • Methods: DCE (n = 199 CHWs in Kenya)

  • Takeaway: CHWs’ most preferred job characteristic was high levels of community appreciation for their work which was valued approximately equivalently to receiving a 2000 Kenya Shillings (~US $20) monthly transport allowance. These incentives were valued more than appreciation from health facility staff or trainings six times per year. [N.B. Salary not one of the options]

  1. Community health workers involvement in preventative care in primary healthcare: a systematic scoping review
  • Comments: N.B. The aim of the review was to look for interventions serving disadvantaged culturally and linguistically diverse patients that may be applicable to the Australian context, so the review is limited to OECD countries
  • Methods: Systematic scoping review
  • Takeaway: A high-quality evidence-base supporting the positive impact of CHWs supporting patients’ access to healthcare and influencing positive behaviour change was found. Positive impacts of CHW interventions included improvements in clinical disease indicators, screening rates and behavioural change. Education-focused interventions were more effective in improving patient behaviour, whereas navigation interventions were most effective in improving access to services. Implementation was enhanced by cultural and linguistic congruence and specific training of CHWs in the intervention but reduced by short duration interventions, dropouts and poor adherence of patients
  1. Unpacking the ‘black box’ of lay health worker processes in a US-based intervention
  • Comments: Does the much needed work of beginning to identify mechanisms that underly the effectiveness of CHW interventions. Useful concepts for future implementation research.
  • Methods: Direct observation using structured form
  • Takeaway: CHWs utilized multiple relational strategies, including preparing an environment that enables relationship building, using recognized teaching methods to engage learners and co-learners as well as using humor and employing culturally specific strategies such as hierarchical forms of address to create trust.
  1. Health Care Hotspotting — A Randomized, Controlled Trial
  • Comments: The Camden Coalition, the subject of Gawande’s 2011 superuser article and a lot of other press, released a widely reported trial this week. The RCT–for which they should be commended for running, suggests that making hotspotting work depends on who you are trying to help (sicker elderly vs. younger poor) and what the program is offering…Colleague Shreya Kangovi has tackled the implications for all of us, penning some eloquent thoughts on regression to the mean and intervention design on her twitter page
  • Methods: RCT
  • Takeaway: In this trial involving patients with very high use of health care services, readmission rates were not lower among patients randomly assigned to the Coalition’s program than among those who received usual care.
1 Like

I wasn’t familiar with Shreya Kangovi’s work but I really appreciated her Twitter commentary on the Camden Coalition study. These CHIC research round ups continue to prove very helpful, thank you for sharing!

Yes, Shreya is awesome! Here’s the next issue:

Community Health Research Round-Up, Issue 024

January 14, 2020 - January 27, 2020

  1. ‘Do you trust those data?’—a mixed-methods study assessing the quality of data reported by community health workers in Kenya and Malawi
  • Comments: High-quality data are essential to monitor and evaluate the performance, quality, coverage and equity of community health programs. The findings are damning. The strong recommendation for supportive supervision is notable

  • Methods: Mixed methods - quantitative data verification ratios + qualitative interviews

  • Takeaway: Only 15% of data were reported consistently between CHWs and their supervisors in Kenya + Malawi. Barriers to data quality mirrored those previously reported elsewhere including unavailability of data collection and reporting tools; inadequate training and supervision; lack of quality control mechanisms; and inadequate register completion. Supportive supervision should be provided to community health workers to ensure they collect and report high-quality data.

  1. Remuneration systems of community health workers in India and promoted maternal health outcomes: a cross-sectional study
  • Comments: This study assessed the association of remuneration systems of paid-for-performance ASHAs and salaried Anganwadi workers (AWWs) on seven maternal health outcomes in four states in India. More bad news for fans of pay-for-performance. (A reminder that the WHO’s CHW Guidelinesuggests not paying CHWs exclusively or predominantly according to performance-based incentives–see the rationale in RR018 under #4 here)

  • Methods: X-sectional

  • Takeaway: ASHAs’ home visits were not more strongly associated with health outcomes for which they were paid than outcomes for which they were unpaid. AWWs’ home visits were positively associated with awareness of NHDs, and associations varied for other recommended health behaviors.

  1. Talk to PAPA: A Systematic Review of Patient/Participant (PAPA) Feedback on Interactions With Community Health Workers Using a Depth Analysis Approach
  • Comments: Interesting premise - “because of their shared backgrounds, CHWs’ care of patients/program participants is assumed to be acceptable, and often not evaluated empirically.” This article does that across studies conducted in the USA
  • Methods: Systematic review + 5-dimensional depth analysis (focus, context, meaning, range,
    and voices)
  • Takeaway: Depth analyses elucidated a spectrum of patient responses from extremely positive to ambivalence to outright distrust and frustration with perceived CHW limitations.
  1. Efficacy of a Community Health Worker–Based Intervention in Improving Dietary Habits Among Community-Dwelling Older People: A Controlled, Crossover Trial in Japan
  • Comments: Interesting healthy ageing paper from Japan. The CHW-based intervention improved dietary habits among older people.
  • Methods: Controlled, crossover design
  • Takeaway: The dietary variety score in the immediate intervention group significantly increased in the initial 2-month period compared with the delayed intervention group (effect size 1.60 points; 95% CI 0.75, 2.45). The intervention had a similar effect in the delayed intervention group in the subsequent 2-month period and the effects persisted for at least 2 months after the intervention in the immediate intervention group.

Increasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi

  • Comments: Great use of routine data
  • Methods: Synthetic control
  • Takeaway: In a rural district in Malawi, uptake of ANC and intrapartum care increased considerably following an intervention using CHWs to identify pregnant women and link them to care. Except for the utilisation of postnatal care, control sites also exhibited increases between pre- and post-intervention, but increases were minimal in comparison to the CHW intervention sites
  1. The supervisory relationships of community health workers in primary health care: social network analysis of ward-based outreach teams in Ngaka Modiri Molema District, South Africa
  • Comments: Sent in by round-up subscriber, Helen Schneider! Interesting identification of critical actors and patterns of relationships in the supervision of ward-based outreach teams (WBOTs) in a rural South African district. (N.B. A WBOT consists of an average of six CHWs, led by a professional nurse called a team leader)
  • Methods: Cross-sectional, social network analysis
  • Takeaway: Supportive supervision of CHWs can be thought of as a system of horizontal and vertical relationships that go beyond just one supervisor–supervisee interaction. In this study, supervisory relationships within teams functioned better than those between teams and the rest of the PHC system.
  1. Evaluation of a training program on primary eye care for an Accredited Social Health Activist (ASHA) in an urban district
  • Comments: More potential interventions that can be carried out by CHWs.
  • Methods: Pre/post, 1 year follow-up
  • Takeaway: ASHAs can be trained as PEC workers provided they have adequate support. Mean knowledge score increased from 14.96 (±4.34) pre-training to 25.38 (±3.48) post- training and sustained at 21.75 (±4.16) at 1year. Monthly average OPD of vision centres increased by 23.6% after ASHA training.
1 Like

So our little round-up just released its 25th issue! The goods are below :slight_smile:

Community Health Research Round-Up, Issue 025
January 28, 2020 - February 10, 2020

  1. Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment
  • Comments: Cost data for the Individualized Management for Patient-Centered Targets (IMPaCT) RCT in the USA. Yet more data suggesting that investment in CHWs produces a positive ROI!

  • Methods: Annualized expenses, cost savings, & return on investment for an average team of community health workers

  • Takeaway: Every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.

  1. The cost of the training and supervision of community health workers to improve exclusive breastfeeding amongst mothers in a cluster randomised controlled trial in South Africa
  • Comments: More cost data. This time from an RCT in South Africa

  • Methods: retrospective cost analysis, from an implementer’s perspective, of CHWs providing care and support to pregnant women and women with babies aged < 1 year in South Africa.

  • Takeaway: The cost per additional mother practicing exclusive breastfeeding was calculated to be US$7647, 88, with the supervision component of the intervention constituting 64% of the trial costs. Whilst CHWs may be a low cost alternative to professional health workers, they require skilled supervision to operate effectively. CHW training and supervision was shown to effectively improve coverage of CHW visits, improve knowledge of mothers about child care practices, as well as leading to improved household breastfeeding practices.

  1. Integrating Community Health Workers Within Patient Protection and Affordable Care Act Implementation
  • Comments: Discusses different strategies for integrating CHW models within Patient Protection and Affordable Care Act (PPACA) implementation through facilitated enrollment strategies, patient-centered medical homes, coordination and expansion of health information technology efforts, and also discusses payment options for such integration.

  • Methods: Programmatic and policy analysis, describing several components of PPACA that offer natural leverage points for the integration of CHWs

  • Takeaway: Community health workers’ unique expertise in conducting outreach make them well positioned to help enroll people in Medicaid or insurance offered by Health Benefit Exchanges. New payment models provide opportunities to fund and sustain CHWs.

  1. A Novel Lay Health Worker Training to Help Women Engage in Postabortion Contraception and Well-Woman Care
  • Comments: New intervention alert - postabortion contraception care delivered by CHWs. (N.B. b/c only four CHWs have completed the training curriculum substantial pre- and posttraining assessments are not possible. Only participant responses are reported.)
  • Methods: Pilot - (i) Evaluation of LHWs’ knowledge and skills throughout the training period consists of self-assessment, simulation trainer-assessment of LHWs, and participant assessment, (ii) LHW simulation session video recordings are reviewed by two study team members to evaluate LWH counseling skills using a modified Motivational Interviewing Global Rubric, (iii) Intervention participants assessed satisfaction with LHW skills using 5-point Likert-type scales and open-ended questions
  • Takeaway: When piloted with 60 patients presenting for abortion who lacked a regular health care provider and desired to delay pregnancy for at least 6 months, participants found the lay health worker skills and the counseling session highly acceptable. Specifically, participants reported feeling comfortable speaking to lay health workers about contraception and reproductive health care.
  1. Factors associated with home visits by volunteer community health workers to implement a home-fortification intervention in Bangladesh: a multilevel analysis
  • Comments: If you pay people for their work, they are able to actually do it! (And some other helpful takeaways on home visitation.) Notably, no talk of simply requiring proactive home visits.
  • Methods: Cross-sectional survey, semi-structured interviews, and analysis of programme-related data from sub-districts included in the caregiver survey of BRAC’s home-fortification programme
  • Takeaway: Households characteristics matter - those with older children and located >300 m from the SS’s house were less likely to have been visited by the SS, whereas those with caregivers who had ≥5 years of schooling were more likely to have been visited by the SS. SS characteristics matter - households in the catchment area of older SS aged >50 years were less likely to have been visited by the SS. Program characteristics matter - those with SS who received incentives of >800 BDT were more likely to have been visited by the SS.
  1. Bringing severe acute malnutrition treatment close to households through community health workers can lead to early admissions and improved discharge outcomes
  • Comments: More evidence that distance matters. (For more on SAM, see Can community health workers manage uncomplicated severe acute malnutrition? review included in RR 002)
  • Methods: Secondary data analysis of this trial consisting of the disaggregation of children by their treatment provider independent of the health area, with the aim to assess whether providing treatment close to households through CHWs allows children to be admitted into treatment earlier and in a relatively less severe condition, with a positive impact on the treatment outcomes compared to standard care at the health facility (HF)
  • Takeaway: The addition of SAM treatment in the curative tasks that the CHWs provided to the families resulted in earlier admission and more integrated care for children than those associated with health facilities. CHW treatment also achieved better discharge outcomes than standard community treatment. (The results showed fewer children with edema at admission in the CHW group than in the HF group, anthropometric measurements at admission were higher in the CHW group, more children in the CHW group were cured, and there were fewer defaulters than in the HF group. The study results also showed that CHWs provided more integrated care, as they diagnosed and treated significantly more cases of infectious diseases (diarrhea, malaria, ARI) than HFs)
  1. Using mHealth to improve health care delivery in India: A qualitative examination of the perspectives of community health workers and beneficiaries
  • Comments: This study aimed to examine CHW and patients’ perceptions of a new mHealth intervention (Common Application Software [CAS]) for CHWs in India
  • Methods: Qual (thematically coded interviews). CHWs (n = 32) and patients (n = 55)
  • Takeaway: The mHealth intervention was acceptable to the CHWs who felt that CAS improved their status in the communities where they worked. Patients’ views were a mix of positive and negative perceptions. The divergent views between CHWs and beneficiaries surrounding the use and impact of CAS highlight an underlying mistrust, socio-cultural barriers in engagement, and technological barriers in implementation.

Issues 26 + 27. Item #3 from issue 027 on the design and implementation of a mobile health electronic data capture platform that functions in fully-disconnected settings is likely of interest to this group!


Community Health Research Round-Up, Issue 026

February 11, 2020 - February 24, 2020

  1. An Emerging Model for Community Health Worker–Based Chronic Care Management for Patients With High Health Care Costs in Rural Appalachia
  • Comments: Helpful look at the process by which insurance companies in the USA offered their resources in support of a CHW program that improves diabetes outcomes

  • Methods: Case study

  • Takeaway: The team implemented a 2-pronged strategy of seeking grant funding and concomitantly engaging health insurance payers to validate the model and establish a payment model. Engaging the payers from the beginning of the project was a critical step.Two milestones: (1) Medicaid-managed care organizations agreed to quarterly meetings for the purpose of monitoring the project (2) Grant funding enabled the team to replicate the model at a scale that would enroll a population large enough produce generalizable results.

  1. An educational intervention in rural Uganda: Risk-targeted home talks by village health workers
  • Comments: Given the ongoing interest in precision public health, this is a nifty study looking at targeting health talks to people with health census-identified risk factors (malnutrition, diarrhea, respiratory disease, HIV, and poverty due to family size)

  • Methods: Each participant received a pre-test, immediate post-test and delayed post-test on their assigned HT topic and a pre-test and delayed post-test on a randomly assigned control topic. Differences in scoring were examined against controls and over time using paired t-tests and general linear regression analysis, respectively.

  • Takeaway: Home talks increase health knowledge of rural African mothers. Learners retain knowledge over time. Lack of literacy does not impede learning core messages.

  1. Development and Evaluation of a Mental Health Training Program for Community Health Workers in Indonesia
  1. Rural-Urban Differences in Roles and Support for Community Health Workers in the Midwest
  • Comments: More reflections on the urban/rural divide. Compare w/this review on expanding the use of community health workers in urban settings in RR issue 020.
  • Methods: Secondary analysis of the Community Health Worker Employer Survey in Nebraska
  • Takeaway: There may not be enough support or definition in the roles of CHWs in the Patient Protection and Affordable Care Act to provide a stable workforce structure to employ CHWs in community settings. Currently, Nebraska has adopted a set of core competencies and provides training resources and policy recommendations for CHWs. There is still considerable flexibility in allowing employers or organizations to train CHWs as they see fit since there are a variety of needs CHWs can help fill, which differ across urban and rural settings.

Community Health Research Round-Up, Issue 027

February 24, 2020 - March 9, 2020

  1. Theory-based Development of an Implementation Intervention Utilizing Community Health Workers to Increase Palliative Care Use
  • Comments: Interesting approach to intervention development. Would be great to see the efficacy tested

  • Methods: Description of intervention development

  • Takeaway: The Behavior Change Wheel (BCW) and Theoretical Domains Framework (TDF) were used to systematically investigate the barriers to use of palliative care services, identify patient and physician target behaviors for change, and design a pragmatic CHW-led intervention based on the barriers and target behaviors

  1. Clinic-Based Community Health Worker Integration: Community Health Workers’, Employers’, and Patients’ Perceptions of Readiness
  • Comments: Readiness to adopt any change and expect success requires a clear set of activities and support as a precursor to change. This is an interesting look at the (oft-overlooked) psychological readiness of those involved in integrating CHWs into clinic-based teams (cCHWs).

  • Methods: Mixed-methods cross-sectional (73 CHWs, 58 employers, & 106 patients)

  • Takeaway: CHWs felt significantly stronger readiness (i.e. appropriateness, management support, & change efficacy) to serve as clinically-integrated CHWs than did employers to hire them. Employers felt stronger readiness to hire than patients to utilize cCHW services.

  1. Design and implementation of a mobile health electronic data capture platform that functions in fully-disconnected settings: a pilot study in rural Liberia
  • Comments: A cool article by our friends at LMH for an increasingly rare, but absolutely critical use case. Context: “Many existing electronic data capture (EDC) mobile software tools are built for occasionally-disconnected settings, allowing a user to collect data while out of range of a cell tower and transmit data to a central server when he/she regains a network connection. However, few tools exist that can be used indefinitely in fully-disconnected settings, where a user will never have access to the internet or a cell network.”

  • Methods: Case study describing the design, pilot-testing, and scale-up of an open-source fork of Open Data Kit Collect that allows for offline Bluetooth-based bidirectional data transfer, enabling a system in which permanently-offline users can collect data and receive application updates.

  • Takeaway: Running a fully-offline EDC program that completely bypasses the cellular network was found to be feasible; the system is still running, over 4 years after the initial pilot program.


Thanks for sharing @mballard!

The paper about Last Mile Health’s use of an ODK fork for peer-to-peer data sync in fully offline settings is indeed very interesting. Many on this form have used different versions of ODK a bunch, and we’ve wanted to work on an offline sync feature like that for the CHT for some time. We just recently received some funding to work on this in the coming year and I imagine @marc and @gareth will be interested in the technical details of Avi’s approach . Here’s another insight from the paper that I’ve discussed offline with Avi:

We also found that many CHWs would conduct client visits without their mobile device. They would then retroactively complete the forms during the evening, either from written notes or from memory. We initially identified this through field observations, and subsequently through an analysis of the timestamps automatically taken at the start and end of each form, noticing that batches of forms would often be filled out at the end of the day by a CHW. Within the time period analyzed, the median time between forms (excluding the time between the last form of a given day to the first form of the next day) was 10 min, which implies that the majority of CHWs were simply using the phones for retroactive “data entry” rather than using them as decision-support tools during the actual patient interaction. This finding led to field-based retraining of CHWs to encourage use of the phones as intended.

I know @erika and others are thinking about as we work on new tools for flagging data quality issues and prompting supervisors to address them.

Hey all,

Breaking with our usual approach of summarizing the latest community health academic papers every two weeks, we just released a special COVID-19 research-round up.

This edition focuses on evidence on the roles of community health workers in pandemics & epidemics and is below

As an additional resource, Community Health Impact Coalition members are sharing COVID-19 explainers, internal policies, clinical protocols, & more live on this doc: Please do use, contribute, and share.

Community Health Research Round-Up, Issue 028

Special COVID-19 Edition

  1. Community Health Workers and Pandemic Preparedness: Current and Prospective Roles
  • Comments: Perspective piece drawing from the response to the 2014 Ebola and 2015 Zika epidemics
  • Methods: Perspective
  • Takeaway: CHWs promoted pandemic preparedness prior to the epidemics by increasing the access to health services and products within communities, communicating health concepts in a culturally appropriate fashion, and reducing the burdens felt by formal healthcare systems. During the epidemics, CHWs promoted pandemic preparedness by acting as community-level educators and mobilizers, contributing to surveillance systems, and filling health service gaps.
  1. Lessons Learned from Reinforcing Epidemiologic Surveillance During the 2017 Ebola Outbreak in the Likati District, Democratic Republic of the Congo
  • Comments: Comprehensive lessons from ebola in DRC - I have highlighted the community health recommendations below
  • Methods: Case study
  • Takeaway: Community health workers supported case finding and contact monitoring activities. At the community level, provide participatory training and supportive supervision to community health workers by reinforcing: (i) Knowledge of EVD signs and symptoms; (ii) Comprehension and application of outbreak definitions relevant to community health worker roles/responsibilities (community case definition, alert, contact), (ii) Procedures for reporting alerts, suspected cases, and other unexplained illness or deaths in the community; (iv) Procedures for tracing and monitoring contacts; and (v) Best practices for infection prevention and control to protect against disease exposure during direct interactions with suspected cases and contacts.
  1. Protecting Home Health Care Workers: A Challenge to Pandemic Influenza Preparedness Planning
  • Comments: A great summary of healthcare safety, security and wellness considerations
  • Methods: Summarized findings from a national stakeholder meeting
  • Takeaway: Federal, state, and local pandemic preparedness planners should consider approaches to help home health care workers protect their income; obtain access to health care, especially in light of their low rate of insurance coverage; obtain structural support for child care and transportation; and receive the necessary training for caring for clients
  1. The first mile: community experience of outbreak control during an Ebola outbreak in Luwero District, Uganda
  • Comments: Interesting piece on the cultural dimensions of public health messaging (adaptation!)
  • Methods: First-hand ethnographic data from the center of an Ebola outbreak in Luwero Country, Uganda
  • Takeaway: Explanations of the disease were undermined by an insensitivity to local culture, a mismatch between information circulated and the local interpretative framework, and the inability of the emergency response team to take the time needed to listen and empathize with community needs. Stigmatization of the local community – in particular its belief in amayembe spirits – fuelled historical distrust of the external health system and engendered community-level resistance to early detection.
  1. Piloting a participatory, community-based health information system for strengthening community-based health services: findings of a cluster-randomized controlled trial in the slums of Freetown, Sierra Leone
  • Comments: Helpful trial of a CHIS during three separate epidemic shocks.
  • Methods: C-RCT
  • Takeaway: Implemented under challenging conditions of cholera and Ebola epidemics, the study provides evidence of moderate effectiveness of the PCBHIS intervention in: improving CHW functionality, improving healthy household behaviors and healthcare-seeking behaviors, as well as strengthening the capacity of Ward Development Committees to fulfil their roles.

6 & 7. Effect of the Ebola-virus-disease epidemic on malaria case management in Guinea, 2014: a cross-sectional survey of health facilities & Implementation research on community health workers’ provision of maternal and child health services in rural Liberia

  • Comments: A pair of complementary studies: the first demonstrating the interruption of PHC services during an epidemic in the context of a weak CH system, the second demonstrating the alternative!
  • Methods: x-sectional (Guinea), repeated cross-sectional cluster surveys before (Liberia)
  • Takeaway: (i) The reduction in the delivery of malaria care because of the Ebola-virus-disease epidemic threatened malaria control in Guinea. (ii) Despite the Ebola virus disease outbreak, which caused substantial declines in health-care utilization
    in other regions of Liberia, a district with a strong CHW program showed increases in health-care use from formal providers for fever, acute respiratory infection and diarrhoea among children and facility-based delivery among pregnant women.
  1. PREPRINT: Prevent, Detect, Respond: Rapidly expanding healthcare teams through community health workers in the fight against COVID-19
  • Comments: Rapidly expanding healthcare teams through community health workers (CHWs) has
    proven fundamental in effective epidemic response. This article explores how lessons from Liberia’s ebola response are being applied to fight COVID-19
  • Methods: Commentary
  • Takeaway: CHWs can (i) Prevent: infection prevention/control measures (social distancing, hand hygiene stations, education) (ii) Detect: signs and symptoms as part of Liberia’s community event-based surveillance system (MOH may alsl involve them in testing), (iii) Respond: support self-isolation, monitor for clinical deterioration & organize rapid referral

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.

Hi All -

I’m stepping in for @mballard today. I recently joined the Community Health Impact Coalition and am pleased to share the latest version of our fortnightly Research Round-Up. This issue covers papers indexed (largely!) since March 24. Please feel free to reply to this thread with anything we may have missed.

Because I’m a new user, I can only post two links at a time. Apologies in advance for multiple posts on this thread! :slight_smile:

Community Health Research Round-Up, Issue 030

March 24, 2020 - April 6, 2020

  1. In-kind incentives and health worker performance: Experimental evidence from El Salvador
  • Comments: BMGF-funded study by IADB evaluates effect of in-kind, group-based incentives on community health worker performance. Incentives were awarded in the form of “points” that teams could choose to redeem for laptops, air conditioners, microwaves, and other assets. (N.B In their recent guideline - which came out at the end of 2018 - the WHO suggests not the WHO suggests not paying CHWs exclusively or predominantly according to performance-based incentives (PBI). The rationale for this recommendation was based on the evidence of potential harm: (1) PBI encouraged uneven focus on certain activities due to their association with higher incentives, especially when CHWs had no basic remuneration, leading to the neglect of other important activities or responsibilities + (2) CHWs expressed dissatisfaction with performance-based incentive models in relation to amounts paid and inconsistent and incomplete payment of incentives. Only the first pitfall is considered in this study)

  • Methods: Randomized trial (12 month intervention)

  • Takeaway: In-kind, group-based incentives generated significant improvements in a variety of indicators (community outreach, quality of care, timeliness of care, and utilization of maternal and child health services after 12 months); “in-kind group incentives may be a viable alternative to monetary incentives in certain contexts” ( Editorial note: that context being a barter economy…?)

[Post 2/5]

  1. Pluralism and practicality: village health workers’ responses to contested meanings of mental illness in Southern Malawi
  • Comments: Explores potential role for Malawian health surveillance assistants (HSAs) to help patients and communities navigate tensions between traditional and biomedical explanations for mental illness

  • Methods: Qualitative

  • Takeaway: Traditional beliefs and spirituality can impact perceptions of the nature and causes of psychological distress; with the right support, HSAs can help promote a biomedical understanding of mental illness in communities where traditional “bewitchment” ideas dominate. A call for pluralism + pragmatism

3. Optimizing Test and Treat in Malawi: health care worker perspectives on barriers and facilitators to ART initiation among HIV-infected clients who feel healthy

  • Comments: Health workers (including CHWs) participating in focus groups report that patients who feel healthy are less likely to initiate ART even after a positive diagnosis due to perception that risks (stigma, disruption of daily routine, side effects) outweigh benefits

  • Methods: Focus group discussions

  • Takeaway: To achieve universal test and treat, more innovative service delivery methods such as potentially extending HIV services like ART initiation beyond the facility setting are needed (although more research would be required )

[Post 3/5]

  1. The fight against lymphatic filariasis: perceptions of community drug distributors during mass drug administration in coastal Kenya
  • Comments: Examines factors that mediate relations between community members and community drug distributors (CDDs) during mass drug administration campaigns (trust, community knowledge, timing of campaigns, fragmented supervision, CDD bias)
  • Methods: Focus group + semi-structured interviews
  • Takeaway: Motivation, supervision, and ongoing training influence quality of care by CDDs in Kenya
  1. Strengthening health care worker engagement with early adolescence in low- and middle-income countries: an overdue area for action
  • Comments: Colleagues from WHO, Kenya MOH, Nepal NFCC, Pop Council, and Columbia call for building health worker capacity to engage with early adolescents since this is a formative time for shaping preventative and promotive health behaviors

  • Methods: Advocacy paper

  • Takeaway: We need to keep innovating on how community health teams can better reach adolescents - a key demographic!

Not sure what happened to post 4/5 and 5/5, but will note that the archive can be found here.

The latest round-up is below. Note particularly # 2 & # 5


  1. National UK programme of community health workers for COVID-19 response
  • Comments: ICYMI, there was a great recent comment in the Lancet calling for a national UK CHW cadre for COVID-19 response. This follows similar calls in other media and other high-income countries for similar. Thanks to founding Coalition member, PIH, Massachusetts, USA has begun!
  • Methods: Commentary
  • Takeaway: Based on experience in Brazil, Pakistan, Ethiopia, and other nations, the authors propose a large-scale emergency programme to train CHWs to support people in their homes, initially the most vulnerable but with potential to provide a long-term model of care in the UK
  1. Using mobile phones to improve community health workers performance in low-and-middle-income countries
  • Comments: Probably a question better answered by a systematic review, but this “debate”-style paper does a good job hitting a wide swathe of relevant issues
  • Methods: Non-systematic review
  • Takeaway: mHealth interventions can improve CHWs’ performance and work environment in LMICs. There are some challenges concerning the implementation and sustainability of mobile phone interventions (incl. lack of CHWs training, weak technical support, issues of internet connectivity, administrative and management related issues, poor sustainability of pilot projects, and high investment, operational, and maintenance costs of equipment.) Future research efforts and policy dialogue should be directed to explore health system readiness for adopting sustainable mHealth solutions.
  1. Prioritizing Competencies for “Research” Promotores and Community Health Workers
  • Comments: Interesting paper that attempts to identifying necessary competencies for CHWs participating in research. Table 1 could serve as a helpful checklist for those involving CHWs in research planning, implementation or reporting.
  • Methods: Mixed-methods - survey and focus-groups
  • Takeaway: There is a clear need for research ethics education designed specifically for people who have limited or no formal academic research training—especially when these individuals play a key role on the research team and related research outcomes. This list of competencies is a start.
  1. Performance of volunteer community health workers in implementing home-fortification interventions in Bangladesh: A qualitative investigation
  • Comments: This qualitative study was conducted as part of a large evaluation of the MIYCN Home- fortification Programme (see RR 029). We’re just shocked by the conclusion!
  • Methods: in-depth interviews, focus group discussions, and key informant interviews w/ thematic analysis
  • Takeaway: Getting an adequate number of volunteers at the community level was a challenge for BRAC local offices. The high dropout of the CHWs mostly related to no or insufficient earning options. The authors conclude: “BRAC’s [CHWs] require a living wage to earn essential income for their family. Considering the current socio-cultural and economic context of Bangladesh, BRAC may need to revise the existing volunteer [CHW] model to ensure that [CHWs] receive an adequate income so that they can devote themselves to implementing its home-fortification intervention”
  1. Surgical symptomatic knowledge among medical staff and community health workers in rural Cambodia: a descriptive study for workforce improvement
  • Comments: The latest in a long line of studies to assess CHWs on subjects for which they have never received trained. The overarching point, however, is a good one and speaks to the need for further integration of CHWs into national health systems.
  • Methods: Self-report questionnaire
  • Takeaway: Knowledge of surgical symptoms among medical staff and CHWs was inadequate. To at least double the surgical workforce by 2030 successfully, accurate evaluation and improvement of surgical symptomatic knowledge among medical staff in rural areas is crucial.
  1. Assessing community health worker service delivery in humanitarian settings
  • Comments: Helpful and timely review from colleagues at UNICEF
  • Methods: Rapid review, summarized as a viewpoint
  • Takeaway: Several, including: (i) more work is needed to develop standard definitions for the spectrum of essential health services. (ii) a database of health facilities, human resources (including CHWs), and services available should be developed pre-crisis, (ii) Cell phone-based data collection could enable evaluation in otherwise inaccessible settings, including in emergencies, (iv) most key implementation strength indicators at community level are not included in the WHO’s HeRAMSHealth Resources Availability Mapping System (HeRAMS) tool
  1. The everyday political economy of health: community health workers and the response to the 2015 Zika outbreak in Brazil
  • Comments: Another cogent and timely political economy piece by our colleague, João Nunes
  • Takeaway: The working conditions of CHWs, overwhelmingly characterized by precarity and low pay, reveal the presence of global neoliberal dynamics pertaining to the reconfiguration of the Brazilian state as healthcare provider in a context of encroaching austerity, privatization and narrowly-defined cost-efficiency. These dynamics impacted detrimentally upon the effectiveness of the Zika response.

Hi All,

The latest round-up (Issue 032) is below. We’re light on digital / mHealth topics this week, although #7 contains a subtle push for equipping CHWs with phones (in the USA).


1. Knowledge of Obstetric and Neonatal Danger Signs among Community Health Workers in the Rongo Sub-County of Migori County, Kenya: Results of a Community-based Cross-Sectional Survey

  • Comments: From our friends at Lwala Community Health Alliance! The team surveyed two groups of community health volunteers: one group had received training on obstetric & neonatal danger signs, and the other group had not. As we expected, the volunteers who received training outperformed on all indicators.
  • Methods: X-sectional survey
  • Takeaway: We cannot neglect the need for frequent training of CHWs.

2. Strengthening Public Health Systems: Policy Ideas from a Governance Perspective [Full Paper] [Blog]

  • Comments: In Bihar, CHWs do not receive steady wages and endure regular scolding at management meetings. Nonetheless, they are expected to operate on the frontlines in our COVID response. This timely paper from the World Bank Development Research Group takes a look at why the global community has underinvested in CHWs, focusing on the Indian context.
  • Method: Descriptive survey, applying economic theory of principal-agent relationships
  • Takeaway: Bihar’s quasi-volunteer CHWs earn high-powered incentives rather than wages. Politicians are reluctant to professionalize CHWs in an institutional context dominated by rent-seeking behavior and systemic distrust. The current pandemic presents a rare opportunity to overturn the status quo. Economic theory points to the need for fair, steady wages for CHWs and a workforce approach that prioritizes their intrinsic motivation.

3. Impact of Community Health Worker Certification on Workforce and Service Delivery for Asthma and Other Selected Chronic Diseases

  • Comments: This technical brief from the US Agency for Healthcare Research and Quality (AHRQ) takes a closer look at how CHW certification impacts patient health outcomes and CHW workforce outcomes (recruitment, retention, financial sustainability, and workforce development). N.B.: WHO suggests competency-based formal certification for CHWs.
  • Method: Technical brief (based on rapid review of published & grey literature plus key informant interviews)
  • Takeaway: The perceived positive impact of CHW certification is undermined by lack of rigorous evidence. The authors recognize a growing interest in the topic of certification and call for further research on the associations between CHW certification and patient health outcomes, perspectives on the usefulness of CHW certification, best practices for establishing CHW certification programs, and CHWs’ own beliefs about certification. Until we have more evidence, CHW certification programs will remain in infancy.

4. Investigating the early impact of the Trump Administration’s Global Gag Rule on sexual and reproductive health service delivery in Uganda

  • Comments: The authors examine the impact of the GGR on various sexual and reproductive health services in Uganda, including CHW engagement in family planning activities.
  • Method: Panel analysis
  • Takeaway: The GGR has significantly reduced CHW involvement in family planning activities in select sites in Uganda (i.e., those “most exposed” to the consequences of the GGR).

5. Promoting Hispanic Immigrant Health via Community Health Workers and Motivational Interviewing

  • Comments: The Healthy Fit health promotion program serves over 2,500 low-income Hispanic immigrants in El Paso, Texas. One of Healthy Fit’s “innovative strategies” involves using CHWs to recruit participants, deliver health promotion messages, and conduct motivational interviews to promote behavior change by participants.
  • Method: Article commentary
  • Takeaway: Healthy Fit is a novel program linking CHWs, vouchers, and motivational interviewing techniques to address the health needs of Hispanic immigrants.

6. Toward an institutional perspective on social capital health interventions: lay community health workers as social capital builders

  • Comments: CHW social networks provide a targeted platform for CHWs to deliver health interventions as well as build social capital.
  • Methods: Lit review + perspective
  • Takeaways: CHWs play a key role in brokering relationships among community members and institutions. Integrating CHWs into the formal health system can improve the effectiveness of CHWs. As we consider the role played by CHWs in shielding the vulnerable from the brunt of COVID-19, this article reminds us that CHWs will be most effective if they are integrated into and supported by the national health system as well as their communities.

7. Deploying Community Health Workers to Support Medically and Socially At-Risk Patients in a Pediatric Primary Care Population

  • Comments: The intervention deployed CHWs in an urban, academic pediatric primary care system. Over 1000 patients were connected to CHWs over a ~2-year period. Early learnings point to the importance of modified outreach processes (CHW phone > clinic phone, home visits), trust (it’s key!), and community partner alignment.
  • Methods: Evaluation of program embedded within Cincinnati Children’s general pediatrics, complex care, adolescent medicine, and school-based health clinics
  • Takeaways: CHWs are effective when tightly integrated into and supported by the health systems in which they operate and communities in which they serve: “The CHWs bring a face to care that families relate to, connect with, and trust.”

8. Safe Start Community Health Worker Program: A Multisector Partnership to Improve Perinatal Outcomes Among Low-Income Pregnant Women With Chronic Health Conditions

  • Comments: The latest in a series of studies on integrating CHWs into high-volume urban hospital settings in the USA (see Research Round-Up 030 for more), this time focusing on a program in Philadelphia, PA.
  • Methods: Quasi-experimental
  • Takeaways: Participants in the Safe Start CHW program demonstrated improved engagement in care, reduced antenatal inpatient admissions, and shorter neonatal intensive care unit stays.

9. Malaria knowledge and experiences with community health workers among recently pregnant women in Malawi

  • Comments: WHO target of 85% coverage of 3 doses of IPTp has not been met in Malawi, even though most women are attending 3+ ANC visits. This study explores women’s knowledge of malaria risks during pregnancy and considers CHW interventions as a way to bridge knowledge gaps.
  • Methods: Pre-implementation baseline survey administered to recently pregnant women (n=370) in two districts in Malawi (Nkhata Bay and Ntcheu)
  • Takeaway: Very few respondents were aware of IPTp as a means of preventing malaria during pregnancy. Most women had a positive view towards CHWs, although only a third reported talking to a CHW during their most recent pregnancy, and among those very few addressed IPTp. To improve awareness and uptake of IPTp, CHWs may need additional education on this topic. (N.B. respondents also cited barriers that are largely unaffected by CHWs education, such as stock-outs of malaria tests and distance to treatment)

10. Hot off the press! COVID-19: It Ain’t Over Until There’s PPE All Over

  • Comments: In our latest article, CHIC calls attention to the critical bottleneck standing in the way of decisive action in our COVID-19 response: community health workers—despite being a critical part of the response—are not receiving personal protective equipment (PPE).
  • Takeaway : None of us are safe until all health workers are protected. Achieving PPE for all is not only necessary, but possible. Read the full article on Think Global Health to find out how.
1 Like

Thanks for sharing @Carey_Westgate! Congrats to you and @helenelizabeth @amanda and @mballard for the Think Global Health piece. The Community Health Impact Coalition is doing fantastic covid advocacy lately. For anyonbe on the forum who hasn’t come across the PPE for All campaign yet, there’s also a short video with testimony from CHWs that is worth watching: