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.
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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.
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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.
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