Community Health Toolkit

Fortnightly Community Health Research Round-Ups (2020)

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.

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!

1 Like

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.

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:


Hi All -

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

7. Social Determinants of Health and Community Health Agent Work

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

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

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

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

Hi all,

Am chiming in w/issue 035. This is a really strong issue that I’d encourage you to scroll through–items #1,2,3, 4, 6, 8, & 9 are all salient to mobile app design & data collection more generally.


Community Health Research Round-Up, Issue 035
June 2 - June 15, 2020

1. Community health workers for pandemic response: a rapid evidence synthesis

  • Comments: A more thorough complement to the COVID-19 Special Edition Research Roundup from March
  • Methods: Rapid evidence synthesis including 36 articles
  • Takeaway: CHWs play a critical role in pandemics. Evidence came mostly from LMICS; evidence from high-income countries was scant. Most common additional activities during pandemics were community awareness and contact tracing. It is important to ensure role clarity, training, supportive supervision, as well as CHW work satisfaction, health and well-being. Providing PPE, housing allowance, training opportunities, transportation allowance, improving salaries (paid on time) & awards in high-profile public events contributed to better recruitment and retention.

2. The distinctive roles of urban community health workers in low- and middle-income countries: a scoping review of the literature

  • Comments: Urbanization will be a defining feature of low- and middle-income countries (LMICs) in the next decades; this study is the first to systematically examine urban CHW roles in LMICs.
  • Methods: Scoping review including 160 studies
  • Takeaway: There are significant similarities in the way CHW roles are delivered in both urban and rural contexts. This may reflect common barriers to accessing health services (e.g. limited transport) and underlying determinants of poor health (e.g. precarious livelihoods) across urban & rural populations–however, it may also be the result of failure to pay sufficient attention to the different realities of urban settings/the simplistic transplantation of rural models to urban contexts. Only two urban adaptations were identified: targeting low-income neighbourhoods (vs. population-wide services) and stigmatized communities (e.g. MSM) who might self-exclude from health services.

3. How do decision-makers use evidence in community health policy and financing decisions? A qualitative study and conceptual framework in four African countries

  • Comments: This study was conducted to understand the use of evidence in policy and financing decisions for large-scale community health programmes in low- and middle-income countries
  • Methods: Qualitative (key informant interviews with 43 respondents in countries with community health embedded in national UHC strategies - Ethiopia, Kenya, Malawi, Mozambique)
  • Takeaway: Evidence use in national community health policy and financing decisions is limited by capacity of decision-makers to use it + perceived poor quality. This perception stems from (i) desire for local evidence that reflects the context, and (ii)much existing economic evidence does not deal with what decision-makers value when it comes to community health systems—i.e. coverage and (to a lesser extent) quality. Elected officials also face structural obstacles to evidence use, including the outsized influence of donor priorities

4. When financial incentives backfire: Evidence from a community health worker experiment in Uganda

  • Comments: Entrepreneurial CHW models are growing in popularity. This study examines how an entrepreneurial community health worker (CHW) model affects CHW effort compared to a free distribution model.
  • Methods: Randomized trial
  • Takeaway: The growth in entrepreneurial CHW models is at odds with a large body of economics literature that documents that households are very sensitive to the price of health products. This study found that, despite stronger financial incentives (CHWs kept the sales revenue), the entrepreneurial model led to less effort (fewer household visits) than the free delivery model and dampened demand. Qualitative evidence suggests that selling had a social penalty whereas free distribution was socially rewarding. Implementors of CHW programs should think carefully before incorporating entrepreneurial features and strive to understand how these features compare to alternatives.

5. Community Health Worker Initiatives: An Approach to Design and Measurement

  • Comments: Another logic model! Though this one is specifically tailed to the distinct bodies of work occurring at a statewide policy level (e.g. vs. Naimoli 2014) so may be particularly relevant for US colleagues
  • Methods: Three phases: (1) gathering and organizing M&E metrics currently used by various CDC organizational units; (2) developing a logic model; and (3) mapping M&E metrics to the logic model.
  • Takeaway: The logic model presents the policy activities needed at
    a statewide infrastructural level, related inputs, and the
    outcomes resulting from these. Public health practitioners can use existing metrics or develop new ones to measure the outcomes reflected in the
    logic model.

6&7. Impact of mobile health-enhanced supportive supervision and supply chain management on appropriate integrated community case management of malaria, diarrhoea, and pneumonia in children 2-59 months: A cluster randomised trial in Eastern Province, Zambia& Cost analysis of integrated community case management of childhood malaria, diarrhea and pneumonia enhanced by mobile health technology in rural Zambia

  • Comments: A randomized trial with cost data! This study looked at if mHealth technology could be used to strengthen supervision and supply chain management of iCCM commodities for community-level workers
  • Methods: C-RCT & cost analysis
  • Takeaway: The paper found the mHealth intervention was not associated w/statistically significant difference in supportive supervision; appropriate treatment of malaria, diarrhoea, or pneumonia; or the overall impact on stockouts of iCCM commodities. Adding mobile health technology to iCCM activities was associated with an incremental cost of USD 11.50 per child contact. Over two thirds of this cost was attributable to program costs; economies of scale would be expected.

8. A monitoring and evaluation gap for WHO’s community health worker guidelines, Botswana

  • Comments: Worth a read. Some damning stats on global reporting of CHWs, which explain why there are no good global estimates. “Since 1978, WHO has asked Member States to report data on CHWs annually to the Global Health Observatory data repository…the definition of CHW is not standardized; WHO lets each country use its own definition…only 57 Member States have ever reported CHW numbers to the repository. Only six Member States have reported CHW numbers more than 10 times”
  • Methods: Perspective
  • Takeaway: The Botswana analysis confirms that the WHO guidelines for CHWs are a useful tool for action at the national level. More robust and systematic monitoring of the WHO guideline will identify trends in evening-out imbalances in CHW integration in the health system, provide evidence for CHW contributions to health system performance and track WHO Member States’ commitment to universal health coverage.

9. Prioritising the role of community health workers in the COVID-19 response

  • Comments: In March, the Community Health Impact Coalition released a widely circulated white paper articulating priorities for the global COVID-19 response. This week, the white paper was published in BMJ Global Health.
  • Methods: NGT
  • Takeaway: The article outlines the targeted actions needed at different stages of the pandemic to achieve the following goals: (1) PROTECT healthcare workers, (2) INTERRUPT the virus, (3) MAINTAIN existing healthcare services while surging their capacity, and (4) SHIELD the most vulnerable from socioeconomic shocks. The four priorities articulated in the paper remain a critical yardstick against which to measure the response - read an update to the paper on CHW Central

Hi All -

It’s time for another Community Health Research Round-Up! Issue 036 contains several articles on mHealth that will be of interest to this audience - check out #3 and #7!

Happy reading,

Community Health Research Round-Up, Issue 036

June 16 - June 29, 2020

1. COVID-19 Outbreak Situation in Nigeria and the Need for Effective Engagement of Community Health Workers for Epidemic Response .

  • Comments: The authors describe a bleak situation in Nigeria: ongoing and increasing community transmission of COVID19, inadequate testing, overwhelming of health resources, and infection of health workers. The solution they propose? CHWs, along with deployment of rapid epidemic intelligence and use of mobile apps for contact tracing.
  • Methods: Rapid review
  • Takeaway: CHWs can help Nigeria prevent, detect, and respond to outbreaks like COVID19; as well as ensure maintenance of essential health services. To do so, CHWs need PPE, training, and a litany of other supports from the national, subnational, and international community.

2 & 3. Improving post-partum family planning services provided by female community health volunteers in Nepal: a mixed methods study & Community-based postpartum contraceptive counselling in rural Nepal: a mixed-methods evaluation.

  • Comments: Two studies on post-partum family planning (PPFP) counselling in Nepal (including one from Coalition Member, Possible, that includes an mHealth intervention). The first study looks at Nepal’s Female Community Health Volunteers (FCHVs), and the second includes paid, salaried CHWs employed by a local NGO, Nyaya Health Nepal.
  • Methods: Mixed methods
  • Takeaway: The first study documents an improvement FCHVs’ knowledge of PPFP which in turn improved their ability to provide wide coverage of counseling on PPFP to women. The second study w/ paid, mHealth-equipped CHWs trained in PPFP found that modern contraceptive use increased from 29% pre-intervention to 46% post-intervention (p<0.0001).

4. Establishing voluntary certification of community health workers in Arizona: a policy case study of building a unified workforce.

  • Comments : WHO recommends formal competency-based certification for CHWs, but this practice is not widespread. That makes this case study from Arizona (USA) especially interesting: the authors describe the process of getting two major CHW workforces ( promotoras de salud and community health representatives) to join forces and advocate for legislated voluntary certification.
  • Methods: Case study
  • Takeaway: Great example of the transformative change that can occur when multiple CHW cadres unite to demand pathways that support professionalization of the CHW workforce. May this be the first of many more case studies on CHW certification!

5. Prevention and treatment of suspected pneumonia in Ethiopian children less than five years from household to primary care.

  • Comments: Adding to the array of literature on CHWs and iCCM, this paper analyzes prevention, care seeking, and treatment of suspected pneumonia from household to health facility in Ethiopia.
  • Methods: x-sectional
  • Takeaway: What caught our eye is this finding in the conclusion: “Some of the health extension workers were not knowledgeable about suspected pneumonia.” The study also confirmed caregivers’ low preference for seeking care from HEWs. Even in an ‘exemplar’ country like Ethiopia, where HEWs have long been lauded for their tremendous contributions to reducing preventable maternal and child mortality, quality-producing practices (supportive supervision, training, supplies, etc.) are needed - urgently - to improve community-level care!

6. Coverage of community case management for malaria through CHWs: a quantitative assessment using primary household surveys of high-burden areas in Chhattisgarh state of India.

  • Comments: Another addition to the CHW + CCM literature, this one focuses on coverage. Nearly 40k CHWs were trained and equipped w/ RDTs, ACTs, and chloroquine as part of a large-scale CCM malaria program in Chhattisgarh.
  • Methods: 3 rounds of household surveys (2015, 2016, and 2018) w/ 15k household interviews per round
  • Takeaway: CHWs achieved high coverage and treatment-completion rates. In 2018, 62% of febrile cases in rural population contacted CHWs. N.B. CHWs had sufficient supplies (RDT, ACT and chloroquine) and cash incentives (CHWs were paid an incentive of Indian Rupees 23 per fever case tested & Indian Rupees 150 per case treated). The potential risks of performance-based incentives (discussed in WHO guidelines) are not addressed in the article.

7. Experiences and intentions of Ugandan household tuberculosis contacts receiving test results via text message: an exploratory study.

  • Comments: This exploratory study (part of a larger RCT) interviewed household contacts to understand how they experience TB test results delivered by SMS.
  • Methods: Semi-structured interviews with household contacts who received TB results via SMS
  • Takeaway: Technology can supplement CHW services, but it cannot replace them! Household contacts were less confident in TB test results delivered via text message versus results delivered via CHWs.

8. A comparative impact evaluation of two human resource models for community-based active tuberculosis case finding in Ho Chi Minh City, Viet Nam.

  • Comments: In a study examining scale up of active case finding (ACF) for TB in Viet Nam, researchers look at whether salaried CHWs or volunteer CHWs generate more TB case notifications.
  • Methods: 2-year controlled intervention
  • Takeaway: Both salaried and volunteer CHWs generated more case notifications using ACF versus the routine case finding approach. Salaried, employed CHWs achieved a greater impact on notifications and should be prioritized for scale-up.

9. “I cannot say no when a pregnant woman needs my support to get to the health centre”: involvement of community health workers in Rwanda’s maternal health.

  • Comments: The title is no shocker - many CHWs are intrinsically motivated and desire to help their communities. That doesn’t mean they shouldn’t be paid. This case study examines maternal-CHWs’ experiences and perceptions on access and provision of maternal health services in Rwanda.
  • Methods: Case study
  • Takeaway: The authors discuss critical issues that prevent CHWs from delivering adequate maternal health services: “The fact that M-CHWs are volunteers operating in limited resources settings with no formal training in maternal health and with considerable workloads translates into challenges regarding the quality and quantity of services they provide in their communities. Such challenges create an impact on M-CHWs service provision, satisfaction and retention.”

10. A qualitative study of social connectedness and its relationship to community health programs in rural Chiapas, Mexico.

  • Comments: From our friends at PIH, this study utilizes video interviews to explore how health programs impact social connectedness of communities. CHW programs are well set up for this by design, given the CHW’s role in conducting home visits and forming relationships with community members.
  • Methods: Qualitative
  • Takeaway: Patients appreciate the social component of CHW home visits! The combination of a staffed health clinic & a CHW program augmented social connectedness. Benefits included a stable community structure, provision of equal access to healthcare, and enhancement of interpersonal relationships among providers, CHWs, and community members.

Issue 037 - some good stuff on PPE for CHWs, online vs. in-person training, new costing analysis

June 30 - July 12, 2020

1. & 2. Two articles on the role of CHWs: (i) Community Health Workers as Influential Health System Actors and not “Just Another Pair Of Hands” (ii) The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability

  • Comments: Two complementary articles on the role of CHWs. Compare w/classics like Lackey or Liberator? and more recent offerings like this GHD Online case study. The latter is interesting in that it breaks with the liberator/lackey dichotomy and suggest CHWs play three roles - see the takeaway.
  • Methods: (i) qualitative case study (India); (ii) critical interpretive synthesis (CIS) of CHWs and accountability in LMICs
  • Takeaway: (i) A narrow and instrumentalist view of CHWs as merely
    an ‘extra pair of hands’ to be called upon to provide ‘technical
    fixes,’ ignores the vast social capital many CHWs accumulate & their emergence as influential social actors in the communities they serve. (ii) CHWs are intended to comprise a ‘bridge’ between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. These three roles can be seen as existing on a continuum from extending the reach of the current health system, to effecting change in the health system and in other social determinants of health; though many CHW job descriptions contain elements of more than one of these roles.

3. Positionality of Community Health Workers on Health Intervention Research Teams: A Scoping Review

  • Comments: A damning (self-) assessment: “Another research team described differing goals between academic and community partners (including CHWs), where academic partners prioritized data and community partners prioritized funding and policy.” Complement with Prioritizing Competencies for Research paper from RR 031
  • Methods: Scoping review including 130 studies
  • Takeaway: CHW positionality as research partners varied greatly across studies, and they are not uniformly integrated within all stages of research. Community based participatory research (CBPR) approach, and CBPR studies included CHWs as research partners in more phases of research relative to non-CBPR studies. CHWs were least involved in identifying the research question, data analysis, and research dissemination. Advantages of CHW involvement include: informing study design to consider contextual factors, improving the content and delivery of health interventions, and validating and explaining research findings.

4. Home visits by community health workers in rural South Africa have a limited, but important impact on maternal and child health in the first two years of life

  • Comments: Many previous CHW interventions have been shown to ameliorate MNCH. This study looks at less often evaluated but potentially protective factors, such as obtaining a child support grant (CSG), avoiding traditional healers, and attending a minimum of four antenatal care visits
  • Methods: Longitudinal prospective cohort study
  • Takeaway: Compared to mothers receiving standard care, mothers who also received home visits by CHWs were more likely to attend the recommended four antenatal care visits, to exclusively breastfeed at 3 months, and were less likely to consult traditional healers at 3 months. CHW home visits resulted in better maternal caretaking, but did not have direct benefits for infants in the domains assessed (infant growth and achievement of developmental milestones were similar at 2 years for both groups)

5. Effectiveness of community health workers in improving early initiation and exclusive breastfeeding rates in a low‐resource setting: A cluster‐randomized longitudinal study

  • Comments: Multiple RCTs indicate that CHW-delivered interventions have a substantial impact on exclusive breastfeeding (EBF) up to six months postpartum. This trial is interesting because it offers evidence from Kenya on both EBF and early breastfeeding initiation (EBI) in a setting where very low EBF rates (2% to 12%) have been documented.
  • Methods: Randomized trial (6 mo)
  • Takeaway: CHWs had potential effectiveness in promoting EBF but not EBI: the prevalence of EBF at 24 weeks was 45.3% in the CHW group compared with 15.0% in the control group (p < .001). The difference was not statistically significant in EBI prevalence between the CHW (58.2%) and control (60.3%; χ 2 = 0.008, p = .928).

6. Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal

  • Comments: Hot off the press from Coalition member, Possible. Context for this costing: in 2017, the Nepal Ministry of Health and Population partnered w/Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. (CHWs (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees) The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization.
  • Methods: Retrospective costing analysis (Both for the pilot and three alternative scenarios: (1) CHW salaries decreased (2) Administrative functions of the program are absorbed into municipal health care unit governance structures (3) CHW program incorporated directly into existing primary health care infrastructure)
  • Takeaway: The average per capita annual cost of a pilot CHW program in rural Nepal is US$3.05. Personnel costs, the largest cost driver, contribute 74% of the total implementation costs and are affected by the number of households covered, population distribution, geographical terrain, and supervision structure.

7. Online versus in-person training of community health workers to enhance hepatitis B virus screening among Korean Americans: Evaluating cost & outcomes

  • Comments: Some relevant considerations for online learning - particularly relevant in the age of COVID-19 where everything is moving to digital. (N.B. previous studies for different disease areas have found online-trained CHWs produced similar health outcomes as in-person-trained CHWs) - context matters!
  • Methods: C-RCT & cost analysis
  • Takeaway: CHWs who attended live training outperformed their online-trained colleagues. Elements of the didactic approach or practice with peers in the live session may have contributed to the superior training effectiveness and, ultimately, improved cost-effectiveness of the in-person approach.
  • Given the convenience of online training (no geographic or time limitations) future such training should better facilitate the interactions among CHWs and seek to improve CHW’s skills in building rapport with participants and facilitating discussion among participants.

8. Contextual factors affecting the integration of community health workers into the health system in Limpopo Province, South Africa

  • Comments: Similar findings as Kok’s 2015 systematic review of contextual determinants of CHW effectiveness in LMIC. This single study also identified community factors (particularly the fear of stigma) as an important determinant and found that the organisational context was the most noteworthy impediment to the potential effectiveness of the CHWs.
  • Methods: In-depth interviews and focus group discussions (grounded theory)
  • Takeaway: Six critical contexts affecting the implementation of the CHW program: geographic, social and economic, community, local governance and authority, and organisational (e.g. tensions between the NDoH and NGOs responsible for paying CHWs, staff shortages, the overburdening of CHWs in terms of their reporting requirements etc.)

9. Protecting Community Health Workers: PPE Needs and Recommendations for Policy Action

  • Comments: As noted in the Coalition’s COVID priorities paper (RR 035) CHWs require personal protective equipment (PPE) to safely support COVID-19 response efforts and maintain essential health services.
  • Methods: Rapid literature review w/partial country validation in nine countries were used to verify CHW estimates. Evidence-based assumptions regarding CHW workflow and PPE use were used to calculate the annual PPE needs for CHWs.
  • Takeaway: In order to provide one year of protection to one million CHWs serving over 400 million people across 24 countries (40% of the continent), 448 million pieces of PPE (masks, gloves, goggles, gowns, biohazard bags) are required annually. Based on current, fluctuating commodity prices, this would require an outlay of circa 100
    million USD.
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Hi Everyone -

Here’s Issue 038 Research Round-Up! This edition has more on CHWs in the COVID-19 response (#PPEforAll) and an article from THINKMD on mHealth platforms. Happy reading!

Community Health Research Round-Up, Issue 038
July 14 - July 27, 2020

  1. Community health workers reveal COVID-19 disaster in Brazil
  • Comments: A frustrating and sobering assessment of the current situation with CHWs and COVID-19 in Brazil.
  • Methods: Comment
  • Takeaway: Brazil’s COVID-19 disaster is a partial consequence of neglecting the country’s 286,000 CHWs. Because CHWs in Brazil are not considered to be health professionals, only an estimated 9% have received infection control training and personal protective equipment (PPE). Unions estimate that at least 50 CHWs have died from COVID-19. The authors call on the Brazilian Government and international community to “recognize and support the role of CHWs in the COVID-19 response and to ensure their health and safety.”
  1. COVID-19: Africa needs unprecedented attention to strengthen community health systems
  • Comments: Adding to the chorus calling for PPE for CHWs (See RR’s 032, 035, 036, and 037) this Lancet comment from colleagues at CHAP and LMH argues that CHWs - key health workers in Africa’s pandemic response - urgently require PPE and merit additional attention/investment.
  • Methods: Comment
  • Takeaway: Against the trillions of dollars that have already been committed in the COVID-19 response, multi-billion dollar investments in CHWs to strengthen PHC and achieve UHC is merely a drop in the bucket. “Now is the time to invest in community health systems in sub-Saharan Africa and avert a greater crisis.”

3. Assessing and reducing risk to healthcare workers in outbreaks

  • Comments: Yet another perspective and urgent call to action to protect health workers during COVID-19 and against future outbreaks. We’re noticing a trend! #PPEforAll
  • Methods: Comment
  • Takeaway: High rates of healthcare-associated and healthcare worker infection (physicians, clinical officers, nurses, midwives, AND CHWs) during outbreaks suggests that our current risk mitigation strategies - including infection prevention and control practices - are insufficient. The authors recommend a 2-pronged solution to address long-term gaps in the health system that impact infection control and emergency response.

4. COVID-19 Crisis Creates Opportunities for Community-Centered Population Health: Community Health Workers at the Center.

  • Comments: A candid and scathing critique of how COVID-19 has revealed glaring weaknesses in the USA health system - and what we can do about it (hint: involves professionalized CHWs).
  • Methods: Comment
  • Takeaway: The USA needs a paradigm shift away from a patient-centered care system towards community-centered, population-based healthcare. Key to this grand vision is integrating CHWs into our COVID response (phase 1) and determining a plan to incorporate these CHWs as a key element in a new community-centered, population-based healthcare system (phase 2).

5. Community-based surveillance in Cote d’Ivoire. (What works? lessons learned in global health security implementation.)

  • Comments: In a priorities paper published earlier this year, CHIC identified a critical role for CHWs in disease surveillance. This article describes how CHWs were engaged for disease surveillance in Cote d’Ivoire in the post-Ebola period, and what lessons we can learn.
  • Methods: Rapid review (retrospective) of a pre/post intervention w/ control
  • Takeaway: Intervention sites saw a significant increase in reporting of unusual health events by CHWs (consistent w/ other studies demonstrating the value of community-based surveillance as an early warning system). However, false positive rates were high; less sensitive signal definitions could reduce some burden on public health systems.

6. Geographic Barriers to Achieving Universal Health Coverage in a rural district of Madagascar

  • Comments: This pre-print from friends at PIVOT Madagascar explores how “utilization at community health sites compensates distance decay observed for PHC use” - if that’s not reason enough to check it out, the beautiful data visualizations certainly are!
  • Methods: Analysis of geographic information from nearly 300,000 primary care visits
  • Takeaway: Facility-based interventions achieve high coverage among populations living nearby. However, to achieve UHC we need professionalized community health programs that increase utilization for all, regardless of proximity to facility.

7. Effectiveness and cost-effectiveness of home-based postpartum care on neonatal mortality and exclusive breastfeeding practice in low-and-middle-income countries: a systematic review and meta-analysis

  • Comments: Speed of post-natal care home visits is one of several indicators CHIC is tracking to promote quality of care. This systematic review confirms the importance of prompt home visits and community mobilization to promote neonatal care practices.
  • Methods: Systematic review & meta-analysis (based on n=14 randomized trials or quasi-experimental studies)
  • Takeaway: CHWs conducting home visits and community mobilization activities to promote neonatal care practices is associated with reduced neonatal mortality, increased practice of exclusive breastfeeding, and is cost-effective in improving newborn health outcomes for LMICs. Further evaluation is needed to determine the optimal package and timing of these home visits.

8. Development and Initial Validation of a Frontline Health Worker mHealth Assessment Platform (MEDSINC) for Children 2-60 Months of Age

  • Comments: From Coalition Member THINKMD and friends, this article describes the development of a next-generation mHealth point-of-care clinical assessment, triage, treatment, and recommendation platform, called MEDSINC, designed to support frontline health workers (FLWs).
  • Methods: Field-based testing in three countries (Burkina Faso, Ethiopia, Bangladesh) comparing MEDSINC-generated diagnoses by FLWs vs. blinded “gold standard” clinical diagnosis by local healthcare professionals assessing the same children; plus usability & acceptability testing
  • Takeaway: The MEDSINC clinical assessment logic, triage recommendations, and user interface are conducive to mHealth technology adoption and scaling. The study found high overall clinical correlations and specificity between MEDSINC evaluations by FLWs compared with “gold standard” assessments; usability and acceptability of the tool was rated highly by FLWs in all three countries.

9. Learning from Community Health Worker Programs, Big and Small

  • Comments: For all our readers thinking about what smaller programs can teach large-scale programs (and vice-versa), this brief editorial is for you! For further reading, check out the article by Nepal et al. in issue 037 of the Round-Up, which the author of this editorial (Stephen Hodgins) cites as a strong example of how small-scale programs can potentially inform large government programs.
  • Methods: Editorial
  • Takeaway: “Small, well-implemented, well-evaluated community health worker programs can provide useful insights and inspiration. Testing, learning, and adapting at progressively larger scale can ultimately lead to national-scale programs that achieve sustainable impact.”

10. What are the roles of community health workers? Looking back at the philosophies of primary health care

  • Comments: Building on the previous edition of the Round-Up (037, Articles 1 & 2), this article explores the different roles of CHWs in a historical context (i.e., Alma Ata = community development actors vs 1980s = extension of health system)
  • Methods: Comment
  • Takeaway: These roles can co-exist: “CHWs can work in continuity with the health system, but they should not be considered as affordable labor” and require significant support in order to develop their communities.
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Hi Everyone -

Here’s Issue 039 of the Research Round-Up! This edition features nine articles and one protocol. Happy reading!

Community Health Research Round-Up, Issue 039
July 28 - August 10, 2020

1. A cluster randomized trial of delivery of intermittent preventive treatment of malaria in pregnancy at the community level in Burkina Faso.

  • Comments: Important addition to the literature on whether community health workers (CHWs) can effectively deliver intermittent preventive treatment of malaria in pregnancy (IPTp) while at the same time promoting ANC attendance at health facilities. Spoiler: IPTp & ANC coverage went up w/ CHWs (but not significant in all categories)!
  • Methods: Cluster Randomized Control Trial w/ intervention (IPTp delivered by CHW) or control (standard practice: IPTp delivered at health facility)
  • Takeaway: Community-based delivery of IPTp by CHWs can potentially lead to a greater number of IPTp doses delivered, with no apparent decrease in ANC coverage (in fact, study found an increase in ANC coverage although this was not statistically significant!)

2. District health teams’ readiness to institutionalize integrated community case management in the Uganda local health systems: a repeated qualitative study.

  • Comments: Important lessons on how to transition integrated community case management (iCCM) programs from external partners to district health teams. Despite DHTs reporting readiness, they were unable to institutionalize most program components.
  • Methods: Qualitative (group interviews & key informant interviews)
  • Takeaway: Barriers to successful institutionalization of iCCM by district health teams included lack of stewardship / coordination by the Ministry of Health and external partners; lack of agreement on community-level drug distribution; failure to integrate key iCCM indicators into national information management systems; and insufficient central government funding. Overall, more collaboration is needed among implementing partners and all levels of the health system.

3. Proactive community case management in Senegal 2014-2016: a case study in maximizing the impact of community case management of malaria.

  • Comments: Additional evidence - this time from Senegal - that proactive case finding by CHWs works! And we love the “comprehensive approach to [CHW] training, supervision, supply chain, and communication” outlined in the program case study.
  • Methods: Narrative case study w/ programmatic results
  • Takeaway: CHWs conducting proactive case finding in Senegal (i.e., they visited all households in their village weekly to identify fever cases and offer case management) detected and treated more malaria cases compared to CHWs who were available for community members to seek care, but who did NOT actively visit households to find cases. The authors note this program which “requires increased time commitment from CHWs also requires timely monetary compensation for the CHWs and supervisors, as well as support for transportation and coordination.”

4. Ethical practice in my work: community health workers’ perspectives using photovoice in Wakiso district, Uganda.

  • Comments: Innovative study from friends at CHW TWG examining what CHWs perceive to to be the most pressing ethical concerns in their work, documented through photovoice.
  • Methods: Qualitative / photovoice
  • Takeaway: Solutions are long overdue for key challenges identified by CHWs including: low commitment to their work due to other obligations; availability of some reference materials and guidelines in English yet majority could only read in the local language; and minimal avenues for knowledge enhancement such as trainings.

5. Measuring motivation among close-to-community health workers: developing the CTC Provider Motivational Indicator Scale across six countries.

  • Comments: New tool to measure motivation levels of close-to-community health service providers, tested in six countries
  • Methods: Mixed: Focus group discussions and interviews; literature search; surveys
  • Takeaway: The new tool measures CTC provider satisfaction across four key factors: organizational commitment, job satisfaction, community commitment, and conscientiousness. Community commitment (“I am proud to be working for my community”) is a novel addition from previous studies of health worker motivation.

6 & 7. Impact of a community-based approach to patient engagement in rural, low-income adults with type 2 diabetes & A Telehealth-supported, Integrated care with CHWs, and MEdication-access (TIME) Program for Diabetes Improves HbA1c: a Randomized Clinical Trial.

  • Comments: Two studies from the USA on the role of CHWs in improving patient outcomes for diabetes management
  • Methods: Feasibility study (6) and randomized clinical trial (7)
  • Takeaway: Both studies demonstrated that CHWs can have a positive effect on diabetes management. The first study found a correlation between CHW engagement and higher patient activation scores, while the second study found that CHW-supported patients had significant HbA1c decreases (p = 0.002), systolic & diastolic blood pressure changes (p = 0.023 and p = 0.046, respectively), and ADA guideline adherence (p < 0.001). Larger-scale trials are needed.

8 & 9. Community health volunteers’ contribution to tuberculosis patients notified to National Tuberculosis program through contact investigation in Kenya & Using community health workers for facility and community based TB case finding: An evaluation in central Mozambique.

  • Comments: Two studies from Kenya and Mozambique, respectively, showing the contributions of CHWs to case finding and contact tracing in TB programs. Important lessons as countries continue to deploy CHWs in the efforts to test, trace, and isolate COVID-19 cases! (N.B. Pay CHWs!)
  • Methods: Retrospective data analysis (8) and pre/post with control (9)
  • Takeaway: Community health workers can play an important role in household contact tracing and referral management for TB.

10. PROTOCOL: Reflecting on principles of primary health care in the implementation of national community health worker programs in low- and middle-income countries: a scoping review protocol.

  • Comments: We can’t wait for this one!
  • Methods: Scoping review will include English-language articles published after September 1978 (Alma Ata) through 2019.
  • Takeaway: Forthcoming review will assess the implementation of national-level CHW programs in LMICs using primary health care principles.