An evaluation of a community dementia screening program in rural Kenya: DEM‐SKY

Systems are investing in workers who come from the communities they serve to meet patient needs that extend well beyond clinic walls.

Background:mHealth is increasingly regarded as having the potential to support service delivery by health workers in low-resource settings. PIERS on the Move (POM) is a mobile health application developed to support community health workers identification and management of women at risk of adverse outcomes from pre-eclampsia. The objective of this study was to evaluate the impact of using POM in Mozambique on community health care workers' knowledge and self-efficacy related to caring for women with pre-eclampsia, and their perception of usefulness of the tool to inform implementation.Method: An evaluation was conducted for health care workers in the Mozambique Community Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial from 2014 to 2016 in Maputo and Gaza provinces (NCT01911494). A structured survey was designed using themes from the Technology Acceptance Model, which describes the likelihood of adopting the technology based on perceived usefulness and perceived ease of use. Surveys were conducted in Portuguese and translated verbatim to English for analysis. Preliminary analysis of open-ended responses was conducted to develop a coding framework for full qualitative analysis, which was completed using NVivo12 (QSR International, Melbourne, Australia).Results: Overall, 118 community health workers (44 intervention; 74 control) and 55 nurses (23 intervention; 32 control) were surveyed regarding their experiences. Many community health workers found the POM app easy to use (80%; 35/44), useful in guiding their activities (68%; 30/44) and pregnant women received their counseling more seriously because of the POM app (75%; 33/44). Almost a third CHWs reported some challenges using the POM app (30%; 13/44), including battery depletion after a full day's activity. Community health workers reported increases in knowledge about pre-eclampsia and other pregnancy complications and increases in confidence, comfort and capacity to advise women on health conditions and deliver services. Nurses recognized the increased capacity of community health workers and were more confident in their clinical and technological skills to identify women at risk of obstetric complications.Conclusions: Many of the community health workers reported that POM improved knowledge, self-efficacy and strengthened relationships with the communities they serve and local nurses. This helped to strengthen the link between community and health facility. However, findings highlight the need to consider program and systematic challenges to implementation.

1 million community health workers in sub-Saharan Africa by 2015

Hope and despair 3/3: pluses and minuses for community health assistants in rural Zambia

Background: Community health workers (CHWs) are trained members of the community who play a crucial role in bridging gaps between health and social care systems. They leverage community networks, cultural competence and knowledge of care systems to enhance service delivery. Working in partnership with health care providers, such as nurses, CHWs address health challenges, that are often intensified by health inequities. The positive impact of CHWs has been demonstrated in areas such as: disease prevention (e.g., vaccination, hand washing),1,2 enhancing provider-patient communication/trust,1-3 ensuring treatment adherence,2-4 linking individuals to health/social services,1,2,4 managing chronic diseases,4 cancer screening,4 and enhancing maternal-child health.1,5 In India, Community Health Workers (CHWs) function within well-established, formalized structures, including the Accredited Social Health Activists (ASHAs), Anganwadi Workers, and Female Health Workers. This structured approach serves as an exemplary model, as CHWs have significantly enhanced population and community health, particularly in underserved areas with limited healthcare resources and access challenges. Our team identified an opportunity for other countries to learn from India’s successful CHW implementation model, drawing insights that could inform both policy development and practical applications internationally Approach: Our team is a partnership between India (Jamia-Hamdard University) and Canada (Dalhousie University), with a shared primary goal to describe strategies to strengthen CHW capacity to enhance health systems and promote healthcare equity amid health human workforce challenges in India. Our secondary goal was to explore how the CHW role can help strengthen the health human workforce in other countries (e.g., Canada) particularly with equity seeking populations. In phase one (of three), we completed semi-structured interviews (60 mins) in Hindi with 12 CHWs, six community members, and two community leaders near New Delhi, India. Interviews were translated into English and analyzed using content analysis. The thematic summary informed the phase 2 scoping review (JBI methodology) to identify strategies for developing and implementing the CHW role. As this work was funded by Research Nova Scotia, we included considerations for integration in high-income contexts (e.g., Canada). Results: We present the thematic findings from 20 interviews, alongside preliminary results from the JBI scoping review. This research describes how CHWs in India enact their roles, addressing critical service gaps shaped by local contexts and cultural factors. In this context, CHWs act as extensions of healthcare services, bridging gaps between health and social care systems. They play pivotal roles in health education, by addressing stigma and misinformation; and provide essential support and advocacy to help patients access appropriate care.1-3,5 Based on these insights, we have developed recommendations to inform CHW role descriptions and guide implementation strategies adaptable to the Canadian context. Implications: This co-developed project was supported by partnership between universities in India and Canda. We learned about effective CHW role enactment and implementation in the Indian context and have considered strategies to adapt this role to Canadian context. Our next steps are to host a policy workshop in Halifax, Nova Scotia to bring together Canadian and Indian partners to develop strategies to enhance CHW capacity.

BackgroundPerson-centered quality for family planning has been gaining increased attention, yet few interventions have focused on this, or measured associations between person-centered quality for family planning and family planning outcomes (uptake, continuation, etc.). In India, the first point of contact for family planning is often the community health care worker, in this case, Accredited Social Health Activists (ASHAs).MethodsIn this study, we evaluate a training on person-centered family planning as an add-on to a training on family planning provision for urban ASHAs in Varanasi, India in 2019 using mixed methods. We first validate a scale to measure person-centered family planning in a community health worker population and find it to be valid. Higher person-centered family planning scores are associated with family planning uptake.ResultsComparing women who saw intervention compared to control ASHAs, we find that the intervention had no impact on overall person-centered family planning scores. Women in the intervention arm were more likely to report that their ASHA had a strong preference about what method they choose, suggesting that the training increased provider pressure. However, qualitative interviews with ASHAs suggest that they value person-centered care for their interactions and absorbed the messages from the intervention.ConclusionsMore research is needed on how to intervene to change behaviors related to person-centered family planning.Trial registrationThis study received IRB approval from the University of California, San Francisco (IRB # 15–25,950) and was retrospectively registered at clinicaltrials.gov (NCT04206527).

Background: Hypertension, a major risk factor for cardiovascular disease, is the leading risk factor for global mortality. Increasing access to hypertension care is critically important to reducing the burden of global cardiovascular disease. The use of community health workers (CHWs) to increase access to care represents a potential strategy to improve hypertension treatment and control; however, it is not known how rural communities in low- and middle-income countries perceive the use of CHWs for this purpose. Our study therefore aims to examine community perceptions of CHWs in hypertension management. Methods: Traditional community gatherings and focus group discussions (20 sessions, 411 participants) were organized in rural western Kenya. Discussion topics included chronic diseases, factors related to linkage to care, and the role of CHWs in hypertension management. We performed inductive content analysis of transcripts from these sessions using NVivo 10 software. Coded items were grouped together into distinct themes, and relationships among these themes were formulated. Results: Six themes emerged from our analysis, each with implications regarding CHWs’ role in linkage and retention to hypertension care (Table). These themes included (1) CHWs’ intimate knowledge of the community; (2) CHWs’ role in providing health education; (3) CHWs’ role in facilitating logistical support to enable community members to access care; (4) the importance of psychosocial support that CHWs can provide; (5) the need for ‘professionalization’ of the CHW workforce; and (6) negative perceptions towards CHWs. Conclusions: Our themes are consistent with findings in the literature regarding the work that CHWs traditionally perform for communicable diseases and maternal/child health. Use of CHWs for hypertension management, leveraging the prior experience of other CHW programs, may be an effective strategy to reduce the burden of hypertension in low-resource settings.

Universal coverage is defined by the World Health Organization as 1 long-lasting insecticidal net (LLIN) for 2 people in a household. While Uganda has been a leader in the distribution of LLINs, there are concerns regarding the longevity of LLINs. The main aim of this study was to address the LLIN coverage gap that emerges in the period after mass distribution campaigns through the implementation of a novel LLIN distribution strategy utilizing the existing community healthcare worker (CHW) infrastructure. We conducted a pilot feasibility study in two villages randomized to be the control or intervention. CHWs in both villages carried out their regular duties and calculated household eligibility to receive LLINs, classified as having a child under five positive for malaria and being below universal coverage. Only CHWs in the intervention village distributed LLINs to eligible households to reach universal coverage. Summary statistics were calculated for intervention implementation and malaria outcomes. Structured interviews were conducted with CHWs to assess burden and community acceptability of the intervention. Of the children evaluated by the CHWs, 102 of 169 (60.3%) and 112 of 171 (65.5%) were tested for malaria, of which 62 (60.7%) and 71 (63.3%) tested positive in the intervention and control villages, respectively. Only three households were at universal coverage. There was an increase from 4.0% to 6.5% of households meeting universal coverage in the intervention village, compared to a decrease from 7.8% to 1.8% in the control village after the follow-up period. There was an increase in the number of children under the age of 5 who slept under an LLIN the previous night from 15.7% to 31.6% in the intervention village compared to a decrease in the control village from 29.1% to 10.5%. No CHWs reported an increased burden from the intervention and all reported favorable opinions. Our pilot study demonstrates the feasibility and acceptability of targeted LLIN distributions leveraging the existing structure to supplement national distribution campaigns in Uganda. Overall, this work highlights the critical need for novel approaches to sustain LLIN coverage between distribution campaigns, particularly towards the end of the 3-year cycle.

Objective The aim of this study was to investigate the status on disaster site first aid skills of community healthcare workers at Hangzhou and to provide medical institution with a reference to train the disaster site first aid skills .Methods The researchers investigated 400 healthcare workers ’ disaster site first aid skills from 8 community health service centers .Results Totals of 373 questionnaires were returned with an effective rate of 93.5%.The average score of disaster site first aid skills of community healthcare workers was （3.83 ±0.28）.The score of using simple breathing bag was （4.33 ±0.70）.The score of performing CPR technique was （4.21 ±0.70）.Logistic regression analysis showed that the influencing factors of disaster site first aid skills were participation in disaster rescue and the male gender （P〈0.05）.100% of the community healthcare workers were interested in learning disaster site first aid skills .93.7% of the community healthcare workers expressed a strong willingness to learn relevant skills .Conclusions The overall level of the disaster site first aid skills of community healthcare workers is not good , but their learning intention are strong .It is necessary to strengthen the disaster site first aid skills training and to take various training programs which cover a wide range of contents , such as disaster rescue simulation exercises , scenario simulation test and participation in the site rescue.Meanwhile, continuing education opportunities should be actively provided to enhance the disaster site first aid skills of community healthcare workers . Key words: Community health care service; Disaster; Data collection; Healthcare professional; On-site first aid skills

Introduction: Community Health Workers (CHWs) have been utilised for various primary health care activities in different settings especially in developing countries. Usually when utilised in well defined terms, they have a positive impact. Objectives: The overall objective of this study was to undertake a cost effect analysis of utilising CHWs in tuberculosis (TB) management. Methods: A retrospective cohort study was conducted in selected health facilities using standard clinical records for each TB patient registered for treatment between 2005 to 2011. Results: The study assessed 2778 tuberculosis patients and among them 1499 (54%) utilized CHWs for their TB treatment. The cost effect analysis revealed that the average cost per Disability Adjusted Life Year (DALY) averted for treatment success was higher (184 US$) in the cohort that utilised CHWs compared to the nonutilising cohort (87 US$). Use of CHWs resulted in better treatment success rate (82.15%) compared to not using at 72.25% (p-value <0.001). Utilising CHWs resulted in less DALYs (5688) from death compared to not utilising CHWs (5725). Of the patients who died, a majority ( ) died within the first month of their treatment and they were in the cohort that did not utilise CHWs. Conclusion: The use of CHWs may be considered as a health and economic benefit because more life was saved with a higher treatment success rate and there seemed to be death averted in the early months of TB treatment.

BackgroundDespite emerging qualitative evidence of gendered community health worker (CHW) experience, few quantitative studies examine CHW gender differentials. The launch of a maternal, newborn, and child health (MNCH) CHW cadre in Morogoro Region, Tanzania enlisting both males and females as CHWs, provides an opportunity to examine potential gender differences in CHW knowledge, health promotion activities and client acceptability.MethodsAll CHWs who received training from the Integrated MNCH Program between December 2012 and July 2013 in five districts were surveyed and information on health promotion activities undertaken drawn from their registers. CHW socio-demographic characteristics, knowledge, and health promotion activities were analyzed through bi- and multivariate analyses. Composite scores generated across ten knowledge domains were used in ordered logistic regression models to estimate relationships between knowledge scores and predictor variables. Thematic analysis was also undertaken on 60 purposively sampled semi-structured interviews with CHWs, their supervisors, community leaders, and health committee members in 12 villages from three districts.ResultsOf all CHWs trained, 97 % were interviewed (n = 228): 55 % male and 45 % female. No significant differences were observed in knowledge by gender after controlling for age, education, date of training, marital status, and assets. Differences in number of home visits and community health education meetings were also not significant by gender. With regards to acceptability, women were more likely to disclose pregnancies earlier to female CHWs, than male CHWs. Men were more comfortable discussing sexual and reproductive concerns with male, than female CHWs. In some cases, CHW home visits were viewed as potentially being for ulterior or adulterous motives, so trust by families had to be built. Respondents reported that working as female–male pairs helped to address some of these dynamics.ConclusionsMale and female CHWs in this study have largely similar knowledge and health promotion outputs, but challenges in acceptance of CHW counseling for reproductive health and home visits by unaccompanied CHWs varied by gender. Programs that pair male and female CHWs may potentially overcome gender issues in CHW acceptance, especially if they change gender norms rather than solely accommodate gender preferences.

BackgroundProfessional certification of community health workers (CHWs) is a debated topic. Although intended to promote CHWs, certification may have unintended impacts given the grassroots nature of the workforce. As such, both intended effects and unintended adverse effects should be carefully evaluated. However, there is a lack of published literature describing such effective evaluations with a robust methodology. In this methods paper, we describe a key component of evaluating CHW certification in Massachusetts-the Massachusetts CHW Workforce Survey.MethodsDesign of the surveys was informed by a program theory framework that delineated both positive and negative potential impacts of Massachusetts CHW certification on CHWs and CHW employers. Using this framework, we developed measures of interest and preliminary CHW and CHW employer surveys. To validate and refine the surveys, we conducted cognitive interviews with CHWs and CHW employers. We then finalized survey tools with input from state and national stakeholders, CHWs, and CHW employers. Our sample consisted of three frames based on where CHWs are most likely to be employed in Massachusetts: acute care hospitals, community-based organizations, and ambulatory care health centers, primarily community health centers and federally qualified health centers. We then undertook extensive outreach efforts to determine whether each organization employed CHWs and to obtain CHW and CHW employer contact information. Our statistical analysis of the data utilized inverse probability score weighting accounting for organizational, site, and individual response.Anticipated resultsWave one of the survey was administered in 2016 prior to launch of Massachusetts CHW certification and wave two in 2021. We report descriptive statistics of the three sample frames and response rates of each survey for each wave. Further, we describe select anticipated results related to certification, including outcomes of the program theory framework.ConclusionsThe Massachusetts CHW Workforce Survey is the culmination of 5 years of effort to evaluate the impact of CHW certification in Massachusetts. Our comprehensive description of our methodology addresses an important gap in CHW research literature. The rigorous design, administration, and analysis of our surveys ensure our findings are robust, valid, and replicable, which can be leveraged by others evaluating the CHW workforce.

Antimicrobial resistance (AMR) remains a critical global health challenge, and is mainly due to inappropriate antimicrobial use in human and animal health sectors. This systematic review examines the roles of Community Animal Health Workers (CAHWs) and Community Health Workers (CHWs) in antimicrobial stewardship (AMS) across Africa where AMR burden is highest and AMS programs are limited. Following PRISMA guidelines, this systematic review analyzed 16 studies (2017-2024) from nine African nations. We identified seven key roles of CAHWs and CHWs in AMS: 1) provision of clinical services (13 studies); 2) community mobilization (8 studies); 3) health promotion (7 studies); 4) provision of preventive services (5 studies); 5) epidemiological surveillance (4 studies); 6) advocacy (2 studies), and 7) medical waste management (2 studies). Despite their roles, challenges such as lack of supportive legislation (3 studies), inadequate remuneration (2 studies), and total reliance on foreign funding hinder AMS program sustainability. While most studies (14 studies) indicated that CAHWs and CHWs had received AMS training, their roles in the national AMR strategies remain unclear. CAHW and CHWs could be leveraged in advancing health promotion, raising AMR awareness, supporting AMR surveillance, enhancing integrated management of diseases, and improving waste management within One Health frameworks. To realize this potential, there is a need to formalize CAHW/CHW roles through targeted legislation, specialized training and sustainable funding. This evidence highlights the critical need for policy reforms to harness their potential in strengthening health systems and curbing AMR across Africa. PROSPERO registration number: CRD420251027215.

Antimicrobial resistance (AMR) remains a critical global health challenge, and is mainly due to inappropriate antimicrobial use in human and animal health sectors. This systematic review examines the roles of Community Animal Health Workers (CAHWs) and Community Health Workers (CHWs) in antimicrobial stewardship (AMS) across Africa where AMR burden is highest and AMS programs are limited.Following PRISMA guidelines, this systematic review analyzed 16 studies (2017–2024) from nine African nations. We identified seven key roles of CAHWs and CHWs in AMS: 1) provision of clinical services (13 studies); 2) community mobilization (8 studies); 3) health promotion (7 studies); 4) provision of preventive services (5 studies); 5) epidemiological surveillance (4 studies); 6) advocacy (2 studies), and 7) medical waste management (2 studies). Despite their roles, challenges such as lack of supportive legislation (3 studies), inadequate remuneration (2 studies), and total reliance on foreign funding hinder AMS program sustainability. While most studies (14 studies) indicated that CAHWs and CHWs had received AMS training, their roles in the national AMR strategies remain unclear.CAHW and CHWs could be leveraged in advancing health promotion, raising AMR awareness, supporting AMR surveillance, enhancing integrated management of diseases, and improving waste management within One Health frameworks. To realize this potential, there is a need to formalize CAHW/CHW roles through targeted legislation, specialized training and sustainable funding. This evidence highlights the critical need for policy reforms to harness their potential in strengthening health systems and curbing AMR across Africa.PROSPERO registration number: CRD420251027215

Community health is a long-established approach to accessing healthcare, the face of which is female. In the case of rural Isiolo, Kenya, the majority of community health volunteers are men. To understand why, we historicise the move to capitalist work economies in Kenya’s pastoralist north, offering a ‘step up’, ‘step down’ framework to explain the gendering of work in urban versus rural settings. We draw on demographic data from Isiolo’s ∼760 community health volunteers alongside qualitative interviews, focus group discussions and observations over 12 months, centring male perspectives. For rural men, such work promised an opportunity to ‘step up’ but did not realise security over time. Men nevertheless stayed in post owing to social pressures and sunk costs. To understand the frustrations and anger we witnessed among pastoralist men, we draw on Hodgson’s dual masculinities – one ‘modernist’, one longer-standing embodying autonomy and self-determination – that sit in tension in community health work. The costs of diversifying away from pastoralist livelihoods are keenly felt, a source of male angst and lower self-esteem. We conclude that our analysis doubles as a window on insecure, part-paid work in rural Kenya that has not served men well but also compounded gender inequity for women.