Integrating multiple community perspectives in intervention development.

Background Community health workers (CHWs) are lay people from within the communities where they work, who share common characteristics with their members, such as ethnicity, culture, and language. They are frontline health workers who often serve socially and linguistically isolated populations. As trusted members of their communities, they provide critical links between community and systems of care. CHWs can empower community members with enhanced health knowledge, help navigating health systems, and access to care. This study examined the central role of CHWs in disseminating colorectal cancer screening guidelines in seven Asian immigrant communities (Cambodian, Chinese, Filipino, Korean, Lao, South Asian, and Vietnamese) in Chicago. Method The parent project was designed to use a community-centered dissemination model to promote the adoption of colorectal cancer (CRC) screening guidelines in seven Asian communities. In this study, we used social marketing campaign and CHWs as part of the intervention to disseminate CRC screening guidelines. Although social marketing campaigns can create public awareness, they rarely shape attitudes and bring behavior change. To take community members from awareness to commitment and then action, we used CHWs as influencers. All ten CHWs recruited in this study were bicultural and bilingual health professionals. In addition, all CHWs had at least a bachelor's degree, had worked in the community for more than a year and well understood the social norms of the community. All CHWs were required to attend a 6-hour training course on CRC screening, motivational interviewing techniques, and the application of Stage of Change Theory. A CHW guidebook, which listed rationales and components of the intervention, was given to the CHWs. The roles and responsibilities of the CHW (outreaching, educating, navigating and collecting data) were also clearly stated in the guidebook. All CHEs were committed 20 hours/week for the project during the 12-week intervention period. Both quantitative and qualitative data were collected during and after the CHW intervention through weekly activity logs, site visits notes, and focus groups with implementation CHWs at the end of the project. Results Our ten CHWs placed 320 posters (in English or native language) to promote CRC screening in different venues, such as restaurants, churches, temples, and grocery stores, that were frequented by local community members. They also sent out 4,665 CRC postcards to clients on their mail lists. Besides one-on-one counselling session, CHW also conducted 32 CRC information sessions (> 5 people). Across the seven communities, over 2,400 community residents were reached through one-on-one education or small group information sessions over the 12-week intervention period. Most of the CHWs used familiar places to do their outreach, such as in-house programs (e.g. senior services or immigrant programs) or other places that they have implemented programs before. They also used other opportunities, such when they were shopping at the community store or in a bible study, as well as family and friend gatherings, to disseminate CRC screening guidelines. Although not all people they encountered wanted to be screened, they felt that they at least got them thinking about CRC and had impact on them. For personal experience, most CHWs stated that the project increased their knowledge of CRC and they also felt valued. Discussion Participation of CHWs in this demonstration project was invaluable. Each CHW brought critical knowledge of their community, its language, values, norms, and health beliefs. CHWs are uniquely positioned to deliver culturally ad linguistically tailored intervention and can serve as a source of peer support and social influence. Citation Format: Karen Kim, Michael Quinn, Edwin Chandrasekar, Helen Lam. The role of community health workers in disseminating colorectal cancer guidelines in Asian Americans. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A30.

Introduction: Innovative interventions are needed to address the growing burden of breast cancer globally, especially among vulnerable patient populations. Given the success of Community Health Workers (CHWs) in addressing communicable diseases and non-communicable diseases, this scoping review will investigate the roles and impacts of CHWs in breast cancer screening programs. This paper also seeks to determine the effectiveness and feasibility of these programs, with particular attention paid to differences between CHW-led interventions in low- and middle-income countries (LMICs) and high-income countries (HICs).Methods: A scoping review was performed using six databases with dates ranging from 1978 to 2019. Comprehensive definitions and search terms were established for ‘Community Health Workers’ and ‘breast cancer screening’, and studies were extracted using the World Bank definition of LMIC. Screening and data extraction were protocolized using multiple independent reviewers. Chi-square test of independence was used for statistical analysis of the incidence of themes in HICs and LMICs.Results: Of the 1,551 papers screened, 33 were included based on inclusion and exclusion criteria. Study locations included the United States (n=27), Bangladesh (n=1), Peru (n=1), Malawi (n=2), Rwanda (n=1), and South Africa (n=1). Three primary roles for CHWs in breast cancer screening were identified: education (n=30), direct assistance or performance of breast cancer screening (n=7), and navigational services (n=6). In these roles, CHWs improved rates of breast cancer screening (n=23) and overall community member knowledge (n=21). Two studies performed cost-analyses of CHW-led interventions.Conclusion: This review extends our understanding of CHW effectiveness to breast cancer screening. It illustrates how CHW involvement in screening programs can have a significant impact in LMICs and HICs, and highlights the three CHW roles of education, direct performance of screening, and navigational services that emerge as useful pillars around which governments and NGOs can design effective programs in this area.

Background: Colorectal cancer (CRC) is the third most common cancer and cause of cancer-related death in the United States. Screening prevents not only mortality but also the occurrence of CRC. Our group reaches out to and educates members of our predominantly low-income Hispanic and African American community about cancer treatment, research, and prevention by establishing partnerships with community-based organizations (CBOs) and training community health workers (CHWs). In 2010, we learned that relatively few CBO clients had been screened or intended to be screened for CRC, and that the CHWs also were not well informed about CRC. Methods: We developed an enhanced training program about CRC for CHWs and their clients. We renewed two of our CBO partnerships, added one more, retrained some previously trained CHWs, and recruited and trained CHWs from the new CBO. We developed a new pre- and post-training 10-question instrument to evaluate what the CHWs already knew and what they learned from our training. We compared the CHWs' average scores (proportions of correct answers) before and after the training. Further training was conducted to reinforce CHWs' knowledge. Using focus groups and community-based participatory research methods with the CHWs, we then developed two educational interventions that the CHWs will implement in the coming months. Results: Fifteen CHWs were trained or retrained. Most of the participating CHWs had previously received our training. All of them answered at least 6 of the 10 questions correctly both before and after the training, but average scores improved from 75% correct before the training to 82% correct afterwards. Next steps: Each CHW will educate 20 clients (n=300) aged 50+ years about CRC screening and attempt to schedule them for screening. In the two intervention groups, we will compare proportions of clients who receive CRC screening. Results will be disseminated to the community in our quarterly community newsletter, a report to the CBOs, and a press release to the local media. Citation Format: Martha Sanchez, Maxine Ashby-Thompson, Judith S. Jacobson, Patricia Hepburn, Victor E. Grann. Promoting colorectal cancer screening in urban, minority populations with community health workers. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A16.

Community health workers (CHWs) have been successful partners in addressing public health and health care challenges but have yet to be engaged in efforts to promote family health history (FHH) collection. FHH information is a key factor in determining disease risk and supporting screening and prevention across multiple diseases. The collection of FHH information could be facilitated by the existing cadre of CHWs already working alongside clients and families. In this qualitative study, we interviewed 30 CHWs from Georgia to better understand the current level of knowledge about FHH, perceptions of how FHH collection aligns with their role, and barriers and facilitators in order to support more active involvement of CHWs in FHH collection. Interviews were completed, transcribed, and double coded by three study team members. More than half of CHWs reported knowing their own FHH information. CHWs showed a strong interest and support for collecting FHH in their job, despite limited current engagement in this role. CHWs acknowledged the collection of FHH as being an opportunity to empower clients to have conversations with their providers. To better support this work, CHWs requested training in using and integrating FHH tools into their workflow and support in communicating about FHH with their clients. Our findings suggest that with support and training, CHWs are uniquely positioned to improve FHH collection among their client base. Ultimately, improving FHH collection skills among the population could allow for better integration of risk-stratified approaches that are informed by FHH information for the prevention, management, and treatment of disease.

Latinos are at higher risk of colorectal cancer (CRC) mortality than non-Hispanic Whites due, in part, to disparities in cancer screening. There is a need to evaluate community-based CRC interventions as they may reach underinsured communities and those at highest risk for CRC. This article describes the development of a group-based CRC intervention (Juntos contra el Cancer). Purposive sampling was used to recruit Latino men and women aged 50 to 75 years not-up-to-date with CRC screening. The development of the intervention was guided by the socioecologic framework, a community needs assessment, literature reviews, five focus groups (n = 39) from the target community and feedback from a Community Advisory Board. Findings from focus groups suggested that a group-based, promotor or community health worker (CHW) led, cancer prevention education with linkages to care would address barriers to CRC screening. Development of community-based CRC screening interventions should be informed by early and sustained community engagement. Interventions led by CHWs with linkages to care are feasible and can reach populations not connected to health care settings.

Background: Disparities in breast cancer screening and survival have been attributed to multiple factors including limited access to breast health education. Innovative information technologies facilitate health education; however, access to information technology is not uniform. The resultant systematic gap in health knowledge has led to a new health disparity where higher socioeconomic individuals acquire health information electronically more easily than the disadvantaged. Promotoras or Community Health Workers (CHWs) facilitate access to culturally appropriate cancer health information, screening and care. Hypothesis: An electronic asynchronous breast cancer educational intervention developed by the Arizona Telemedicine Program and the Arizona Health Sciences Library will improve CHW computer literacy and will enhance health education communication. Specific Aims: to develop, implement and assess a 6-session e-promotora training curriculum with a focus on breast health. Methods: The first step in developing a training curriculum was a needs assessment and a computer literacy assessment. This assessment served as the foundation for the computer literacy curriculum which focused on breast health content. The educational intervention was delivered as a combination of on-line, webinar, and face-to-face seminars. To meet the needs of the participants all sessions were delivered bilingually, Spanish and English. Program evaluation included pre and post knowledge assessments, session assignments, program satisfaction and 6-month follow up focus groups or structured interviews to evaluate the utility, implementation and dissemination of knowledge gained. Results: 26 CHWs have completed the training. All participants identified as Latinas, average age – 51 years of age and educational attainment – 58% (15/26) reported high school or less. Pre and post assessment data reveal high program satisfaction scores, increased participant knowledge and confidence in knowledge, consistent and ongoing use of information learned and computer skills gained and effective dissemination of health information gained. Conclusions: The e-promotora training curriculum effectively improves CHW computer literacy, facilitates dissemination of electronic health information and helps address the disparities in electronic health information. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-12-03.

BACKGROUND Hypertension remains a leading global health challenge, particularly in low- and middle-income countries (LMICs), where limited healthcare infrastructure and resources limit effective management. Community health workers (CHWs) are critical in delivering care in these settings, and mobile health (mHealth) applications offer a promising strategy to enhance chronic disease management. Involving CHWs in the design and development at all stages is essential for the success of the program, yet this is not common in the literature. OBJECTIVE This study aims to evaluate CHW involvement through feedback on a hypertension program employing a novel tablet-based mHealth tool designed for hypertension diagnosis and management in rural Guatemala. METHODS We conducted a mixed-methods analysis as part of a pilot study in San Lucas Tolimán, Guatemala, involving six CHWs over a six-month period. Quantitative data were collected using the System Usability Scale (SUS) and Likert-scale surveys before and after study completion. Qualitative insights were gathered through written surveys and focus group interviews conducted in Spanish by bilingual team members. These methods assessed the application’s ease of use, workflow integration, and cultural appropriateness. CHWs provided detailed perspectives on technical challenges, training adequacy, and patient engagement, which guided iterative refinements to both the mHealth application and the overall hypertension management program. RESULTS The mHealth application was generally well-received. Average SUS scores exceeded 70, surpassing established usability thresholds. Likert scale data revealed CHWs found the application to be useful and easy to use, but found technician support and training protocols as key areas for improvement. Through focus groups and written surveys, participants identified practical short term areas for improvement regarding training, medication dosing, transparency in treatment protocols, fasting for laboratory testing, and survey burden and redundancy. Larger structural concerns identified by participants highlighted cultural sensitivity of certain mHealth application questions, compensation and incentives for the work, and access challenges for hard-to-reach patients. Participants shared the benefits of the program, with key themes including enhanced patient care and improved hypertension management in their communities, the empowerment provided by the educational tools, the streamlined workflow and visit efficiency, as well as the pride and community trust fostered by the hypertension program. CONCLUSIONS Our findings demonstrate that iteratively integrating user feedback into the development and refinement of mHealth interventions is key to improve usability, cultural appropriateness, and overall effectiveness of chronic disease management in resource-constrained settings. This study contributes to the growing literature on mHealth applications for non-communicable diseases in LMICs and provides a scalable model for incorporating local insights into health technology design. Addressing both technical barriers and systemic challenges is essential for sustainable impact, improved CHW performance, and ultimately, a reduction in the burden of hypertension in underserved communities. CLINICALTRIAL Our ongoing clinical trial: NCT06444308 (ClinicalTrials.gov ID)

Emergency response plans in unprecedented public health events prioritize community-based interventions for addressing health disparities. Due to their close connections and shared values with community members, positioning community health workers (CHWs) as leaders is a promising strategy for addressing health disparities. Hence, prominent public health institutions in Indiana co-developed a CHW-driven statewide infrastructure, the “Indiana Health Equity Council Community Health Worker Model” (Model) to serve as a practical framework for building a resilient and responsive public health system that strengthens the community health workforce and addresses health disparities. The objective of this study was to leverage the statewide CHW Model to generate evidence for community-centered interventions addressing health disparities across state's public health preparedness districts. A qualitative study was conducted among CHWs and CHW-affiliated organization representatives across 9 districts in Indiana. Data collection consisted of demographic surveys and audio-recorded focus groups facilitated by trained district CHWs. Verbatim transcripts of focus group recordings were coded by researchers using deductive approaches, and district-level focus group summaries were produced identifying emergent themes and proposed interventions. To assess the accuracy of findings, member checking was conducted with focus group participants. The proposed ideas to address health disparities were mapped to the Healthy People 2030 domains on Social Determinants of Health. A total of 54 individuals participated in 14 focus group sessions across nine districts. Most study participants were female (n = 49, 90.7%) and non-Hispanic (n = 46, 85.2%). A high proportion worked in community-based organizations (n = 22, 41.5%) and performed CHW roles (n = 37, 69.8%). Proposed interventions for mitigating health disparities spanned health literacy programs, enculturation of communication resources, transportation services, community needs assessments, preventative health and psychosocial programs. Fifteen proposed interventions were mapped to the social and community context domain of Healthy people 2030 framework; eight aligned with healthcare access quality and two with neighborhood and built environment. Study findings demonstrate that leveraging the statewide Model positions CHWs to lead district efforts and generate evidence for interventions addressing health disparities across state Public Health Preparedness Districts. Future studies should assess the effectiveness of the statewide CHW Model and explore its policy implications.

As the South African government re-engineers primary healthcare (PHC), the need for additional information on stakeholders involved in the process has emerged. Of these are community health workers (CHWs), who have been identified as central to PHC success. To profile the current CHWs within KwaDabeka and Clermont in KwaZulu-Natal, to describe their roles and to explore the barriers and enablers influencing their service delivery. A convergent mixed methods design was employed with a sample of CHWs with the use of a survey (n = 53) and two focus groups (n = 10) and semi-structured interviews with four ward councillors (n = 4). Data were analysed statistically and thematically. The profile of CHWs reflected only women with a mixed age range and a majority of 59% who had not completed formal schooling. General work experience as a CHW varied. There were diverse opinions expressed towards the CHW role which related to their job title and identity, supervision, remuneration, growth pathways and psychological and emotional issues. Whilst the National Community Health Worker Profile Framework was established for the CHW programme, there are several factors lacking in the current CHW programme such as a formal growth pathway or formal training to align the CHWs with the National Qualifications Framework. The study findings are essential for the monitoring and evaluation as well as development and refinement of policies that will assist in ensuring adequate rollout of PHC with CHWs.

Community Health Workers (CHWs) can effectively implement maternal and child health interventions, but there is paucity of evidence on how to integrate child stimulation into these interventions, and their delivery at scale. In rural Bangladesh, CHWs implemented an intervention integrating psychosocial stimulation, nutrition, maternal mental health, water, sanitation, hygiene (WASH) and lead exposure prevention. In each of 16 intervention villages, one CHW worked with 20 households. CHWs bi-weekly held group meetings or alternated group meetings and home visits with pregnant women and lactating mothers. We assessed the intervention through five focus groups, four interviews and one group discussion with CHWs and their supervisors to explore success factors of implementation. CHWs’ training, one-on-one supervision and introduction by staff to their own community, and adoption of tablet computers as job aids, enabled successful session delivery to convey behavioral recommendations. CHWs reported difficulties delivering session due to the complexity of behavioral recommendations and struggled with age-specific intervention material. Young children’s attendance in group sessions generated distractions that undermined content delivery. We identified ways to minimize the difficulties to strengthen intervention-delivery during implementation, and scale-up. Iterative revisions of similarly integrated interventions based on qualitative evaluation findings could be delivered feasibly by CHWs and allow for implementation at scale.

South Africa has a long history of community health workers (CHWs). It has been a journey that has required balancing constrained resources and competing priorities. CHWs form a bridge between communities and healthcare service provision within health facilities and act as the cornerstone of South Africa’s Ward-Based Primary Healthcare Outreach Teams. This study aimed to document the CHW policy implementation landscape across six provinces in South Africa and explore the reasons for local adaptation of CHW models and to identify potential barriers and facilitators to implementation of the revised framework to help guide and inform future planning. We conducted a qualitative study among a sample of Department of Health Managers at the National, Provincial and District level, healthcare providers, implementing partners [including non-governmental organizations (NGOs) who worked with CHWs] and CHWs themselves. Data were collected between April 2018 and December 2018. We conducted 65 in-depth interviews (IDIs) with healthcare providers, managers and experts familiar with CHW work and nine focus group discussions (FGDs) with 101 CHWs. We present (i) current models of CHW policy implementation across South Africa, (ii) facilitators, (iii) barriers to CHW programme implementation and (iv) respondents’ recommendations on how the CHW programme can be improved. We chronicled the differences in NGO involvement, the common facilitators of purpose and passion in the CHWs’ work and the multitude of barriers and resource limitations CHWs must work under. We found that models of implementation vary greatly and that adaptability is an important aspect of successful implementation under resource constraints. Our findings largely aligned to existing research but included an evaluation of districts/provinces that had not previously been explored together. CHWs continue to promote health and link their communities to healthcare facilities, in spite of lack of permanent employment, limited resources, such as uniforms, and low wages.

BackgroundThe World Health Organization recommends that community health workers (CHWs) receive a mix of financial and non-financial incentives, yet notes that there is limited evidence to support the use of one type of incentive (i.e. financial or non-financial) over another. In preparation for a larger scale trial, we investigated the acceptability and feasibility of two different forms of incentives for CHWs in Malang District, Indonesia.MethodsCHWs working on a cardiovascular disease (CVD) risk screening and management programme in two villages were assigned to receive either a financial or non-financial incentive for 6 months. In the financial incentives village, CHWs (n = 20) received 16,000 IDR (USD 1.1) per patient followed up or 500,000 IDR (USD 34.1) if they followed up 100% of their assigned high-risk CVD patients each month. In the non-financial incentive village, CHWs (n = 20) were eligible to receive a Quality Care Certificate for following up the highest number of high-risk CVD patients each month, awarded in a public ceremony. At the end of the 6-month intervention period, focus group discussions were conducted with CHWs and semi-structured interviews with programme administrators to investigate acceptability, facilitators and barriers to implementation and feasibility of the incentive models. Data on monthly CHW follow-up activity were analysed using descriptive statistics to assess the preliminary impact of each incentive on service delivery outcomes, and CHW motivation levels were assessed pre- and post-implementation.ResultsFactors beyond the control of the study significantly interrupted the implementation of the financial incentive, particularly the threat of violence towards CHWs due to village government elections. Despite CHWs reporting that both the financial and non-financial incentives were acceptable, programme administrators questioned the sustainability of the non-financial incentive and reported CHWs were ambivalent towards them. CHW service delivery outcomes increased 17% for CHWs eligible for the non-financial incentive and 21% for CHWs eligible for the financial incentive. There was a statistically significant increase (p < 0.0001) in motivation scores for the performance domain in both villages.ConclusionIt was feasible to deliver both a performance-based financial and non-financial incentive to CHWs in Malang District, Indonesia, and both incentive types were acceptable to CHWs and programme administrators. Evidence of preliminary effectiveness also suggests that both the financial and non-financial incentives were associated with improved motivation and service delivery outcomes. These findings will inform the next phase of incentive design, in which incentive feasibility and preliminary effectiveness will need to be considered alongside their longer-term sustainability within the health system.

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.

Background:Community health workers (CHWs) bridge the gap in health and social services delivery for marginalized communities, providing critical health information to those with limited access to health resources.Objectives:The purpose of our study was to understand CHWs' approaches to identifying salient and credible health information for migrant and seasonal farmworkers in rural North Carolina (NC).Methods:Two focus group discussions were held with CHWs in eastern NC and one in western NC in February 2020.Results:CHWs seek health information on chronic health conditions disproportionately experienced by farmworkers such as diabetes and high blood pressure. They search for information from existing resources in their possession, via the internet, and through consultation with health professionals. CHWs also verify the information and transform the content into resources that are accessible to farmworkers.Discussion:Our findings suggest that CHWs possess a strong set of information literacy skills that could be enhanced through additional training in crediting sources, creating new materials, and organization and storage.Conclusion:This study adds to the very limited body of knowledge about how CHWs seek and transmit information to their communities and sheds light on their information need and literacy abilities.

BackgroundLike any other health worker, community health workers (CHWs) need to be supported to ensure that they are able to contribute effectively to health programmes. Management challenges, similar to those of managing any other health worker, relate to improving attraction, retention and performance.MethodsExploratory case studies of CHW programmes in the Democratic Republic of Congo, Ghana, Senegal, Uganda and Zimbabwe were conducted to provide an understanding of the practices for supporting and managing CHWs from a multi-actor perspective. Document reviews (n = 43), in-depth interviews with programme managers, supervisors and community members involved in managing CHWs (n = 31) and focus group discussions with CHWs (n = 13) were conducted across the five countries. Data were transcribed, translated and analysed using the framework approach.ResultsCHWs had many expectations of their role in healthcare, including serving the community, enhancing skills, receiving financial benefits and their role as a CHW fitting in with their other responsibilities. Many human resource management (HRM) practices are employed, but how well they are implemented, the degree to which they meet the expectations of the CHWs and their effects on human resource (HR) outcomes vary across contexts. Front-line supervisors, such as health centre nurses and senior CHWs, play a major role in the management of CHWs and are central to the implementation of HRM practices. On the other hand, community members and programme managers have little involvement with managing the CHWs.ConclusionsThis study highlighted that CHW expectations are not always met through HRM practices. This paper calls for a coordinated HRM approach to support CHWs, whereby HRM practices are designed to not only address expectations but also ensure that the CHW programme meets its goals. There is a need to work with all three groups of management actors (front-line supervisors, programme managers and community members) to ensure the use of an effective HRM approach. A larger multi-country study is needed to test an HRM approach that integrates context-appropriate strategies and coordinates relevant management actors. Ensuring that CHWs are adequately supported is vital if CHWs are to fulfil the critical role that they can play in improving the health of their communities.