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Task-Shifting to Community Health Workers: Evaluation of the Performance of a Peer-Led Model in an Antiretroviral Program in Uganda
Abstract and Figures
Task shifting to community health workers (CHW) has received recognition. We examined the performance of community antiretroviral therapy and tuberculosis treatment supporters (CATTS) in scaling up antiretroviral therapy (ART) in Reach Out, a community-based ART program in Uganda. Retrospective data on home visits made by CATTS were analyzed to examine the CATTS ability to perform home visits to patients based on the model's standard procedures. Qualitative interviews conducted with 347 randomly selected patients and 47 CATTS explored their satisfaction with the model. The CATTS ability to follow-up with patients worsened from patients requiring daily, weekly, monthly, to three-monthly home visits. Only 26% and 15% of them correctly home visited patients with drug side effects and a missed clinic appointment, respectively. Additionally, 83% visited stable pre-ART and ART patients (96%) more frequently than required. Six hundred eighty of the 3650 (18%) patients were lost to follow-up (LTFU) during the study period. The mean number of patients LTFU per CATTS was 40.5. Male (p = 0.005), worked for longer durations (p = 0.02), and had lower education (p = 0.005). An increased number of patients (p = 0.01) were associated with increased LTFU. Ninety-two percent of the CATTS felt the model could be improved by reducing the workload. CATTS who were HIV positive, female, not residing in the same village as their patients, more educated, married, on ART, and spent less time with the patients were rated better by their patients. The Reach-Out CHW model is labor-intensive. Triaged home visits could improve performance and allow CATTS time to focus on patients requiring more intensive follow-up.
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... The sample sizes of the 17 studies, which met the inclusion criteria, ranged from 19 to 393. Participants were from South Africa (10), [24][25][26][27][28][29][30][31][32][33] Kenya (2), 34,35 Uganda (2), 36,37 Malawi (1), 38 Zambia (1), 39 Ethiopia (1), 37 Lesotho (1), 40 Mozambique (1), 41 Zimbabwe (1), 42 and eSwatini (1). 33 One study was performed in four countries within the southern African region, namely Lesotho, Mozambique, South Africa, and eSwatini. ...
... 35,38,44,45 CHWs were also responsible for referring all individuals who tested HIV positive, screened positive for opportunistic infections or acute illnesses, or ART side effects to health facilities. 36 In one study, CHWs were playing an important role in supporting women on prevention of mother-to-child transmission (PMTCT) programs. 35 Multiple studies reported that CHWs, supported by social workers, nurses, and clinicians, were providing psychosocial support, including marital counseling and teaching coping strategies. ...
... 35 Multiple studies reported that CHWs, supported by social workers, nurses, and clinicians, were providing psychosocial support, including marital counseling and teaching coping strategies. 25,26,[34][35][36]39,42 Some studies reported that CHWs even provided general homebased support, such as household cleaning for child-headed households affected by HIV 25 and activities such as cooking for and feeding patients, 34,36,38 cleaning, and fetching water for sick individuals unable to perform these activities themselves. 26 ...
While the impact of Community Health Workers (CHWs) on home-based human immunodeficiency virus (HIV) care has been documented, barriers and recommendations have not been systematically reviewed. Following the reporting requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used an aggregative narrative synthesis approach to summarize the results of qualitative studies published between January 1, 2000, and November 6, 2020 in the following databases: PubMed, CINAHL, PsychINFO, Web of Science, and Google Scholar. In total, 17 studies met the selection criteria and were included in the analysis. They reported on a range of roles played by CHWs in HIV care, including education and health promotion; HIV-specific care (HIV testing services; screening for opportunistic infections and acute illness); medication delivery; tracing persons who had defaulted from care; and support (treatment support; referral; home-based care; and psychosocial support).
Many different barriers to community-based HIV care were reported and centered on the following themes: Stigma and nondisclosure; inadequate support (lack of resources, inadequate training, inadequate funding, and inadequate monitoring); and health system challenges (patients' preference for more frequent visits and poor integration of CHWs in the wider health care system). Recommendations to mitigate these barriers included: addressing HIV-related stigma; introducing updated and relevant CHW training; strengthening the supervision of CHWs; coordinating care between the home and facilities; incorporating patient-centered mHealth approaches; and committing to the funding and resources needed for successful community-based care. In summary, CHWs are providing a variety of important community-based HIV services but face challenges with regards to training, resources, and supervision.
... There is a lack of basic entitlements such as leave and complaints mechanisms for CHWs [105]. Also, policies addressing remuneration and incentives are often absent [97], or there is a fragmentation in salaries between different CHWs [129]. ...
... In Malawi, HSAs are supervised by the environmental health officers or senior HSAs [140,178], and expert patients by the facility nurse [160]. In Uganda, community antiretroviral therapy and TB treatment supporters who are expert patients (PLWHA) were supervised weekly by their team leaders; they were part of monthly staff meetings to feedback on community activities [129]. Lay mental health workers in Zimbabwe were supervised by the facility nurse, psychologist and psychiatrist [93]. ...
... Over half reported that they see their supervisors on a weekly basis [94]. Community antiretroviral therapy and TB treatment supporters in Uganda were also supervised on a weekly basis [129]. For Zimbabwean HIV care facilitators, there was one supervisor and one counsellor at each project site. ...
http://www.reachoutconsortium.org/media/2856/reachout-international-literature-review.pdf
https://www.kit.nl/wp-content/uploads/2020/08/reachout-international-literature-review.pdf
... Through this approach, cohabiting relatives of the index patient are screened for HIV and TB, where follow-up visits upon treatment initiation are made, and active search of default patients is performed. The use of community-based health professionals to reach, test, and refer HIV and TB patients has received a great deal of support in literature and experience from sources outside of Mozambique [7][8][9][10][11][12]. ...
... Using community-based health professionals to reach, test, and refer HIV and TB patients has shown overwhelmingly favorable results in literature and experience outside of Mozambique [7][8][9][10][11][12]. Similar to what happened in several studies, Infomóvel demonstrated the positive impacts of using mobile technology to strengthen community-level management of suspected HIV, and to reinforce links between CHWs and district health facilities and improve counseling and testing, linkage to care, and treatment adherence [14][15][16], with a counseling and testing rate of 68% of contacts of index cases, from all HIV positives identified at communities; the community linkage rate to the health facilities was 81%. ...
Background
Mobile health is gradually revolutionizing the way medical care is delivered worldwide. In Mozambique, a country with a high human immunodeficiency virus prevalence, where antiretroviral treatment coverage is 77% accompanied by a 67% of retention rate, the use of mobile health technology may boost the antiretroviral treatment, by delivering care beyond health facilities and reaching underrepresented groups. Leveraging new technologies is crucial to reach the 95–95-95 United Nations target by 2030. The design, development, implementation, and evaluation of a mobile health platform called Infomóvel were covered in this article. Its intended use involves collaboration with community health workers and aims to increase human immunodeficiency virus patient access, adherence, and retention to care.
Methods
Using the Design Science Research Methodology, Infomóvel was created, as well as this publication. The explanation of various actions includes everything from problem description to observational study and goal-following for a solution, which results in the design and development of a platform proposal. Before the utility assessment of Infomóvel was conducted to make adjustments, a demonstration phase was conducted in one region of Mozambique.
Results
The initial subjects of the Infomóvel flowchart and physical process design were patients receiving antiretroviral medication who were enrolled in the patients tracking system and who had consented to home visits. The case manager examines the file before importing it into the Infomóvel database stored on a cloud server using the website www.commcarehq.org. The case manager application synchronises with the Infomóvel server database, enabling the import of latest data and access to the lists of new patients and community health workers. The community health worker uses his phone to access his application, which allows him to record the geographic coordinates and sort the list of patients by priority and type of visit.
Conclusion
Results from Infomóvel add to the growing body of data showing that mobile health techniques are beneficial for managing stable individuals with chronic conditions in Mozambique. These approaches can be scaled up and better utilised. However, additional studies should be conducted to quantify the resources needed to implement on a larger scale.
... To fill an important gap in CHW training, a peer-to-peer training model was introduced based on the idea that not only do the CHWs themselves need to enhance their knowledge of related topics but they also need to train others, resulting in delivering cost-effective health promotion and prevention services in a more culturally appropriate manner. 21 Today, much attention has been given to the use of Peer Assisted Learning (PAL) in various fields of health sciences and most of the studies have confirmed the usefulness of this approach in terms of educational purposes. 22 Since CHW peer training is hypothesized to be a supportive strategy for the robustness of standardized training, we conducted a study to compare the knowledge and attitude levels acquired by CHWs about HIV-related issues through two different methods of teaching (PAL and a classic training method). ...
Background: Community health workers (CHWs) act as a bridge between community and clinical care in caring for HIV patients. This study aimed to evaluate the effectiveness of peer education in improving HIV knowledge, attitude, and perception of CHWs in Babol, Iran in 2019. Methods: This was a quasi-experimental study conducted among CHWs in the health centers of Babol, Iran. The city was divided into two areas of the North and the South according to the geographical map. Then, based on the list of the health centers in each of the areas, one health center was randomly selected and assigned to either the experimental or the control group. Results: Following peer education, all study variables including knowledge score, attitude, and perception about HIV-related issues significantly improved in the experimental group compared to the pre-intervention phase (P=0.002, P=0.02, and P=0.00 respectively). The most significant change was in misconception score with a approximately large effect size (0.78), presenting an increase of 95.53% from 15 to 29.33 after the intervention, while attitude and knowledge respectively presented 85.04% and 81.07% increase with a smaller effect size of 0.57 and 0.52. Conclusion: In the study peer education proved to be an effective strategy in improving the knowledge, attitudes, and perception of CHWs concerning HIV/AIDS. Therefore, the peer-to-peer training model can fill a critical gap in the training of CHW based on the idea that not only do the CHWs themselves need to enhance their knowledge of related topics but they also need to train others. In turn, this will result in providing cost-effective health promotion and prevention services in a more culturally appropriate manner.
... FSWs in HIV care (20). Continuous training should be implemented, and expert clients should be fully integrated into HIV care. ...
Background
Sex work is a global driver of the HIV epidemic, and the risk of acquiring HIV is 13 times higher for female sex workers (FSWs) compared to the general population. The enrollment and retention of FSWs in HIV care is a challenge and has been a major contributing factor to increased new HIV infections.
Methods
We conducted a qualitative study among 30 FSWs and 21 healthcare workers (HCWs) working in antiretroviral therapy (ART) clinics at the selected three primary health facilities in Mbarara City, Southwestern Uganda. The study participants were enrolled by both purposive and snowball sampling techniques. We obtained informed consent from all the participants, and data were collected using in-depth interviews and thematically analyzed.
Results
Three themes emerged as facilitators toward enrollment and retention of FSWs into HIV care, namely, (1) good health living, (2) receptive HCWs and availability of health services, and (3) community outreach services and peer support. The barriers are summarized into four major themes: (1) stigma, community discrimination, and beliefs; (2) social obstacles; (3) adverse effects of ART; and (4) inadequate services at the health facilities.
Conclusion
FSWs are challenged by unsupportive environments and communities where they live and work, which hinders their enrollment and retention in HIV care. Creating awareness of the utilization of HIV care services and extending such services to hotspot communities could enhance the response of HIV-positive FSWs to ART.
... Community health workers (CHW) have been involved in various HIV interventions before DSD roll-out [3][4][5][6]. Their role in DSD varies depending on whether they are supporting or coordinating the specific intervention. In a supportive role, they assist other HCW to provide adherence counseling, distribute pre-packaged antiretrovirals (ARVs), client tracking, documentation, and home visits. ...
Background
Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery). ART clubs, 15-30 clients who usually meet within the community, are one of the most common DSD options. However, evidence about the quality of care (QoC) delivered in ART clubs is still limited.Materials and methodsWe conducted a concurrent triangulation mixed-methods study as part of the Test & Treat project in northwest Tanzania. We surveyed QoC among stable clients and health care workers (HCW) comparing between clinics and clubs. Using a Donabedian framework we structured the analysis into three levels of assessment: structure (staff, equipment, supplies, venue), processes (time-spent, screenings, information, HCW-attitude), and outcomes (viral load, CD4 count, retention, self-worth).ResultsWe surveyed 629 clients (40% in club) and conducted eight focus group discussions, while 24 HCW (25% in club) were surveyed and 22 individual interviews were conducted. Quantitative results revealed that in terms of structure, clubs fared better than clinics except for perceived adequacy of service delivery venue (94.4% vs 50.0%, p = 0.013). For processes, time spent receiving care was significantly more in clinics than clubs (119.9 vs 49.9 minutes). Regarding outcomes, retention was higher in the clubs (97.6% vs 100%), while the proportion of clients with recent viral load
... These findings were concordant with study [7] where only higher education was found to be associated with a better performance unlike factors like years of experience, age, marital status and social class which were found to have a mixed effect on performance. [13][14][15][16][17] Another study [18] shows increased years of experience was found to be associated with better performance and documented predominant involvement of married women belonging to below poverty line similar to our findings yet not significant. As their years of experience as CHW proportionally increases with age, their performance tends to improve due to community trust, supportive supervision and self-efficacy. ...
Introduction:
Induction of Community Health Workers (CHWs) into various health programs is considered as an integral strategy to achieve universal health coverage. Thus, it is prudent to explore and understand the CHWs individual and the system level interactions and their further translation into performance and actionable domains.
Objective:
To quantify the relationship structure between envisioned competencies and CHW performance with factors operating at individual and the immediate system level as effect modifiers.
Methodology:
A cross-sectional study was done in primary rural health care settings of Madhya Pradesh state in Central India. CHWs were stratified as relatively low performing (RLP) and relatively high performing (RHP) based on their annual performance-based incentives for the year (April 2017- March 2018). CHWs were administered a self-reported questionnaire that included socio demographic details, knowledge, skills assessment and availability of logistics.
Results:
Among the 90 eligible CHWs, 31 RLP and 30 RHP CHWs were interviewed. The CHWs performance was found to be significantly associated with age, education, caste, presence of under 5 children, knowledge and competency scores. However, while adjusting for the confounders only age and educational status were found to be significant. Further cluster analysis revealed two clusters based on individual and system characteristics which was found to influence the CHWs performance.
Conclusion:
The relationship between the CHWs truest competencies and performance based incentivisation tends to have been influenced by age and education which could help in developing a more focused supportive supervision catering to their needs.
Keywords: community health worker, performance, health system, competency.
Peer-led HIV interventions are an increasingly common and low-cost strategy to address shortages of professionally trained health workers for implementing evidence-based HIV prevention and treatment interventions to populations who experience health disparities. There is a need to understand the experiences and unmet needs of this essential workforce responsible for implementing and delivering HIV interventions to ensure their implementation efforts are sustainable. This commentary provides a brief overview of barriers to peer deliverers' sustained engagement in the HIV workforce and potential implementation strategies to promote the sustainment of peer deliverers' implementation efforts.
Introduction
There is a growing recognition that Community Health Workers are effective at improving health outcomes and expanding health access. However, the design elements that lead to high-quality Community Health Worker programing are relatively understudied. We looked at the predictors of Community Health Worker knowledge of obstetric and early infant danger signs as well as performance in achieving antenatal care and immunization uptake among their clients.
Methods
The study takes place in the context of an intervention implemented jointly by Lwala Community Alliance and the Kenya Ministry of Health which sought to professionalize Community Health Worker cadres through enhanced training, payment, and supervision. There were four cohorts included in the study. Two cohorts started receiving the intervention prior to the baseline, one cohort received the intervention between the baseline and endline, and a final cohort did not receive the intervention. Data on Community Health Worker demographics, knowledge tests, and key performance indicators were collected for 234 Community Health Workers. Regression analyses were used to explore education, literacy, experience, training, and gender as potential predictors of CHW performance.
Results
We found that clients of Community Health Workers trained through the intervention were 15% more likely to be fully immunized and 14% more likely to have completed four or more antenatal care visits. Additionally, recency of training and experience caring for pregnant women were associated with increased Community Health Worker knowledge. Finally, we found no association between gender and CHW competency and tenuous associations between education/literacy and Community Health Worker competency.
Discussion
We conclude that the intervention was predictive of increased Community Health Worker performance and that recency of training and experience were predictive of increased knowledge. Though education and literacy are often used in the selection processes of Community Health Workers globally, the link between these characteristics and Community Health Worker knowledge and performance are mixed. Thus, we encourage further research into the predictive value of common Community Health Worker screening and selection tools. Further, we encourage policymakers and practitioners to reconsider the use of education and literacy as means of Community Health Worker selection.
Background: Mobile health (mHealth) is gradually revolutionizing the way medical care is delivered worldwide. In Mozambique, a country with a high human immunodeficiency virus (HIV) prevalence where antiretroviral treatment (ART) coverage is s77% accompanied by 67% of retention rate, the use of mHealth technology may boost the ART, by delivering care beyond health facilities and reaching underrepresented groups. Leveraging new technologies is crucial to reach the 95-95-95 UN (United Nations) target by 2030. Here we describe the design, implementation and piloting phase of development of a mHealth platform (“Infomóvel”) whose intended use is coupled to community health workers (CHW) and aims at improving access, adherence and retention to HIV care services.
Infomóvel was designed, developed and implemented using the Design Science Research Methodology (DSRM). In this paper, DSRM’s different activities are explained, from the definition of the problem through observational study following of objectives for a solution, which leads to the design and development of platform proposal. Demonstration phase was carried out in one region of Mozambique, before the usability evaluation of the web platform was carried out to made adjustment on the platform.
Results: The Infomóvel flowchart and physical process architecture start with ART patients registered in patients tracking system who have accepted home visits. The case manager checks the file and through the website www.commcarehq.org, imports the file into the database of Infomóvel set on the cloud server. Case manager application, performs synchronization with Infomóvel Server database, allowing to import recent data and to access to the list of CHW and the list of new patients. The CHW with his phone accesses in his application the list of patients by priority, type of visit and allows to record the geographical coordinates.
Conclusion: Results obtained from Infomóvel bring a growing body of evidence that supports the use of mHealth approaches in Mozambique, and it can be scaled-up and better exploited to manage patients with chronic diseases, if the patients are stable. However, additional studies should be conducted after this pilot in order to quantify the resources needed to implement the approach on a larger scale.
OBJECTIVE: To analyse the early loss of patients to antiretroviral therapy (ART) programmes in resource-limited settings. METHODS: Using data on 5491 adult patients starting ART (median age 35 years, 46% female) in 15 treatment programmes in Africa, Asia and South America with ³ 12 months of follow-up, we investigated risk factors for no follow-up after treatment initiation, and loss to follow-up or death in the first 6 months. FINDINGS: Overall, 211 patients (3.8%) had no follow-up, 880 (16.0%) were lost to follow-up and 141 (2.6%) were known to have died in the first 6 months. The probability of no follow-up was higher in 2003-2004 than in 2000 or earlier (odds ratio, OR: 5.06; 95% confidence interval, CI: 1.28-20.0), as was loss to follow-up (hazard ratio, HR: 7.62; 95% CI: 4.55-12.8) but not recorded death (HR: 1.02; 95% CI: 0.44-2.36). Compared with a baseline CD4-cell count ³ 50 cells/µl, a count
In this paper we attempt to provide an overview of the concepts and practice of community health workers (CHWs) from across a range of (developing and developed) countries, and draw some insights into policy challenges that remain in designing effective CHW schemes, particularly in the Indian context. In the subsequent sections, we provide a review of the various ways in which community health workers have been deployed in different settings. [from introduction]
In this second article of the neonatal survival series, we identify 16 interventions with proven efficacy (implementation under ideal conditions) for neonatal survival and combine them into packages for scaling up in health systems, according to three service delivery modes (outreach, family-community, and facility-based clinical care). All the packages of care are cost effective compared with single interventions. Universal (99%) coverage of these interventions could avert an estimated 41-72% of neonatal deaths worldwide. At 90% coverage, intrapartum and postnatal packages have similar effects on neonatal mortality—two-fold to three-fold greater than that of antenatal care. However, running costs are two-fold higher for intrapartum than for postnatal care. A combination of universal—ie, for all settings—outreach and family-community care at 90% coverage averts 18-37% of neonatal deaths. Most of this benefit is derived from family-community care, and greater effect is seen in settings with very high neonatal mortality. Reductions in neonatal mortality that exceed 50% can be achieved with an integrated, high- coverage programme of universal outreach and family-community care, consisting of 12% and 26%, respectively, of total running costs, plus universal facility-based clinical services, which make up 62% of the total cost. Early success in averting neonatal deaths is possible in settings with high mortality and weak health systems through outreach and family-community care, including health education to improve home-care practices, to create demand for skilled care, and to improve care seeking. Simultaneous expansion of clinical care for babies and mothers is essential to achieve the reduction in neonatal deaths needed to meet the Millennium Development Goal for child survival.