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PubMed2001

Community health worker performance in the management of multiple childhood illnesses: Siaya District, Kenya, 1997-2001.

OBJECTIVES: To characterize community health worker (CHW) performance using an algorithm for managing common childhood illnesses in Siaya District, Kenya, we conducted CHW evaluations in 1998, 1999, and 2001. METHODS: Randomly selected CHWs were observed managing sick outpatient and inpatient children at a hospital, and their management was compared with that of an expert clinician who used the algorithm. RESULTS: One hundred, 108, and 114 CHWs participated in the evaluations in 1998, 1999, and 2001, respectively. The proportions of children treated "adequately" (with an antibiotic, antimalarial, oral rehydration solution, or referral, depending on the child's disease classifications) were 57.8%, 35.5%, and 38.9%, respectively, for children with a severe classification and 27.7%, 77.3%, and 74.3%, respectively, for children with a moderate (but not severe) classification. CHWs adequately treated 90.5% of malaria cases (the most commonly encountered classification). CHWs often made mistakes assessing symptoms, classifying illnesses, and prescribing correct doses of medications. CONCLUSIONS: Deficiencies were found in the management of sick children by CHWs, although care was not consistently poor. Key reasons for the deficiencies appear to be guideline complexity and inadequate clinical supervision; other possible causes are discussed.

Algorithms↗
PubMedDate not supplied

State of evaluation: community health workers.

Disparity groups, especially racial and ethnic minority groups, are at greater risk for poor health yet experience numerous obstacles in accessing health care. Community health workers (CHWs) are indigenous, trusted, and respected members of the underserved community. They can serve as a bridge between peers and health professionals. Use of CHWs has fluctuated since the federal government first endorsed their use for expanded health access to the underserved in the 1960s. National demands to eliminate health disparities and recent socioeconomic pressures have focused attention on use of CHWs to improve community health. Still, underutilization exists due to, in part, a lack of understanding of the CHW concept and a dearth of evaluation literature on CHWs. This article describes the CHW concept, provides a summary of CHW evaluation literature, and suggests quality care indicators to strengthen evaluation. The review of evaluation research relating to CHWs provides a preliminary state of the science for nurses to begin building an evidence-based practice. Quality of care indicators pertinent to CHW are summarized from the existing evaluation literature. The three best practice domains (therapeutic alliance, risk reduction and health care utilization) are proposed along with suggestions for using quality indicators to improve evaluation. A reduction in health disparities can occur with enhanced CHW utilization.

Benchmarking↗
PubMed1997

Effect of a bicultural community health worker on completion of diabetes education in a Hispanic population.

OBJECTIVE: To determine the effect of a bicultural community health worker (CHW) on completion of diabetes education in an inner-city Hispanic patient population and to evaluate the impact of completion of the education program on patient knowledge, self-care behaviors, and glycemic control. RESEARCH DESIGN AND METHODS: Patients were randomized into CHW intervention and non-CHW intervention groups. All patients received individualized, comprehensive diabetes education from a certified diabetes nurse educator after baseline demographic information, diabetes knowledge, diabetes self-care practices, and glycohemoglobin levels were assessed. Rates of education program completion were determined. Diabetes knowledge, self-care practices, and glycohemoglobin levels were reassessed at program completion and at a later postprogram follow-up medical appointment and compared to baseline. Logistic regression analysis and the Mantel-Haenszel chi 2 statistic were used to determine the effect of the CHW assignment on program completion. Analyses of covariance were performed with end-of-treatment behavior scores, knowledge scores, and glycohemoglobin levels as outcome variables, controlling for baseline values and testing for the effect of CHW assignment. RESULTS: Of 64 patients enrolled in the study, 40 (63%) completed and 24 (37%) dropped out before completing the diabetes education program. Of the patients having CHW intervention, 80% completed the education program, compared with 47% of patients without CHW intervention (P = 0.01). "Dropouts" were younger (age 47.5 +/- 12.5 years [mean +/- SD]) compared with patients who completed the program (55.9 +/- 9.9 years) (P = 0.004). Dropout status showed no significant relationship to educational level achieved or literacy level. For the program "completers," knowledge levels and selected self-care practices significantly improved, and glycohemoglobin levels improved from a baseline level of 11.7% to 9.9% at program completion (P = 0.004) and 9.5% at the postprogram follow-up (P < 0.001). The effect of the CHW assignment on program completion, controlling for financial status and language spoken, was extremely robust (P = 0.007). The effect of the CHW on knowledge, self-care behavior, or glycohemoglobin outcome variables was not statistically significant. CONCLUSIONS: These findings suggest that intervention with a bicultural CHW improved rates of completion of a diabetes education program in an inner-city Hispanic patient population irrespective of literacy or educational levels attained. Our data further suggests that completion of individualized diabetes educational strategies leads to improved patient knowledge, self-care behaviors, and glycemic control.

Adult↗
PubMedDate not supplied

Community diagnosis: its uses in the training of community health workers and in primary health care in East Africa.

Over the last 20 years, medical schools in Uganda, Kenya and Tanzania have been developing teaching programs in community health which have placed increasing emphasis on community diagnosis. This process, which involves students, health workers and the community, is a team effort to obtain a wide variety of information using epidemiologic methods and to establish priorities for health action. The programs which are developed following community diagnosis often rely on primary health workers and small health centers for their execution. Experience in community diagnosis is an important element in the training of health workers. Such experience is also an excellent means of teaching the management skills that are essential for operating primary health care programs. This paper traces the evolution of the methods of community diagnosis used in East Africa.

Africa, Eastern↗
PubMed1993

Community health worker competency in managing acute respiratory infections of childhood in Bolivia.

A competency-based training and evaluation method was developed to improve and assess the management of acute respiratory infections (ARI) in young children by community health workers (CHWs) in Bolivia. This method was used to evaluate three groups of Bolivian CHWs, provide them with a one-day refresher course in ARI management, and assess the effects of the course. The results showed the CHWs capable of acquiring the skills needed to effectively manage ARI cases in accordance with the World Health Organization's ARI case management strategy. It was found important, however, that their training emphasize how to count the respirations of children with tachypnea and how to identify chest indrawing. In general, the competency-based methods appeared to be effective in training and evaluating CHWs in the area of ARI case management; it is expected that these methods will prove useful in other community-based health interventions.

Acute Disease↗
PubMed2005

Community health workers as interventionists in the prevention and control of heart disease and stroke.

A considerable body of research indicates that community health workers (CHWs) are effective in improving chronic disease care and health outcomes. Much of the focus of cardiovascular research involving CHWs has been on hypertension because of its high prevalence and because it is a major risk factor for cardiovascular, cerebrovascular, and renal diseases. Adding CHWs to the patient-provider team has a beneficial effect on the quality of care for populations most in need. CHWs have contributed to significant improvements in community members' access to and continuity of care and adherence to treatment for the control of hypertension. CHWs assume multiple roles, including patient and community education, patient counseling, monitoring patient health status, linking people with health and human services, and enhancing provider patient communication and adherence to care. Current recommendations for CHWs to be interventionists on healthcare teams and in community-based research increase opportunities for CHWs to play an important role in eliminating disparities in heart disease and stroke. Adequate translation of research into clinical practice remains a major challenge, however. Addressing this issue, which has national implications, will require sustainable funding; appropriate reimbursement; enhanced efforts to incorporate CHWs into healthcare teams; better utilization of their skills; improved CHW supervision, training, and career development; policy changes; and ongoing evaluation, including a reporting of costs.

Baltimore↗
PubMed2004

[Safe sex negotiation on TV: gender discourses among female community health workers under the Family Health Program in Porto Alegre, Rio Grande do Sul, Brazil].

This paper analyzes the understanding among female community health workers in the Family Health Program in Porto Alegre, Rio Grande do Sul State, Brazil, concerning the notion of safe sex negotiation promoted by the Brazilian government in AIDS prevention campaigns targeting women. The paper is based on empirical data gathered in 2003. The study focused on TV advertisements used in campaigns by the Brazilian Ministry of Health from 1994 to 2000. The analytical approach was informed by feminist and cultural studies, taken from a post-structuralist and Foucauldian perspective. The research aimed to produce knowledge to support a critical reading of such education for HIV/AIDS prevention, especially concerning gender relations. The paper argues that knowledge and practices permeating the "safe sex negotiation" discourse incorporate, reproduce, and/or transmit hegemonic representations of masculinity and femininity and that these representations differentiate and highlight hierarchical positions of women in relation to men and/or women in relation to other women, producing and/or reinforcing prejudices and inequalities.

Acquired Immunodeficiency Syndrome↗
PubMed2003

Hepatitis A virus seropositivity among hospital and community healthcare workers in Israel-the role of occupation, demography and socioeconomic background.

Hospital and community-clinic workers were tested for hepatitis A virus antibodies (HAV)-IgG to identify variables associated with presence of (HAV-IgG) and to determine whether sociodemographic background may explain all differences in HAV seropositivty among healthcare workers. Logistic regression analysis was used to identify variable associated with HAV-immunity. Multivariate logistic regression analysis revealed that HAV-seroprevalence correlated significantly (P<0.01) with age, siblings, residence in rural areas and origin. Nurse aides had an increased risk for HAV seropositivity (OR=5.04; 95% CI: 1.49-17.08) whereas physicians had a lower risk (OR=0.54: 95% CI: 0.30-0.98). Age and socioeconomic background were independently correlated with HAV immunity but did not explain all difference in HAV-seroprevalence. The higher susceptibility and elevated incidence of hepatitis A amongst physicians, prioritize primary prevention in this group.

Academic Medical Centers↗
PubMed2002

Occupational assault among community care workers.

The author presents the findings of a study that attempted to analyze the frequency, trend, and pattern of workplace assaults among community care workers who provide care for severely emotionally and behaviorally disturbed children in a state government agency in Australia between 1997 and 2000. He identifies the high risk groups and discusses activities for prevention opportunities.

Adolescent↗
PubMed1995

Community rehabilitation workers: do they offer hope to disabled people in South Africa's rural areas?

This article outlines the thinking behind the Wits/Tintswalo community rehabilitation worker training programme which is located in South Africa's eastern Transvaal Lowveld. Drawing on a combination of qualitative and quantitative evidence collected during the first eighteen months in which the CRWs were working full-time (January 1993 - June 1994) it suggests that the two year training programme has been successful in providing therapeutic skills. Key issues raised are whether the coverage of disability is adequate in terms of numbers treated or in terms of categories of disability treated.

Activities of Daily Living↗
PubMed1998

The potential role of peripheral health workers and community key informants in the rapid assessment of community burden of disease: the example of lymphatic filariasis.

Data for planning disease control programs in most developing countries is often not available because they are usually expensive to gather. This study explored the potential use of peripheral health staff and community key informants in gathering community-level data about lymphatic filariasis. Agreement between findings of health workers and those of physicians was very high (kappa 0.66-0.87) for the clinical conditions examined. The prevalence of hydrocele was found to be a good predictor of communities at risk of filariasis. Community key informants provided very useful qualitative and quantitative data on the prevalence of clinical filariasis. The need to use nontraditional health professionals in gathering data for planing control programs is discussed.

Community Health Workers↗
PubMed2005

Tobacco cessation services through community health workers for Spanish-speaking populations.

Partnerships were established with the University of Arizona's Healthcare Partnership to train promotores--Spanish-speaking community health workers--as tobacco cessation counselors. Tobacco Free El Paso certified promotores to help identify tobacco users and offer tobacco cessation counseling services. The project certified 89 participants, of whom 95% were promotores; 88% were Hispanic/Latino, 67% were females, and 62% indicated Spanish as their primary language. Participants who completed Técnicas Básicas, Treatment Specialist, and Déjate de ese Vicio certifications significantly increased self-confidence levels to deliver brief smoking cessation interventions (P < .05). Satisfaction scores (scale = 1-5) were also relatively high for each certification (Técnicas Básicas, mean = 4.8; Treatment Specialist, mean = 4.7; Déjate de ese Vicio, mean = 4.6). The results suggest that promotores understood the concepts and methodologies presented.

Community Health Services↗
PubMed2006

Can community health workers and caretakers recognise pneumonia in children? Experiences from western Uganda.

Acute respiratory infections (ARI) are leading killers of children. Case management using community health workers (CHW) has halved ARI mortality in children in Asia. WHO/UNICEF recommend integrating pneumonia into Home Management of Malaria strategies. However, in sub-Saharan Africa, CHW's performance to recognise pneumonia is rarely demonstrated. We evaluated the ability of CHWs to assess rapid breathing in under 5 year olds and explored caretaker interpretation of pneumonia symptoms. Ninety-six CHWs were evaluated for their skills to count and classify breathing rate in inpatient children. Respiratory illness concepts and actions were obtained from focus group discussions with mothers, video probing and key informant interviews. Of the CHW assessments, 71% were within +/-5 breaths/min from the gold standard. The sensitivity of CHW classification was 75% and the specificity was 83%. Many local terms existed for ARIs, such as "quick breathing" and "groaning breathing". There was consistency in the interpretation of severity, cause and treatment, most being related to fever and treated with antimalarials. Given the ability of CHWs to classify pneumonia, their skills should be tested in real life. To minimise failure to treat and overtreatment, context-specific communication strategies that improve care-seeking and increase illness prevalence among patients assessed by CHWs are needed. A toolkit including a set of methods for this purpose is proposed.

Adolescent↗
PubMed1997

Control of tuberculosis by community health workers in Bangladesh.

BACKGROUND: Tuberculosis remains a major public-health problem in Bangladesh, despite national efforts to improve case identification and treatment compliance. In 1984, BRAC (formerly the Bangladesh Rural Advancement Committee), a national, non-governmental organisation, began an experimental tuberculosis-control programme in one thana (subdistrict). Community health workers screened villagers for chronic cough and collected sputum samples for acid-fast bacillus (AFB) microscopy (phase one). Positive patients received 12 months of directly observed therapy. Phase two (1992-94) included another nine thanas and, in phase three (1995), eight more thanas were included. From 1995, the treatment was an 8-month oral regimen. METHODS: In 1995-96, we analysed all programme data from 1992 to 1995. First we analysed phases two (12-month therapy) and three (8-month therapy) separately for proportion cured, died, treatment, failed, defaulted, migrated, and referred. Second, we did a cross-sectional survey of tuberculosis cases in more than 9000 randomly selected households in two phase-two thanas and one non-programme thana, and analysed the follow-up of all patients treated in the programme thanas. FINDINGS: In the phase-two analysis, 3497 (90%) of 3886 cases identified had accepted 12-month treatment. In phase three, all of 1741 identified cases accepted the 8-month regimen. 2833 (81.0%) and 1496 (85.9%) in phases two and three, respectively, were cured; 336 (9.6%) and 133 (7.6%) died. The relapse rate 2 or more years after treatment was discontinued was higher than the early relapse rate. The drop-out rate was 3.1%. In the cross-sectional survey, the prevalence of tuberculosis in the two programme thanas was half of that in the comparison thana, where only government services were available (0.07 vs 0.15 per 100 [corrected]). INTERPRETATION: The BRAC tuberculosis-control programme has successfully achieved high rates of case detection and treatment compliance, with a cure rate of at least 85% and a drop-out rate of 3.1%. The prevalence survey suggested that at least half of all existing cases had been detected by the programme.

Adolescent↗
PubMed1989

Low utilization of community health workers: results from a household interview survey in Burkina Faso.

A representative household survey was carried out in order to study the utilization of community health workers (CHW) in relation to other sources of health care. We found three main results: (1) For mild diseases, villagers consulted their CHW only in 8.8% of mild diseases, in 69% the family remained the main provider of primary care. (2) In the case of serious diseases, which the CHW was supposed to identify and refer, the villagers bypassed the CHW in 96.5%. The professional health worker were consulted directly in the majority of serious disease. (3) Sick infants were not taken to the CHW for treatment. (4) No pattern of referral between professional and CHWs could be traced. Severity of disease and perceived effectiveness of the treatment were the most important determinants of health seeking behavior. Availability, distance, and cost of travel and drugs were important service related determinants. Individual and household characteristics such as income, ethnicity, and household size were only weakly associated with choice of curative care. Reasons for the low utilization of CHWs are outlined and policy implications discussed.

Attitude to Health↗
PubMed1998

Detroit's East Side Village Health Worker Partnership: community-based lay health advisor intervention in an urban area.

In recent years, there have been few reports in the literature of interventions using a lay health advisor approach in an urban area. Consequently, little is known about how implementation of this type of community health worker model, which has been used extensively in rural areas, may differ in an urban area. This article describes the implementation of the East Side Village Health Worker Partnership, a lay health advisor intervention, in Detroit, Michigan, and notes how participatory action research methods and principles for community-based partnership research are being used to guide the intervention. Findings are presented on how the urban context is affecting the design and implementation of this intervention. Implications of the findings for health educators are also presented and include the utility of a participatory action research approach, the importance of considering the context and history of a community in designing a health education intervention, and the importance of recognizing and considering the differences between rural and urban settings when designing a health education intervention.

Adult↗
PubMed2005

Perspectives on obesity and barriers to control from workers at a community center serving low-income Hispanic children and families.

Community center workers serving children and families in a predominantly Hispanic, low-income neighborhood were interviewed qualitatively, to ascertain their perspectives on obesity and barriers to control and prevention, to design a practical and culturally appropriate intervention for obesity control. All 19 respondents recognized obesity as a problem, identified healthy eating and physical activity as requisites for controlling obesity, and mentioned fast food and cultural influences in Hispanic families as contributory factors. Lack of time emerged as a major barrier to all preventive practices related to eating healthy or being physically active. Safety concerns and lack of safe places for walking and running were mentioned as a barrier to being physically active. Further studies have to be conducted with parents of at-risk children, to understand time constraints. Community health workers should be sensitive to issues of time constraints and incorporate time management recommendations into obesity prevention and education.

Adult↗