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Background Acute respiratory illness (ARI) is one of the most common reasons children receive antibiotic treatment. Measurement of C-reaction protein (CRP) has been shown to reduce unnecessary antibiotic use among children with ARI in a range of clinical settings. In many resource-constrained contexts, patients seek care outside the formal health sector, often from lay community health workers (CHWs). This study's objective was to determine the impact of CRP measurement on antibiotic use among children presenting with febrile ARI to CHW in Uganda. Methods and findings We conducted a cross-sectional, stepped wedge cluster randomized trial in 15 villages in Bugoye subcounty comparing a clinical algorithm that included CRP measurement by CHW to guide antibiotic treatment (STAR Sick Child Job Aid [SCJA]; intervention condition) with the Integrated Community Care Management (iCCM) SCJA currently in use by CHW in the region (control condition). Villages were stratified into 3 strata by altitude, distance to the clinic, and size; in each stratum, the 5 villages were randomly assigned to one of 5 treatment sequences. Children aged 2 months to 5 years presenting to CHW with fever and cough were eligible. CHW conducted follow-up assessments 7 days after the initial visit. Our primary outcome was the proportion of children who were given or prescribed an antibiotic at the initial visit. Our secondary outcomes were (1) persistent fever on day 7; (2) development of prespecified danger signs; (3) unexpected visits to the CHW; (4) hospitalizations; (5) deaths; (6) lack of perceived improvement per the child's caregiver on day 7; and (7) clinical failure, a composite outcome of persistence of fever on day 7, development of danger signs, hospitalization, or death. The 65 participating CHW enrolled 1,280 children, 1,220 (95.3%) of whom had sufficient data. Approximately 48% (587/1,220) and 52% (633/1,220) were enrolled during control (iCCM SCJA) and intervention periods (STAR SCJA), respectively. The observed percentage of children who were given or prescribed antibiotics at the initial visit was 91.8% (539/587) in the control periods as compared to 70.8% (448/633) during the intervention periods (adjusted prevalence difference -24.6%, 95% CI: -36.1%, -13.1%). The odds of antibiotic prescription by the CHW were over 80% lower in the intervention as compared to the control periods (OR 0.18, 95% CI: 0.06 to 0.49). The frequency of clinical failure (iCCM SCJA 3.9% (23/585) v. STAR SCJA 1.8% (11/630); OR 0.41, 95% CI: 0.09, 1.83) and lack of perceived improvement by the caregiver (iCCM SCJA 2.1% (12/584) v. STAR SCJA 3.5% (22/627); OR 1.49, 95% CI: 0.37, 6.52) was similar. There were no unexpected visits or deaths in either group within the follow-up period. Conclusions Incorporating CRP measurement into iCCM algorithms for evaluation of children with febrile ARI by CHW in rural Uganda decreased antibiotic use. There is evidence that this decrease was not associated with worse clinical outcomes, although the number of adverse events was low. These findings support expanded access to simple, point-of-care diagnostics to improve antibiotic stewardship in rural, resource-constrained settings where individuals with limited medical training provide a substantial proportion of care. Trial registration ClinicalTrials.gov NCT05294510. The study was reviewed and approved by the University of North Carolina Institutional Review Board (#18-2803), Mbarara University of Science and Technology Research Ethics Committee (14/03-19), and Uganda National Council on Science and Technology (HS 2631)., Author(s): Emily J. Ciccone 1,*, Di Hu 2, John S. Preisser 2, Caitlin A. Cassidy 3, Lydiah Kabugho 4, Baguma Emmanuel 4, Georget Kibaba 4, Fred Mwebembezi 4, Jonathan J. [...]

Nepalese Female Community Health Volunteers' (FCHVs) knowledge on social attention and communication development and the early signs of autism was evaluated before, immediately after, and 12-months following training on typical and atypical social-communicative development in infants/toddlers, early signs of autism, and monitoring of key 'markers' of autism using Social Attention and Communication Surveillance. FCHVs (N = 60) significantly improved their knowledge about autism and reported increased perceived confidence in monitoring and referring young children at high likelihood of autism following training, which was sustained one year later. FCHVs also reported a positive impact of training on their work. These findings indicate the effectiveness of training in improving FCHVs' knowledge and perceived confidence to monitor and refer young children at high likelihood of autism., Author(s): Rena Shrestha [sup.1] , Josephine Barbaro [sup.1] , Cheryl Dissanayake [sup.1] Author Affiliations: (1) grid.1018.8, 0000 0001 2342 0938, Olga Tennison Autism Research Centre, School of Psychology and Public [...]

Objectives Community health worker (CHW) interventions have been shown to be effective in areas of maternal and child health (MCH), mostly in relation to infant and neonatal mortality. The specific aims of this review were to expand outcomes to include improving knowledge related to pregnancy and infant health and the receipt of antenatal care (ANC), along with birth outcomes. We also summarized the role, characteristics and activities of CHWs in interventions conducted in settings with demonstrated improvements in key MCH outcomes. Methods Articles were retrieved from: PubMed, CINAHL, Global Health, Scopus, Web of Science, and the Cochrane Library from January 2008 through 2018. We included evaluation studies that utilized CHWs as all or part of an intervention to improve outcomes, were printed in English, and published in peer-reviewed journals. Results Initial electronic database search identified 816 studies and 123 studies met inclusion criteria for full text review. The quality assessment resulted in 0 strong-, 19 moderate-, and 25 weak-rated studies. In most interventions, CHWs were a component of a larger intervention. The majority of the studies (n = 10) found that a CHW intervention can have a positive impact on outcomes. CHW interventions showed improvements in knowledge and ANC. When combined with clinical services, the interventions positively impacted birth outcomes. Most conducted home visits and utilized CHW that were members of the community. Conclusions for Practice CHWs serve an important role as health educators conducting home visits as a member of the community they serve. They should also continue to collaborate with clinical providers to address MCH outcomes., Author(s): Darcell Scharff [sup.1] , Kimberly R. Enard [sup.2] , Donghua Tao [sup.3] , Gretta Strand [sup.4] , Rauta Yakubu [sup.2] , Victoria Cope [sup.5] Author Affiliations: (1) grid.262962.b, 0000 [...]

Context Food insecurity increases an individual's risk for some of the most costly and preventable chronic diseases, including diabetes. Poverty, racism, and food insecurity co-mingle to create significant health inequities and make improvement of diet a hurdle among underserved individuals. Objective To bridge the food insecurity gap for patients while ensuring they are linked to the appropriate resources for sustainable food access to improve diabetes outcomes. Design This randomized controlled pilot study assigned patients to a control group receiving food or an intervention group receiving food in combination with community health work counseling and resource linkage. Setting Patients were recruited from an academic medical center. Study visits were conducted virtually by community health workers via partnership with a community-based organization. Population 31 primary care patients with type 2 diabetes and self-reported food insecurity. Participants were 84% female, 32% Black, 58yrs on average, with an average A1C of 8%. Intervention Study participants received 12 weekly home-deliveries of locally grown produce and shelf-stable food. Sixteen of these patients (intervention group) also received support from community health workers including 9 telehealth visits, nutrition and cooking education, and tailored resource linkage. Outcome Measures We collected Hemoglobin A1C, blood pressure, and weight for each participant at three time points: baseline, 3 months (immediately after food deliveries and CHW intervention), and six months (3 months post intervention). We also collected data on diet quality and knowledge and utilization of food access resources. Results For the intervention group, there was a statistically significant reduction in average value of A1C by 0.85 points from baseline to 3 months (p=0.039) and by 1.65 points from baseline to 6 months (p=0.012). Eighty one percent of participants in the intervention group (13/16) had a reduction in A1C over the course of the intervention. There was no significant change in A1C for the control group in either time point. Diastolic blood pressure increased 6.5 mmHg (p= 0.02) between baseline and 3 months for the control group and remained stable for the intervention group. Systolic blood pressure and weight showed no significant changes for either group. Expected Outcomes These findings suggest that support from CHWs significantly enhances a patient's ability to reduce A1C and sustain this reduction., Presenters Megan Murray, MHSA, Kristina Bridges, PhD, Manuel Solano, MD, Educational Specialist, K Greiner, MD, MPH, Jennifer Woodward, MD, MPH, [...]

Introduction Federal and state policies often require utilization of evidence-based home visiting programs. Measurement of specified interventions is important for tracking program implementation and achieving program outcomes. Thus, the Strong Beginnings program worked to define community health worker (CHW) interventions, a core service of the program to improve maternal and child health. Methods A workgroup consisting of CHWs, supervisors and other program staff was created in order to develop and define specific CHW interventions within a nurse or social worker care team. Basic interventions were first compared to the nurse or social worker care coordinator home visiting interventions by risk topic. The evaluator then grouped each CHW intervention into categories per risk domain using thematic analysis and assigned a CHW core function or role based on literature review findings. The workgroup confirmed the results. The workgroup then continued discussions to further enhance CHW interventions per risk domain once the general structure was created. Results The workgroup identified seven core functions and 28 maternal and child health risk topics to be addressed by the CHW. The process resulted in a detailed document of program interventions that the CHWs use to guide care. Conclusions The process helped CHWs feel more valued with their role in team care. The specified interventions will help others understand the CHW role within the care team, ensure consistent interventions are delivered across program partners, provide a foundation to better understand how specific CHW contributions are related to health outcomes, and support program sustainability., Author(s): Jennifer E. Raffo [sup.1] , Celeste Lloyd [sup.2] , Monica Collier [sup.3] , LaDynah Slater [sup.4] , Belinda Cunningham [sup.2] , Katherine Penninga [sup.4] , Susan Henning [sup.2] , [...]

Introduction: Maintaining optimal self-care in managing Type 2 diabetes is a common struggle for patients due to several barriers, including access to quality services, financial insecurity and/or lack of insurance, [...]

Background: Nearly 100% of pregnant/lactating women living with HIV (WLHIV) in Malawi are on ART, yet only 68% of children living with HIV (CLHIV) are. This treatment gap between mothers [...]

Byline: Maryellen. Potts, Kathleen. Cartmell, Lynne. Nemeth, Suparna. Qanungo Aim: In India, the need for rural palliative care is increasing with the rising number of people diagnosed with late-stage cancers. [...]

Background Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home. Methods and findings As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82-1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30-0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified. Conclusions A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC. Trial registration ClinicalTrials.gov NCT01932138, Author(s): Pascal Geldsetzer 1, Eric Mboggo 2,*, Elysia Larson 3, Irene Andrew Lema 2, Lucy Magesa 2, Lameck Machumi 2, Nzovu Ulenga 2, David Sando 1, Mary Mwanyika-Sando 4, Donna [...]

To achieve universal health coverage, health systems will have to reach into every community, including the poorest and hardest to access. Since Alma-Ata, inconsistent support of community health workers (CHWs) and failure to integrate them into the health system have impeded full realization of their potential contribution in the context of primary health care. Scaling up and maintaining CHW programmes is fraught with a host of challenges: poor planning; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision and support, and under-recognition of CHWs' contribution. The current drive towards universal health coverage (UHC) presents an opportunity to enhance people's access to health services and their trust, demand and use of such services through CHWs. For their potential to be fully realized, however, CHWs will need to be better integrated into national health-care systems in terms of employment, supervision, support and career development. Partners at the global, national and district levels will have to harmonize and synchronize their engagement in CHW support while maintaining enough flexibility for programmes to innovate and respond to local needs. Strong leadership from the public sector will be needed to facilitate alignment with national policy frameworks and country-led coordination and to achieve synergies and accountability, universal coverage and sustainability. In moving towards UHC, much can be gained by investing in building CHWs' skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are no shortcut to progress. [TEXT NOT REPRODUCIBLE IN ASCII] [TEXT NOT REPRODUCIBLE IN ASCII] Pour parvenir a une couverture sanitaire universelle, les systemes de sante devront etendre leur portee a toutes les communautes, y compris celles qui sont les plus pauvres et les plus difficiles d'acces. Depuis la Declaration de Alma-Ata, le soutien inegal des agents sanitaires des collectivites et l'echec de leur integration dans les systemes de sante ont empeche la pleine realisation de leur contribution potentielle dans le contexte des soins de sante primaires. Le developpement et le maintien des programmes des agents sanitaires des collectivites se heurtent a une multitude de defis a relever: mauvaise planification; multitude d'acteurs concurrents avec peu de coordination; formation fragmentee et specifique aux maladies; gestion et financement a l'initiative des donateurs; lien tenu avec le systeme de sante; coordination, supervision et soutien de mauvaise qualite, et sous-reconnaissance de la contribution des agents sanitaires des collectivites. La campagne actuelle vers une couverture sanitaire universelle offre une opportunite d'ameliorer l'acces des personnes a des services de sante, ainsi que leur confiance, demande et utilisation de tels services par le biais des agents sanitaires des collectivites. Pour que leur potentiel puisse etre pleinement realise, les agents sanitaires des collectivites devront toutefois etre mieux integres dans les systemes nationaux de soins de sante en termes d'embauche, de supervision, de soutien et d'evolution de carriere. Les partenaires au niveau du monde, du pays et du district devront harmoniser et synchroniser leurs engagements dans le soutien aux agents sanitaires des collectivites tout en maintenant suffisamment de flexibilite pour permettre aux programmes d'innover et de repondre aux besoins locaux. Un leadership fort du secteur public sera necessaire pour faciliter l'alignement avec les cadres politiques nationaux et la coordination dirigee par le pays et pour realiser des synergies et des responsabilites, la couverture universelle et la durabilite. En avancant vers la couverture sanitaire universelle, il y a beaucoup gagner en investissant dans l'acquisition de competences des agents sanitaires des collectivites et en les soutenant en tant que membres a part entiere des equipes de sante. Les investissements autonomes au benefice des agents sanitaires des collectivites ne sont pas des raccourcis vers le progres. [TEXT NOT REPRODUCIBLE IN ASCII] A fin de lograr la cobertura universal de la salud, los sistemas sanitarios deben llegar a todas las comunidades, incluidas las mas pobres y de dificil acceso. Desde la conferencia de Alma-Ata, el apoyo inconstante de los trabajadores comunitarios de salud (TCS) y la falta de integracion de estos en el sistema sanitario han impedido la plena realizacion de su contribucion potencial en el contexto de la atencion primaria de la salud. La ampliacion y el mantenimiento de los programas de trabajadores comunitarios de salud suponen muchos desafios: la mala planificacion, los agentes multiples que compiten con insuficiente coordinacion, la fragmentacion en los programas de capacitacion orientados a combatir enfermedades especificas, la gestion y la financiacion impulsadas por los donantes, la escasa union con el sistema sanitario, la falta de coordinacion, supervision y apoyo, y la infravaloracion de la contribucion de los trabajadores comunitarios de la salud. El avance actual hacia la cobertura universal de la salud (CUS) ofrece una oportunidad para mejorar el acceso de la poblacion a los servicios de salud, asi como para aumentar la confianza, la demanda y el uso de dichos servicios a traves de los trabajadores comunitarios de salud. Sin embargo, es necesario integrar mejor a los trabajadores comunitarios de salud, en terminos de empleo, supervision, apoyo y desarrollo profesional, en los sistemas nacionales sanitarios para aprovechar plenamente su potencial. Los socios a nivel mundial, nacional y local deben armonizary sincronizar su compromiso a favorde los trabajadores comunitarios de salud, manteniendo la flexibilidad suficiente para que los programas tengan capacidad de innovacion y respuesta frente a las necesidades locales. Se requiere un fuerte liderazgo por parte del sector publico para facilitar la alineacion con los marcos de las politicas nacionales y la coordinacion dirigida por el pais, y para lograr sinergias y la rendicion de cuentas, la cobertura universal y la sostenibilidad. En la consecucion de la cobertura universal de la salud, pueden obtenerse grandes beneficios si se invierte en el desarrollo de competencias de los trabajadores comunitarios de salud, y se les apoya como miembros valiosos del equipo sanitario. Por el contrario, las inversiones aisladas en trabajadores comunitarios de salud no son atajos hacia el progreso., From Alma-Ata to universal health coverage From the early years of primary health care, community-based health workers and volunteers (henceforth referred to as community health workers [CHWs]) have played a [...]

Background Community health worker (CHW) programs are believed to be poorly coordinated, poorly integrated into national health systems, and lacking long-term support. Duplication of services, fragmentation, and resource limitations may have impeded the potential impact of CHWs for achieving HIV goals. This study assesses mediators of a more harmonized approach to implementing large-scale CHW programs for HIV in the context of complex health systems and multiple donors. Methods and findings We undertook four country case studies in Lesotho, Mozambique, South Africa, and Swaziland between August 2015 and May 2016. We conducted 60 semistructured interviews with donors, government officials, and expert observers involved in CHW programs delivering HIV services. Interviews were triangulated with published literature, country reports, national health plans, and policies. Data were analyzed based on 3 priority areas of harmonization (coordination, integration, and sustainability) and 5 components of a conceptual framework (the health issue, intervention, stakeholders, health system, and context) to assess facilitators and barriers to harmonization of CHW programs. CHWs supporting HIV programs were found to be highly fragmented and poorly integrated into national health systems. Stakeholders generally supported increasing harmonization, although they recognized several challenges and disadvantages to harmonization. Key facilitators to harmonization included (i) a large existing national CHW program and recognition of nongovernmental CHW programs, (ii) use of common incentives and training processes for CHWs, (iii) existence of an organizational structure dedicated to community health initiatives, and (iv) involvement of community leaders in decision-making. Key barriers included a wide range of stakeholders and lack of ownership and accountability of non-governmental CHW programs. Limitations of our study include subjectively selected case studies, our focus on decision-makers, and limited generalizability beyond the countries analyzed. Conclusion CHW programs for HIV in Southern Africa are fragmented, poorly integrated, and lack long-term support. We provide 5 policy recommendations to harmonize CHW programs in order to strengthen and sustain the role of CHWs in HIV service delivery., Author(s): Jan-Walter De Neve 1,2,*, Henri Garrison-Desany 3, Kathryn G. Andrews 2, Nour Sharara 4, Chantelle Boudreaux 2, Roopan Gill 5, Pascal Geldsetzer 2, Maria Vaikath 2, Till Bärnighausen 1,2,6, [...]

The potential for using community health workers (CHW) for administering timely and effective treatment for presumptive malaria attacks was evaluated in the Katana health zone in Zaire. In each of the 12 villages of an intervention area (area A) with 13000 inhabitants, a CHW was trained in the use of a simple fever management algorithm. The CHWs performed their services under the supervision of the nurse in charge of the area's health centre (HC). Malaria morbidity and mortality trends were monitored during 2 years in area A and in an ecologically comparable control area (area B), where malaria treatment continued to be available at the HC only. Health care behaviour changed dramatically in the intervention area, and by the end of the observation period 65% of malaria episodes were treated at the community level. Malaria morbidity declined 50% in area A but remained stable in the control area. Parasitological indices showed similar trends. Malaria-specific mortality rates remained, however, at essentially the same levels in both areas. The non-comprehensiveness of the CHWs' care and their ambiguous position in the health care system created problems that compromise the sustainability of the intervention., Introduction Early diagnosis and prompt treatment of malaria are essential to avert severe morbidity and mortality in non-immune individuals (1). Together with the implementation of sustainable preventive measures and the [...]

Thirty-nine primary health care workers were interviewed in the Esteli Region of Nicaragua to determine their knowledge, attitudes and ideas for change regarding mental illness in primary care. The aim was to provide a qualitative description in order to assess learners' needs and plan a training programme in mental health care to be carried out by the Esteli mental health team. The results showed a wide range in knowledge regarding diagnoses and treatments. Many of the workers were keen to learn more and nearly all had positive ideas as to how primary care and links with secondary care could be improved. The study is an example of how a small qualitative study can help planning of training programmes and can highlight those primary health care issues relevant to the local situation.

This article contains the findings from an evaluation of a prenatal education program to Hispanic migrant farmworker families using peer health workers. The focus of the evaluation was on establishing the validity of the intervention model in the target population. Data are presented on the program setting, characteristics of the clients served, and effects of the educational program on the clients and peer health workers. The evaluation identified factors that established confidence in the program model: (1) there were existing barriers to health care and health information; (2) the program served a culturally specific and disadvantaged population; (3) the prenatal curriculum was culturally sensitive; (4) the peer workers were accepted by the target community; and (5) the model did not threaten the medical community. The directions for future research are presented.