Strengthening the role of community health workers in supporting the recovery of ill, undernourished children post hospital discharge: qualitative insights from key stakeholders in Bangladesh and Kenya

Abstract

Background Undernourished children in low- and middle-income countries remain at elevated risk of death following hospital discharge, even when treated during hospitalisation using World Health Organisation recommended guidelines. The role of community health workers (CHWs) in supporting post-discharge recovery to improve outcomes has not been adequately explored. Methods This paper draws on qualitative research conducted as part of the Childhood Acute Illnesses and Nutrition (CHAIN) Network in Bangladesh and Kenya. We interviewed family members of 64 acutely ill children admitted across four hospitals (a rural and urban hospital in each country). 27 children had severe wasting or kwashiorkor on admission. Family members were interviewed in their homes soon after discharge, and up to three further times over the following six to fourteen months. These data were supplemented by observations in facilities and homes, key informant interviews with CHWs and policy makers, and a review of relevant guidelines. Results Guidelines suggest that CHWs could play a role in supporting recovery of undernourished children post-discharge, but the mechanisms to link CHWs into post-discharge support processes are not specified. Few families we interviewed reported any interactions with CHWs post-discharge, especially in Kenya, despite our data suggesting that opportunities for CHWs to assist families post-discharge include providing context sensitive information and education, identification of danger signs, and supporting linkages with community-based services and interventions. Although CHWs are generally present in communities, challenges they face in conducting their roles include unmanageable workloads, few incentives, lack of equipment and supplies and inadequate support from supervisors and some community members. Conclusion A multi-pronged approach before or on discharge is needed to strengthen linkages between CHWs and children vulnerable to poor outcomes, supported by clear guidance. To encourage scale-ability and cost-effectiveness of interventions, the most vulnerable, high-risk children, should be targeted, including undernourished children. Intervention designs must also take into account existing health worker shortages and training levels, including for CHWs, and how any new tasks or personnel are incorporated into hospital and broader health system hierarchies and systems. Any such interventions will need to be evaluated in carefully designed studies, including tracking for unintended consequences.

Diagnostic, Management, and Research Considerations for Pediatric Acute Respiratory Distress Syndrome in Resource-Limited Settings: From the Second Pediatric Acute Lung Injury Consensus Conference

“…Acceptability of systematic long-term post-discharge follow-up in RLS has shown to be highly successful (21), but efficacy remains unknown for post-discharge patients, and may be influenced by human, financial, physical, or infrastructural resource constraints and barriers encompassed in the social determinants of health and health-seeking behavior. Health systems should therefore take the needs, experiences, and preferences of patients and their families into account when developing follow-up services (96, 97).…”

Morbidity and unplanned healthcare encounters after hospital discharge among young children in Dar es Salaam, Tanzania and Monrovia, Liberia

“…17 However, unlike our study, prior studies have not compared healthcare seeking among those who died to those who survived. [18][19][20][21][22][23][24] Given the high proportion of children who died during readmission, clinicians should have heightened concern for young children who present to a hospital with 60 days following a recent hospital discharge in such settings.…”

Caregivers’ perceptions of and experiences with severe acute malnutrition among children aged 6 to 59 months in the Ari Zone, South Ethiopia: An exploratory-descriptive qualitative study.

“…As a study in Kenya and Bangladesh reported on equivalent community health workers (CHWs), concerning the perceived potential role of CHWs, the majority of communities felt that more involvement with health workers would assist families facing similar challenges, including through door-to-door visits to help family members identify problems, advice, and referrals to health facilities where necessary. The most vulnerable, high-risk children should be targeted (57). The ndings revealed that early detection and treatment in the community can enhance the coverage of SAM in a cost-effective way.…”