What do community health workers have to say about their work, and how can this inform improved programme design? A case study with CHWs within Kenya

Abstract

Background: Community health workers (CHWs) are used increasingly in the world to address shortages of health workers and the lack of a pervasive national health system. However, while their role is often described at a policy level, it is not clear how these ideals are instantiated in practice, how best to support this work, or how the work is interpreted by local actors. CHWs are often spoken about or spoken for, but there is little evidence of CHWs' own characterisation of their practice, which raises questions for global health advocates regarding power and participation in CHW programmes. This paper addresses this issue. Design: A case study approach was undertaken in a series of four steps. Firstly, groups of CHWs from two communities met and reported what their daily work consisted of. Secondly, individual CHWs were interviewed so that they could provide fuller, more detailed accounts of their work and experiences; in addition, community health extension workers and community health committee members were interviewed, to provide alternative perspectives. Thirdly, notes and observations were taken in community meetings and monthly meetings. The data were then analysed thematically, creating an account of how CHWs describe their own work, and the tensions and challenges that they face. Results: The thematic analysis of the interview data explored the structure of CHW's work, in terms of the frequency and range of visits, activities undertaken during visits (monitoring, referral, etc.) and the wider context of their work (links to the community and health service, limited training, coordination and mutual support through action and discussion days, etc.), and provided an opportunity for CHWs to explain their motivations, concerns and how they understood their role.

Partnering with insiders: A review of peer models across community-engaged research, education and social care

“…The current review provides an important contribution to understanding the use, development and evolution of peer models. Taken together, the results of this review suggest that peer models offer an innovative and powerful response to strengthening the usefulness, acceptability, relevance, reach, credibility and community benefit within research, education and social care (Oliver, Geniets, Winters, Rega, & Mbae, ). Based on our results, we offer six best practice recommendations for future implementation of peer models and for reporting them in scientific papers.…”

“…In order to maximise participation of peer community members from start to finish of a project, it is crucial that logistical and structural support is provided in the form of childcare, food, community locations for meetings, transportation, compensation and convenient meeting times (Jurkowski et al., ; Vaughn et al., ). High‐quality, interactive training for peers is essential and can be provided through supervision/ mentoring, formal courses/workshops and team‐based approaches (Oliver et al., ; Vaughn et al., ). Focus on partnership . Peer models appear to be most successful when conducted within a theoretical model like HCD or action research that supports ongoing commitment to collaboration, co‐learning, mutual leadership and shared decision‐making throughout the project.…”

Technology and rehabilitation training for community health workers: Strengthening health systems in Malawi

“…In this study, CHWs noted how training programmes, phones and manuals are helpful. Several studies also identified similar barriers in various rural settings for CHWs (Huang et al, ; Knettel et al, ; Oliver, Geniets, Winters, Rega, & Mbae, ; Rachlis et al, ). In this study, CHWs in Malawi faced the barriers of limited transportation, resources and materials for patient care, and rapport between CHWs and target population.…”

Impacts of community lay-leader health worker training and practice (Uttarakhand, India)

“…Participation in the course had also had an overall positive impact on candidates' self-confidence as well as their relationships with family members and villagers, echoing the experience of ASHAs in Manipur and CHWs abroad. 2,3,7 The activities of CLHTC graduates had also engendered a strengthening of relationships with local service providers, mainly in health but also in local governance roles. This was achieved in part through their activity within community structures and institutions: participating in (or initiating) village meetings, collaborating with local health practitioners, and establishing links with local schools.…”

“…1 Acting as a link to formal healthcare services, CHWs also support or organise community development activities and data collection. 2,3 Worldwide, the specifics of CHW programs and activities vary greatly, however, and the National Health Mission of India initiated an effective CHW program in 2008 to train villagers as Accredited Social Health Activists (ASHAs) to expand healthcare coverage. This program alone remains insufficient to meet the needs of the large Indian population in rural areas, and the work of ASHAs has for the most part been limited to maternal and child health.…”