What makes community health worker models for tuberculosis active case finding work? A cross-sectional study of TB REACH projects to identify success factors for increasing case notifications

Abstract

Background In the field of tuberculosis (TB), Community Healthcare Workers (CHWs) have been engaged for advocacy, case detection, and patient support in a wide range of settings. Estimates predict large-scale shortfalls of healthcare workers in low- and middle-income settings by 2030 and strategies are needed to optimize the health workforce to achieve universal availability and accessibility of healthcare. In 2018, the World Health Organization (WHO) published guidelines on best practices for CHW engagement, and identified remaining knowledge gaps. Stop TB Partnership’s TB REACH initiative has supported interventions using CHWs to deliver TB care in over 30 countries, and utilized the same primary indicator to measure project impact at the population-level for all TB active case finding projects, which makes the results comparable across multiple settings. This study compiled 10 years of implementation data from the initiative’s grantee network to begin to address key knowledge gaps in CHW networks. Methods We conducted a cross-sectional study analyzing the TB REACH data repository (n = 123) and primary survey responses (n = 50) of project implementers. We designed a survey based on WHO guidelines to understand projects’ practices on CHW recruitment, training, activities, supervision, compensation, and sustainability. We segmented projects by TB notification impact and fitted linear random-effect regression models to identify practices associated with higher changes in notifications. Results Most projects employed CHWs for advocacy alongside case finding and holding activities. Model characteristics associated with higher project impact included incorporating e-learning in training and having the prospect of CHWs continuing their responsibilities at the close of a project. Factors that trended towards being associated with higher impact were community-based training, differentiated contracts, and non-monetary incentives. Conclusion In line with WHO guidelines, our findings emphasize that successful implementation approaches provide CHWs with comprehensive training, continuous supervision, fair compensation, and are integrated within the existing primary healthcare system. However, we encountered a great degree of heterogeneity in CHW engagement models, resulting in few practices clearly associated with higher notifications.

A systematic review of the types, workload, and supervision mechanism of community health workers: lessons learned for Indonesia

“…The supportive supervision method was mentioned several times in articles [ 24 , 33 , 36 , 38 , 40 , 48 , 49 , 52 , 57 , 62 , 64 , 66 , 71 – 73 ] with promising results. Supportive supervision is an accommodative and facilitative process where supervisors facilitate solutions for problems not only those related to medicine or public health, but also any social and psychological issues.…”

Exploring opportunities to strengthen rural tuberculosis health service delivery: a qualitative study with health workers in Tibet autonomous region, China

“…Indeed, as both our study and others from resource-constrained settings have identified, community health workers must be adequately trained, protected and compensated, as they carry out this work. 37 Finally, our study highlights how, depending on its application and quality, information technology can both hinder and help TB care providers across the cascade of care. Shigatse lacks comprehensive and interoperable information technology platforms that span the health system.…”

“…Indeed, as both our study and others from resource-constrained settings have identified, community health workers must be adequately trained, protected and compensated, as they carry out this work. 37 …”

“…Other studies in highburden settings both in China and elsewhere globally have reported similar findings. [37][38][39] Some TB programmes have also leveraged community health workers for innovative risk communication and community engagement strategies to create context-specific public health messaging about TB. For example, community health workers in India provide TB education for hard-to-reach groups and effectively augment the cascade of care with greater rates of TB case detection and improved treatment success rates.…”

Community and health systems factors contributing to delayed tuberculosis detection in an urban setting: situating software and hardware bottlenecks in local health systems

“…Indeed, a growing body of literature on scaling up community-based TB interventions recognizes the contribution of both formal and community health systems factors to their success [19,20]. In particular, several studies have shown that community health workers improve tuberculosis case detection [21,22], and treatment success whilst strong investment in TB diagnostic equipment has similarly contributed the improved treatment success in most countries.…”