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Objectives. We sought to estimate the return on investment of a streamlined version of an evidence-based community health worker (CHW) asthma home visit program. Methods. We used a randomized parallel group trial of home visits by CHWs to Medicaid-enrolled children with uncontrolled asthma versus usual care. Results. A total of 373 participants enrolled in the study (182 in the intervention group and 191 in the control group, of whom 154 and 179, respectively, completed the study). The intervention group had greater improvements in asthma symptom–free days (2.10 days more over 2 weeks; 95% CI =  1.17, 3.05; P < .001) and caretakers’ quality of life (0.43 units more; 95% CI = 0.20, 0.66; P < .001) and a larger reduction in urgent health care utilization events (1.31 events fewer over 12 months; 95% CI = −2.10, −0.52; P = .001). The intervention arm compared with the control arm saved$1340.92 for the $ 707.04 additional costs invested for the average participant. The return on investment was 1.90. Conclusions. A streamlined CHW asthma home visit program for children with uncontrolled asthma improved health outcomes and yielded a return on investment of 1.90.

To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary-care settings in Goa, India. Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary-care facilities. Subjects were randomly assigned to an intervention or a control arm. Eligible subjects in the intervention arm were given psycho-education, case management, interpersonal psychotherapy and/or antidepressants by lay health workers. Subjects in the control arm were treated by physicians. The use of health-care resources, the disability of each subject and degree of psychiatric morbidity, as measured by the Revised Clinical Interview Schedule, were determined at 2, 6 and 12 months. Complete data, from all three follow-ups, were collected from 1243 (75.4%) and 938 (81.7%) of the subjects enrolled in the study facilities from the public and private sectors, respectively. Within the public facilities, subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm. Time costs were also significantly lower in the intervention arm than in the control arm, whereas health system costs in the two arms were similar. Within the private facilities, however, the effectiveness and costs recorded in the two arms were similar. Within public primary-care facilities in Goa, the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving.

Objectives. To establish a validated, standardized set of core competencies for community health workers (CHWs) and a linked workforce framework. Methods. We conducted a review of the literature on CHW competency development (August 2015), completed a structured analysis of literature sources to develop a workforce framework, convened an expert panel to review the framework and write measurable competencies, and validated the competencies (August 2017) by using a 5-point Likert scale survey with 58 participants in person in Biloxi, Mississippi, and electronically across the United States. Results. The workforce framework delineates 3 categories of CHWs based upon training, workplace, and scope of practice. Each of the 27 competencies was validated with a mean of less than 3 (range = 1.12–2.27) and a simple majority of participants rated all competencies as “extremely important” or “very important.” Conclusions. Writing measurable competencies and linking the competencies to a workforce framework are significant advances for CHW workforce development. Public Health Implications. The standardized core competencies and workforce framework are important for addressing health disparities and maximizing CHW effectiveness.

Objectives. To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions. Methods. We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013–2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences. Results. Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: −0.4 vs 0.0; body mass index: −0.3 vs −0.1; cigarettes per day: −5.5 vs −1.3; systolic blood pressure: −1.8 vs −11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs −0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 28% (P = .11). There were no differences in patient activation or self-rated physical health. Conclusions. A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for health care systems. Trial Registration. clinicaltrials.gov identifier: NCT01900470.

Similar protocols are already in place and used by CHWs in diverse settings—eg, as part of the Integrated Management of Newborn and Childhood Illness.5 Additionally, home visits for vulnerable people would allow CHWs to assess whether individuals have adequate supplies of food and medicines for long-term conditions, are aware of basic hygiene precautions, and whether they have mental health problems. Marco Di Lauro/Stringer/Getty Images Entry criteria could include occupations that provide basic training in first aid or assessing medical emergencies, such as flight attendants, or registration on a health professional training programme. CHWs in Brazil have been established for many years, are well integrated into their communities, and provide a wide range of health and social care support activities to each of the 100–150 households that they are responsible for. [...]in Brazil, additional roles for preventing the spread of and supporting those infected with COVID-19 or in self-isolation could be integrated into the work of CHWs.

Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in lowand middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review. A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed. Le personnel de santé communautaire (PSC) est de plus en plus reconnu comme élément prépondérant du personnel de santé nécessaire pour atteindre les objectifs de santé publique dans les pays à faible et moyen revenu. Beaucoup de facteurs influencent les performances des PSC. Nous avons mené une revue systématique pour identifier les facteurs lors de la conception d’initiatives qui ont une influence sur les performances des PSC. Nous avons cherché systématiquement dans six bases de données provenant d’études quantitatives et qualitatives incluant les PSC travaillant pour la promotion, la prévention et les soins curatifs dans les services de santé primaires pour les pays à faible et moyen revenu. Nous avons trouvé 140 études correspondant aux critères d’inclusion et dont la qualité a été évaluée ainsi qu’une relecture pour extraire les données pertinentes pour la conception de programmes de PSC. Un cadre préliminaire contenant des facteurs influençant la performance des PSC ainsi que les caractéristiques des performances des PSC (telles que la motivation et les compétences) a permis de diriger la recherche de documents et leur analyse. Un mixe d’incitations financières ou non financières, prévisibles pour le PSC, semble être une stratégie efficace pour améliorer la performance, spécialement pour les PSC qui ont plusieurs rôles. Les incitations financières pour encourager la performance peuvent parfois entrainer une négligence sur les t âches non rémunérées. La conception des initiatives, qui implique une supervision fréquente et une formation continue, a entrainé une meilleure performance des PSC dans certains cas. La supervision et la formation ont souvent été mentionnées comme éléments facilitateurs mais peu d’études ont testé quelle approche marchait le mieux et quel est le meilleur moyen de les mettre en place. L’intégration du PSC dans la communauté et dans le système de santé a permis de diminuer la charge de travail et d’augmenter la crédibilité du PSC. Le fait de clairement définir le rôle du PSC et d’introduire un processus de communication clair entre les différents niveaux du système de santé pourrait renforcer la performance du PSC. Lorsque les programmes de santé communautaire sont conçus, les éléments qui favorisent l’amélioration des performances du PSC dans des contextes comparables doivent être pris en compte. Nous avons besoins d’initiatives supplémentaires afin de développer un meilleur cadre pour une formation efficace, pour des mécanismes de supervisions ainsi que pour des recherches qualitatives afin d’informer les législateurs du développement des initiatives du PSC. 在低收入和中等收入国家（LMICs）中，为了达到公共医疗 目标，社区医疗工作者（CHWs）越来越多得被认为是医疗 工作者的一个组成部分。很多因素影响社区医疗工作者的绩 效。本文对这些影响因素做了一个系统评价。我们对六个数 据库定量和定性的研究进行了系统搜索，包括了在低收入和 中等收入国家中在促进、预防和基础医疗服务领域工作的社 区医疗工作者。达到我们标准的 140 个研究被进行了质量评 估，并被再次阅读提取出与社区医疗工作者项目设计相关的 数据。我们提前设计好了一个框架来指导文献搜索和综述工 作，框架里包括了影响社区医疗工作者绩效的因素和绩效的 特点（比如动机和能力）。 经济和非经济动机的混合，可以预见到，是提高绩效的有效 措施，特别是对于有多项工作的社区医疗工作者来说。以绩 效为基础的经济刺激有时会导致对一些不支付金钱的工作的 忽视。在一些情景中，包含了经常性监督和持续培训的干预 措施的设计能够带来更好的绩效。监督和培训是经常被提到 的影响因素，但是很少有研究试验哪种方式最有效或者如何 实施最有效。将社区工作者融入社区和医疗系统中能减少工 作量并增加社区工作者的可信度。清晰地界定社区工作者的 角色和引入医疗系统中不同层面的人的对话机制也能加强绩 效。 当设计以社区为基础的医疗项目时，应该考虑在对比情境下 增加社区医疗工作者绩效的因素。还应该进行额外的干预措 施研究建立一个证据库用以找出最有效的培训和监督机制和 为政策制定者设计干预措施提供定性研究。 Los trabajadores de salud comunitaria (TSCs) son reconocidos cada vez más como un componente integral del personal de la salud necesario para lograr los objetivos de la salud pública en los países de ingresos bajos y medianos (PIBMs). Muchos factores influyen en el rendimiento de los TSCs. Se realizó una revisión sistemática para identificar los factores relacionados con el diseño de la intervención que influyen en el rendimiento de los TSCs. De forma sistemática usamos seis bases de datos para buscar estudios cuantitativos y cualitativos que incluyeron los TSCs que trabajan en servicios promocionales, preventivos o curativos de atención primaria de salud en PIBMs. Ciento cuarenta estudios cumplieron los criterios de inclusión y fueron evaluados en materia de calidad. Se hizo doble lectura para extraer datos relevantes al diseño de programas de los TSCs. Un marco preliminar que contiene los factores que influyen en el rendimiento de los TSC y sus características de rendimiento (tales como motivación y competencias) orientaron la búsqueda bibliográfica y la revisión. Una combinación de incentivos financieros y no financieros, previsibles para los TSCs, resultó ser una estrategia efectiva para mejorar el rendimiento, especialmente para aquellos TSCs con múltiples tareas. Los incentivos financieros basados en el rendimiento resultaron a veces en el abandono de las tareas no pagadas. Los diseños de las intervenciones que implicaron la supervisión frecuente y la formación continua llevaron a un mejor rendimiento de los TSC en ciertos contextos. La supervisión y la capacitación se mencionaron a menudo como factores facilitadores, pero pocos estudios probaron cual enfoque funcionó mejor o cómo éstas se implementaron de mejor manera. Se encontró que el arraigamiento de los TSCs en los sistemas comunitarios disminuyó la carga de trabajo y aumentó su credibilidad. Funciones de los TSCs claramente definidas y la introducción de procesos claros para la comunicación entre los diferentes niveles del sistema de salud podrían fortalecer el rendimiento de los TSCs. Al diseñar los programas de salud basados en la comunidad, los factores que aumentan el rendimiento de los TSCs en contextos comparables deben ser tenidos en cuenta. Son necesarias investigaciones adicionales sobre la intervención para desarrollar una mejor base de pruebas sobre los mecanismos de formación y supervisión más eficaces, e investigaciones cualitativas para informar a los responsables de las políticas en el desarrollo de las intervenciones de los TSCs.

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. 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. 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. ClinicalTrials.gov NCT01932138.

Background Community health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs. Methods This is a cluster randomised controlled trial to investigate the effectiveness of a continuous quality improvement (CQI) intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention ( n  = 15) and control ( n  = 15) arms. Four CHWs were randomly selected from those routinely supported by each supervisor ( n  = 60 per arm). In the intervention arm, these four CHWs and their supervisor formed a quality improvement team. Intervention CHWs received a 2-week training in WHO Community Case Management followed by CQI mentoring for 12 months (preceded by 3 months lead-in to establish QI processes). Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs. Results Interviews were conducted with 736 and 606 mothers at baseline and follow-up respectively; socio-demographic characteristics were similar in both study arms and at each time point. At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy (75.7 vs 29.0%, p  < 0.0001) and the postnatal period (72.6 vs 30.3%, p  < 0.0001). Intervention mothers had higher maternal and child health knowledge scores (49 vs 43%, p  = 0.02) and reported higher exclusive breastfeeding rates to 6 weeks (76.7 vs 65.1%, p  = 0.02). HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW (78.7 vs 50.0%, p  = 0.007). Uptake of facility-based interventions were not significantly different. Conclusions Improved training and CQI-based mentoring of CHWs can improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers’ knowledge and infant feeding practices. Trial registration ClinicalTrials.Gov NCT01774136

Community Health Workers (CHWs) play a vital role delivering health services to vulnerable populations in low resource settings. In Rwanda, CHWs provide village-level care focused on maternal/child health, control of infectious diseases, and health education, but do not receive salaries for these services. CHWs make up the largest single group involved in health delivery in the country; however, limited information is available regarding the socio-economic circumstances and satisfaction levels of this workforce. Such information can support governments aiming to control infectious diseases and alleviate poverty through enhanced healthcare delivery. The objectives of this study were to (1) evaluate CHW opportunity costs, (2) identify drivers for CHW motivation, job satisfaction and care provision, and (3) report CHW ideas for improving retention and service delivery. In this mixed-methods study, our team conducted in-depth interviews with 145 CHWs from three districts (Kirehe, Kayonza, Burera) to collect information on household economics and experiences in delivering healthcare. Across the three districts, CHWs contributed approximately four hours of volunteer work per day (range: 0-12 hrs/day), which translated to 127 684 RWF per year (range: 2 359-2 247 807 RWF/yr) in lost personal income. CHW out-of-pocket expenditures (e.g. patient transportation) were estimated at 36 228 RWF per year (range: 3 600-364 800 RWF/yr). Participants identified many benefits to being CHWs, including free healthcare training, improved social status, and the satisfaction of helping others. They also identified challenges, such as aging equipment, discrepancies in financial reimbursements, poverty, and lack of formal workspaces or working hours. Lastly, CHWs provided perspectives on reasonable and feasible improvements to village-level health programming that could improve conditions and equity for those providing and using the CHW system.

Background The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation. Methods We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members. Results We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related “expectation gaps”, including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector. Conclusions Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or “broken promises”, which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.