Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives Improving Diabetes Care and Health Measures Among Hispanics Using Community Health Workers Acceptability and trust of community health workers offering maternal and newborn health education in rural Uganda. Comparison of Community Health WorkerLed Diabetes Medication Decision-Making Support for Low-Income Latino and African American Adults With Diabetes Using E-Health Tools Versus Print Materials Perceptions of Community Health Workers (CHWs/PS) in the U.S.-Mexico Border HEART CVD Study Evidence-based training of frontline health workers for door-to-door health promotion: a pilot randomized controlled cluster trial with Lady Health Workers in Sindh Province, Pakistan. Value of a mobile information system to improve quality of care by community health workers. Task-Shifting of Antiretroviral Delivery From Health Care Workers to Persons Living With HIV/AIDS: Clinical Outcomes of a Community-Based Program in Kenya Using IT to improve access, communication, and asthma in African American and Hispanic/Latino Adults: Rationale, design, and methods of a randomized controlled trial. A systematic review of online interventions for mental health in low and middle income countries: a neglected field Defining and measuring health equity effects in research on task shifting interventions in high-income countries: a systematic review protocol Feasibility and evaluation of a pilot community health worker intervention to reduce hospital readmissions. Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomised controlled trial Factors related to retention of community health workers in a trial on community-based management of fever in children under 5 years in the Dangme West District of Ghana. Training Community Health Workers as Diabetes Educators for Urban African Americans: Value Added Using Participatory Methods A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol The Mexican-American Trial of Community Health workers (MATCH): design and baseline characteristics of a randomized controlled trial testing a culturally tailored community diabetes self-management intervention.
Background Community health workers ( CHWs ) can play important roles in primary health care delivery , particularly in setting s of health workforce shortages . However , little is known about CHWs ’ perceptions of barriers and motivations , as well as those of the beneficiaries of CHWs . In Rw and a , which faces a significant gap in human re sources for health , the Ministry of Health exp and ed its community health programme beginning in 2007 , eventually placing 4 trained CHWs in every village in the country by 2009 . The aim of this study was to assess the capacity of CHWs and the factors affecting the efficiency and effectiveness of the CHW programme , as perceived by the CHWs and their beneficiaries . Methods As part of a larger report assessing CHWs in Rw and a , a cross-sectional descriptive study was conducted using focus group discussion s ( FGDs ) to collect qualitative information regarding educational background , knowledge and practice s of CHWs , and the benefits of community-based care as perceived by CHWs and household beneficiaries . A r and om sample of 108 CHWs and 36 beneficiaries was selected in 3 districts according to their food security level ( low , middle and high ) . Qualitative and demographic data were analyzed . Results CHWs were found to be closely involved in the community , and widely respected by the beneficiaries . Rw and a ’s community performance-based financing ( cPBF ) was an important incentive , but CHWs were also strongly motivated by community respect . The key challenges identified were an overwhelming workload , irregular trainings , and lack of sufficient supervision . Conclusions This study highlights the challenges and areas in need of improvement as perceived by CHWs and beneficiaries , in regards to a nationwide scale-up of CHW interventions in a re source -challenged country . Identifying and underst and ing these barriers , and addressing them accordingly , particularly within the context of performance-based financing , will serve to strengthen the current CHW system and provide key guidance for the continuing evolution of the CHW system in Rw and The increasing prevalence of diabetes and obesity , growing health disparities , and shortage of bilingual and culturally trained health care professionals underscore the role of trained community health workers ( CHWs ) to provide economically sustainable and culturally relevant services . This prospect i ve r and omized design evaluated the relative effectiveness of a CHW intervention among Hispanic persons with newly diagnosed type 2 diabetes , as compared with usual clinic practice in three inner-city health centers . In sum , 189 Hispanic patients newly diagnosed with type 2 diabetes were r and omly assigned to one of three 6-month diabetes management approaches — CHW , case management , and st and ard provider care— and assessed for diabetes-related health measures and clinical indicators at baseline and postintervention . Participants in the CHW group achieved greater improvements than did the controls in program measures : health status , emergency department utilization , dietary habits , physical activity , and medication adherence . They also had 2.9 times greater odds of decreasing body mass index When trusted , Community Health Workers ( CHWs ) can contribute to improving maternal and newborn health outcomes in low- and middle-income countries through education . Issues of acceptability of CHWs by communities were explored through experiences gained in a qualitative study that is part of a cluster r and omized trial in East Ug and a. Initially , focus group discussion s with key community members and leaders were undertaken regarding preventative health and 40 CHWs were observed making home visits by supervisors during the initial 6 months of fieldwork of the trial in eight villages in the Jinja District in Ug and a. The results were analyzed using the 5-SPICE framework . Observation of CHWs in the field identified a number of unanticipated issues including a general mistrust of the public health system by community members in areas that had an impact on maternal and newborn health . At the outset , CHWs often did not trust their own abilities and faced community expectations that they would provide curative rather than preventative care . Early community engagement , non-threatening home visits that enhanced friendship and supportive supervision improved the confidence of the CHWs and improved the trust and acceptance of the CHWs and the willingness of the community members to act on what was discussed Adults with type 2 diabetes mellitus often struggle with their antihyperglycemic medication regimens . To improve medication management , providers must ensure that their patients underst and potential benefits , harms , and burdens of available options and elicit patients ' preferences and barriers to taking medications . Patients who are actively involved in treatment decision making tend to be more satisfied with their health care , be more adherent to treatment , and have improved clinical outcomes ( 13 ) . Such discussion s , however , can be too time-consuming for clinic visits . For inner-city low-income African American and Latino adults , low health literacy and limited English proficiency are often additional barriers ( 4 ) that reduce the exchange of information and decrease patient participation during primary care visits ( 58 ) . This contributes to less optimal treatment decisions and lower patient satisfaction , leading to poor medication adherence and outcomes ( 3 , 911 ) . There is therefore an urgent need for cost-effective approaches to enable low-re source health systems to help these high-risk population s gain information and decision support so that they can more actively participate in and improve satisfaction with their treatment decision making . Since 2000 , the REACH ( Racial and Ethnic Approaches to Community Health 2010 ) Detroit Partnership , a coalition of community , health system , and academic partners , has used community-based participatory research principles to guide development , implementation , and evaluation of interventions to meet this need among African American and Latino adults with diabetes in Detroit , Michigan . These interventions have built on evidence that community health workers ( CHWs ) are effective in improving diabetes outcomes , particularly among racial and ethnic minority communities ( 12 ) . CHW interventions train community members to work as bridges between their ethnic , cultural , or geographic communities and health care providers ( 13 ) . Two cohorts of participants in our previous CHW-led diabetes self-management support interventions  improved hemoglobin A1c ( HbA1c ) levels and diabetes distress compared with usual care ( 14 , 15 ) . An important next step in increasing the potential effect of CHWs and other lay health care workers is to develop and test effective tools they can use to better present evidence -based information to patients and to help patients make better self-management decisions ( 16 ) . Little is known about the effectiveness of different approaches for nontraditional care providers , such as CHWs , to deliver health information to ethnic minority and low-literacy population s ( 17 ) . By definition , CHWs and other lay workers do not have medical expertise and thus rely on effectively sharing printed educational and support material s with patients as part of their coaching and counseling efforts . Decision aids can increase satisfaction with treatment decisions and result in treatments that better reflect patients ' preferences ( 18 , 19 ) . There is also evidence that tailored health messages are more effective than generic group messages ( 20 , 21 ) , including for patients with diabetes ( 22 , 23 ) . Tailoring individualizes information and behavior change strategies to reach each person based on characteristics unique to that person derived from an individual assessment and related to the outcome of interest ( 24 ) . Software programs that are being developed to automatically embed tailored content into portable e-health Web applications show promise in improving health behaviors and outcomes ( 25 , 26 ) . To date , however , most e-health applications have been design ed for use by patients with relatively high literacy and the skills to navigate them ( 27 ) . Do more sophisticated , tailored , interactive e-health tools increase the effectiveness of CHW outreach with underserved patients compared with reliance on printed educational material s alone ? We addressed this question by developing and evaluating a personally tailored , interactive diabetes medication decision aid ( iDecide [ in English ] or iDecido [ in Spanish ] ) design ed for CHWs to deliver on tablet computers with 3 G wireless access to African American and Latino adults with diabetes and low health literacy . We then evaluated the effectiveness of iDecide in improving key diabetes outcomes compared with CHW delivery of the same evidence -based information , without tailoring , through print consumer booklets developed by the Agency for Healthcare Research and Quality ( AHRQ ) . Methods Setting This study was developed and implemented by using community-based participatory research principles ( 28 ) in partnership with the REACH Detroit Partnership and the Community Health and Social Services Center ( CHASS ) , a federally qualified health center in Southwest Detroit serving more than 13000 patients with 47099 visits in 2012 ( 29 ) . The University of Michigan and CHASS institutional review boards approved the study . Content of AHRQ Consumer Guides The AHRQ guides ( Pills for Type 2 Diabetes and Premixed Insulin for Type 2 Diabetes ) ( 30 , 31 ) provide information on diabetes and summarize the effectiveness of currently available medication classes  ( oral and insulin ) on HbA1c . They also provide information on administration methods , costs , medication adverse effects , risks for diabetes complications , suggested questions to discuss with health care providers , and prompts to make notes of any questions for the doctor . The booklets include pictures of patients and tables and graphs summarizing information . Content of iDecide The development process and content of the iDecide program have been described in detail elsewhere ( 32 ) . Briefly , we used community-based participatory research and user-centered design ( 33 , 34 ) principles to iteratively develop and refine the iDecide tool . iDecide is available in English and Spanish , can be delivered via tablet computers , and enables navigation by the CHW and participant to selectively explore issues most important to the participant . The iDecide program is organized into 4 main sections and includes the same content as the AHRQ consumer guides . However , its information is presented in a more graphical style suited to patients with low literacy . Table 1 summarizes key differences between the presentation of information in iDecide and the printed material s. The first section illustrates , through animations , how diabetes affects the way glucose is processed in the body and how different medication classes , foods , and physical activity affect blood glucose . The second section includes pictographs showing participants ' own risk for diabetes complications ( tailored according to their baseline HbA1c ) and enabling participants to explore how their risk for different complications changes with their HbA1c levels . In the third section , participants review their current diabetes medications and barriers to taking the medications they had reported on the baseline survey . This section includes an interactive issue card approach to help elicit patient preferences and priorities about different medication characteristics ( for example , cost , adverse effects , effects on weight , and dosing schedules ) ( 22 , 35 ) . The fourth section prompts participants to set goals and develop specific action plans to address identified barriers or other concerns and identify specific questions and concerns to discuss with their doctor about their medications or making lifestyle changes . Personal information from the baseline assessment is interwoven throughout the program ( high-depth tailoring within sentences ) . Motivational interviewingbased , tailored discussion prompts encourage autonomy-supportive CHWpatient interactions at key points with open-ended questions and values exploration to help participants discover their motivation , overcome barriers to change , and develop an action plan ( 36 ) . Table 1 . Comparison of Content and Mode of Delivery Between the iDecide Study Group and the Printed Material s Group Recruitment and R and omization From September 2011 to August 2012 , potentially eligible participants were identified from a computer-generated list of CHASS patients with physician-diagnosed type 2 diabetes . Inclusion criteria required a HbA1c value greater than 7.5 % in the previous 6 months or expressed concerns about current diabetes medications during the screening assessment . Exclusion criteria were age younger than 21 years , terminal health conditions , self-reported alcohol or drug abuse , and conditions ( such as blindness and dementia ) that would impede meaningful participation . Pregnant women and individuals who reported that they could not be contacted by telephone were also excluded . Introductory letters were sent in timed batches . Research staff then telephoned patients and screened them for eligibility . Interested eligible patients met with research staff , who facilitated completion of written informed consent , administered baseline surveys in English or Spanish , and measured HbA1c and blood pressure . Participants received a stipend of $ 20 after each assessment . Within 1 to 14 days , participants were scheduled for a visit with a CHW ( at home , the clinic , or another agreed-upon place ) . At the beginning of the CHW visits , participants were registered into the iDecide program and r and omly assigned by the computer program , through use of a r and om-sequence algorithm , into 1 of 2 study groups . There were no differences between the steps to participate in either study group . Patients , research staff , and CHWs were blinded to r and omization results through completion of all baseline measures up to the start of the intervention . Data assessors remained blinded to group assignment throughout the study . CHW Intervention for Both Study Groups All participants received an initial one-on-one , face-to-face session with a CHW and a copy of the printed material s to take home . The iDecide sessions lasted approximately 2 hours , and the sessions using printed material s lasted Although prior research has shown that Community Health Workers/Promotores de Salud ( CHW/PS ) can facilitate access to care , little is known about how CHW/PS are perceived in their community . The current study reports the findings of a r and omized telephone survey conducted in a high-risk urban community environment along the U.S.-Mexico border . In preparation for a community-based CHW/PS intervention called the HEART ecological study , the survey aim ed to assess perceptions of CHW/PS , availability and utilization of community re sources ( recreational and nutrition related ) and health behaviors and intentions . A total of 7,155 calls were placed to complete 444 surveys in three zip codes in El Paso , Texas . Results showed that participants felt that healthful community re sources were available , but utilization was low and variable : 35 % reported going to a park , 20 % reported having taken a health class , few reported using a gym ( 12 % ) , recreation center ( 8 % ) , or YMCA/YWCA ( 0.9 % ) . Awareness and utilization of CHW/PS services were low : 20 % of respondents had heard of CHW/PS , with 8 % reporting previous exposure to CHW/PS services . Upon review of a definition of CHW/PS , respondents expressed positive views of CHW/PS and their value in the healthcare system . Respondents who had previous contact with a CHW/PS reported a significantly more positive perception of the usefulness of CHW/PS ( p = 0.006 ) , were more likely to see CHW/PS as an important link between providers and patients ( p = 0.008 ) , and were more likely to ask a CHW/PS for help ( p = 0.009 ) . Participants who utilized CHW/PS services also had significantly healthier intentions to reduce fast food intake . Future research is needed to evaluate if CHW/PS can facilitate utilization of available community re sources such as recreational facilities among Hispanic border residents at risk for CVD OBJECTIVE Demonstrate the effective use of community-based evidence for health promotion by Lady Health Workers ( LHWs ) in Sindh , Pakistan . METHODS A baseline study on mothers and children provided local evidence for risk communication tools design ed and tested by LHWs . The communities were r and omized to intervention and control . LHWs visited  women before and after childbirth  to discuss safe practice s in pregnancy , in the intervention group LHW using the new tools and in the control group using their st and ard procedures . A household survey and focus groups permitted assessment of the impact of the intervention . RESULTS Women in the intervention communities were more likely to attend prenatal checkups , to stop routine heavy work during pregnancy , to give colostrum to newborn babies , and to maintain exclusive breastfeeding for four months . Community focus groups confirmed a positive reaction to the tools . CONCLUSION Discussion by lay health workers of local evidence underlying safe motherhood messages improved uptake of protective health practice s. PRACTICE IMPLICATION S Door-to-door health promotion based on culturally appropriate interaction around relevant evidence can have a positive impact on health practice s. Engaging health workers from the onset builds capacities , improves dialogue within the health system and performance of frontline health workers INTRODUCTION We will be unable to achieve sustained impact on health outcomes with community health worker (CHW)-based interventions unless we bridge the gap between small scale efficacy studies and large scale interventions . Effective strategies to support the management of CHWs are central to bridging the gap . Mobile phones are broadly available , particularly in low and middle income countries ( LAMIC 's ) , where the penetration rate approaches 100 % . In this article we describe how mobile phones may be combined with mobile web-based technology to assist in the management of CHWs in two projects in South Africa . METHODS This paper is a descriptive one , drawing lessons from two R and omised Controlled Trials ( RCT ' s ) , outlining how a mobile phone information system can be utilized to enhance the quality of health interventions . We organized our comprehensive management and supervision system around a previously published management framework . The system is composed of mobile phones utilized by CHWs and a web-based interface utilized by CHW supervisors  . Computerized algorithms were design ed with intervention and assessment protocol s to aid in the real-time supervision and management of CHWs . RESULTS CHWs used mobile phones to initiate intervention visits and trigger content to be delivered during the course of intervention visits . Supervisors used the web-based interface for real-time monitoring of the location , timing , and content of intervention visits . Additional real-time support was provided through direct support calls in the event of crises in the field . CONCLUSION Mobile phone-based information system platforms offer significant opportunities to improve CHW-delivered interventions . The extent to which these efficiency gains can be translated into realized health gains for communities is yet to be tested Objectives : To assess whether community-based care delivered by people living with HIV/AIDS ( PLWAs ) could replace clinic-based HIV care . Design : Prospect i ve cluster r and omized controlled clinical trial . Setting : Villages surrounding 1 rural clinic in western Kenya . Subjects : HIV-infected adults clinical ly stable on antiretroviral therapy ( ART ) . Intervention : The intervention group received monthly Personal Digital Assistant supported home assessment s by PLWAs with clinic appointments every 3 months . The control group received st and ard of care monthly clinic visits . Main Outcomes Measured : Viral load , CD4 count , Karnofsky score , stability of ART regimen , opportunistic infections , pregnancies , and number of clinic visits . Results : After 1 year , there were no significant intervention-control differences with regard to detectable viral load , mean CD4 count , decline in Karnofsky score , change in ART regimen , new opportunistic infection , or pregnancy rate . Intervention patients made half as many clinic visits as did controls ( P < 0.001 ) . Conclusions : Community-based care by PLWAs result ed in similar clinical outcomes as usual care but with half the number of clinic visits . This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs , expediting ART rollout and increasing access to treatment while exp and ing the capacity of health care institutions in re source -constrained environments Asthma morbidity is high among inner-city minority adults . Improving access to care and patient-provider communication are believed to be essential for improving outcomes . Access and communication in turn increasingly rely on information technology including features of the Electronic Health Record . Its patient portal offers web-based communication with providers and practice s. How patients with limited re sources and educational opportunities can benefit from this portal is unclear . In contrast , home visits by community health workers ( CHWs ) have improved access to care for asthmatic children and promoted caretaker-clinician communication . We describe the planning , design , and methodology of an ongoing r and omized controlled trial for 300 adults , predominantly African American and Hispanic/Latino , with uncontrolled asthma recruited from low income urban neighborhoods who are directed to the most convenient internet access and taught to use the portal , with and without home visits from a CHW . The study 1 ) compares the effects of the 1-year interventions on asthma outcomes ( improved asthma control , quality of life ; fewer ED visits and hospitalizations for asthma or any cause ) , 2 ) evaluates whether communication ( portal use ) and access ( appointments made/kept ) mediate the interventions ' effects on asthma outcomes , and 3 ) investigates effect modification by literacy level , primary language , and convenience of internet access . In home visits , CHWs 1 ) train patients to competency in portal use , 2 ) enhance care coordination , 3 ) communicate the complex social circumstances of patients ' lives to providers , and 4 ) compensate for differences in patients ' health literacy skills . The practical challenges to design and implementation in the targeted population are presented Background . Low and middle income countries ( LMICs ) are facing an increase of the impact of mental health problems while confronted with limited re sources and limited access to mental health care , known as the ‘ mental health gap ’ . One strategy to reduce the mental health gap would be to utilize the internet to provide more widely-distributed and low cost mental health care . We undertook this systematic review to investigate the effectiveness and efficacy of online interventions in LMICs . Methods . We systematic ally search ed the data -bases PubMed , PsycINFO , JMIR , and additional sources . MeSH terms , Thesaurus , and free text keywords were used . We included all r and omized controlled trials ( RCTs ) of online interventions in LMICs . Results . We found only three articles reported results of RCTs on  online interventions for mental health conditions in LMICs , but none of these interventions was compared with an active control condition . Also , the mental health conditions were diverse across the three studies . Conclusions . There is a dearth of studies examining the effect of online interventions  in LMICs , so we can not draw a firm conclusion on its effectiveness . However , given the effectiveness of  online interventions in high income countries and sharp increase of internet access in LMICs , online interventions may offer a potential to help reduce the ‘ mental health gap ’ . More studies are urgently needed in LMICs Introduction Task shifting interventions are intended to both deliver clinical ly effective treatments to reduce disease burden and address health inequities or population vulnerability . Little is known about how health equity and population vulnerability are defined and measured in research focused on task shifting . This systematic review will address the following questions : Among  task shifting interventions in high-income setting s that have been studied using r and omised controlled trials or variants , how are health inequity or population vulnerability identified and defined ? What methods and indicators are used to describe , characterise and measure the population ’s baseline status and the intervention ’s impacts on inequity and vulnerability ? Methods and analysis Studies were identified through data base search es ( MEDLINE , Embase , CINAHL , PsycINFO and Web of Science ) . Eligible studies will be r and omised controlled trials published since 2004 , conducted in high-income countries , concerning task shifting interventions to treat any disease , in any population that may face health disadvantage as defined by the PROGRESS-Plus framework ( place of residence , race/ethnicity/culture/ language , occupation , gender/sex , religion , social capital , socioeconomic position , age , disability , sexual orientation , other vulnerable groups ) . We will conduct independent and duplicate title and abstract screening , then identify related papers from the same programme of research through further data base and manual search ing . From each programme of research , we will extract study details , and definitions and measures of health equity or population vulnerability based on the PROGRESS-Plus framework . Two investigators will assess the quality of reporting and measurement related to health equity and vulnerability using a scale developed for this study . A narrative synthesis will highlight similarities and differences between the gathered studies and offer critical analyses and implication s. Ethics and dissemination This review does not involve primary data collection , does not constitute research on human subjects and is not subject to additional institutional ethics review or informed consent procedures . Dissemination will include open-access peer- review ed publication and academic conference presentations . PROSPERO Registration Number CRD42017049959 OBJECTIVE To pilot-test the feasibility and preliminary effect of a community health worker ( CHW ) intervention to reduce hospital readmissions . DESIGN Patient-level r and omized quality improvement intervention . SETTING An academic medical center serving a predominantly low-income population in the Boston , Massachusetts area and 10 affiliated primary care practice s. PARTICIPANTS Medical service patients with an in-network primary care physician who were discharged to home ( n = 423 ) and had one of five risk factors for readmission within 30 days . INTERVENTION Inpatient introductory visit and weekly post-discharge telephonic support for 4 weeks to assist patient in coordinating medical visits , obtaining and using medications , and in self-management . MAIN OUTCOME MEASURES Number of completed CHW contacts ; CHW-reported barriers and facilitators to assisting patients ; primary care , emergency department and inpatient care use . RESULTS Roughly 70 % of patients received at least one post-discharge CHW call ; only 38 % of patients received at least four calls as intended . Hospital readmission rates were lower among CHW patients ( 15.4 % ) compared with usual care ( 17.9 % ) ; the difference was not statistically significant . CONCLUSION Under performance-based payment systems , identifying cost-effective solutions for reducing hospital readmissions will be crucial to the economic survival of all hospitals , especially safety-net systems . This pilot study suggests that with appropriate supportive infrastructure , hospital-based CHWs may represent a feasible strategy for improving transitional care among vulnerable population s. An ongoing , r and omized , controlled trial of a CHW intervention , developed according to the lessons of this pilot , will provide further insight into the utility of this approach to reducing readmissions Background Birth attendance by trained health workers is low in rural Nepal . Local participation in improving health services and increased interaction between health systems and communities may stimulate dem and for health services . Significant increases in birth attendance by trained health workers may be affected through community mobilisation by local women 's groups and health management committee strengthening . We will test the effect of community mobilisation through women 's groups , and health management committee strengthening , on institutional deliveries and home deliveries attended by trained health workers in Makwanpur District . Design Cluster r and omised controlled trial involving 43 village development committee clusters . 21 clusters will receive the intervention and 22 clusters will serve as control areas . In intervention areas , Female Community Health Volunteers are supported in convening monthly women 's groups . The groups work through an action research cycle in which they consider barriers to institutional delivery , plan and implement strategies to address these barriers with their communities , and evaluate their progress . Health management committees participate in three-day workshops that use appreciative inquiry methods to explore and plan ways to improve maternal and newborn health services . Follow-up meetings are conducted every three months to review progress . Primary outcomes are institutional deliveries and home deliveries conducted by trained health workers . Secondary outcome measures include uptake of antenatal and postnatal care , neonatal mortality and stillbirth rates , and maternal morbidity . Trial registration numberIS RCT BACKGROUND In re source -constrained setting s of developing countries , promotion of community-based health interventions through community health workers ( CHWs ) is an important strategy to improve child health . However , there are concerns about the sustainability of such programmes owing to the high rate of CHW attrition . This study examined factors influencing retention of volunteer CHWs in a cluster r and omised trial on community management of under-5 fever in a rural Ghanaian district . METHODS Data were obtained from structured interviews ( n=520 ) and focus group discussion s ( n=5 ) with CHWs . Factors influencing CHWs ' decisions to remain or leave the programme were analysed using a probit model , and focus group discussion results were used to eluci date the findings . RESULTS The attrition rate among CHWs was 21.2 % . Attrition was comparatively higher in younger age groups ( 25.9 % in 15 - 25 years group , 18.2 % in 26 - 45 years group and 16.5 % in ≥46 years group ) . Approval of a CHW by the community ( p<0.001 ) and the CHW 's immediate family ( p<0.05 ) were significant in influencing the probability of remaining in the programme . Motivation for retention was related to the desire to serve their communities as well as humanitarian and religious reasons . CONCLUSION The relatively moderate rate of attrition could be attributed to the high level of community involvement in the selection process as well as other aspects of the intervention leading to high community approval and support . Attention for these aspects could help improve CHW retention in community-based health interventions in Ghana , and the lessons could be applied to countries within similar setting Background : With growing use of Community Health Workers ( CHWs ) to reach underserved population s , there is a need for more information on training methods to prepare CHWs , particularly in a health educator role . Objectives : To describe procedures used to recruit , train , and evaluate CHWs in Project Sugar 2 , a r and omized controlled trial of a nurse case manager and CHW team intervention design ed to improve diabetes care and control in a sample of 542 urban African Americans with type 2 diabetes . Methods : CHWs received a Core Training on guidelines and procedures , didactic diabetes self-management education , and research protocol training . However , barriers to CHW implementation of the intervention were encountered , including CHW attrition , job performance and satisfaction issues , low self-confidence in knowledge and skills as educators , difficulties with maintaining a large caseload , and inefficiencies experienced in conducting home visits . To address barriers , the initial training was modified and Results : The supplemental training result ed in CHW retention , satisfaction , confidence in skills , and feelings of ownership of the intervention . Participant satisfaction with care received from the CHWs and the Project Sugar 2 intervention was rated as high by 97 % and 93 % of responders , respectively . Conclusion : Core training in research intervention policies , procedures , and protocol s , combined with an extended participatory training , led to effective preparation of laypersons to serve as CHWs Background Countries in sub-Saharan Africa ( SSA ) are experiencing an epidemic of cardiovascular disease ( CVD ) propelled by rapidly increasing rates of hypertension . Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs . Although SSA bears 24 % of the global disease burden , it has only 3 % of the global health workforce . Given such limited re sources , cost-effective strategies , such as task shifting , are needed to mitigate the rising CVD epidemic in SSA . Ghana , a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization ( WHO ) task-shifting strategy . This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage , on blood pressure ( BP ) reduction . Methods Using a cluster r and omized design , 32 community health centers ( CHCs ) and district hospitals in Ghana will be r and omized to either the  intervention  group ( 16 CHCs ) or the control group ( 16 CHCs ) . A total of 640 patients with uncomplicated hypertension ( BP 140–179/90–99 mm Hg and absence of target organ damage ) will be enrolled in this study ( 20 patients per CHC ) . The intervention consists of WHO Package of CV risk assessment , patient education , initiation and titration of antihypertensive medications , behavioral counseling on lifestyle behaviors , and medication adherence every three months for 12 months . The primary outcome is the mean change in systolic BP from baseline to 12 months . The secondary outcomes are rates of BP control at 12 months ; levels of physical activity , percent change in weight , and dietary intake of fruits and vegetables at 12 months ; and sustainability of intervention effects at 24 months . All outcomes will be assessed at baseline , six months and 12 months . Trained community health nurses will deliver the intervention as part of Ghana ’s community-based health planning and services ( CHPS ) program . Discussion Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in re source -poor setting s . Trial registration NCT01802372 OBJECTIVES Community Health Workers ( CHWs ) have been recommended to reduce diabetes disparities , but few robust trials of this approach have been conducted . Limitations of prior studies include : unspecified a priori outcomes ; lack of blinded outcome assessment s ; high participant attrition rates ; and lack of attention to intervention fidelity . These limitations reflect challenges in balancing method ologic rigor with the needs of vulnerable population s. The Mexican-American Trial of Community Health workers ( MATCH ) was a blinded r and omized controlled trial testing CHW efficacy in improving physiologic outcomes and self-management behaviors among Mexican-Americans with type 2 diabetes . This paper describes methods used to overcome limitations of prior studies . RESEARCH DESIGN AND METHODS The primary aim was to determine if a CHW intervention would result in significant reductions in Hemoglobin A1c and rates of uncontrolled blood pressure .  144 Mexican-Americans with diabetes were r and omized . The intervention consisted of self-management training delivered by CHWs over a 24-month period ; the comparison population received identical information via bilingual newsletter . Blinded research assistants completed assessment s at baseline , 12 months , and 24 months post-r and omization . RESULTS The MATCH cohort was characterized by low acculturation and socioeconomic status . Study participants had low rates of medication adherence and glucose monitoring . 70 % had poor glycemic control with A1c levels over 7.0 , and 57.3 % had blood pressures worse than ADA target levels ( < 130/80 ) . CONCLUSIONS MATCH preserved community sensitivity and method ologic rigor . The study 's attention to intervention fidelity , behavioral attention control , blinded outcomes assessment , and strategies to enhance participant retention can be replicated by research ers testing culturally-tailored CHW interventions
We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS , and additional evidence exists for the potential to achieve cost savings from activities related to malaria , NCDs , NTDs , childhood illness , and other disease areas , especially at the primary health care and community levels .
Conclusions Task shifting presents a viable option for health system cost savings in LMICs .
Background Task shifting has become an increasingly popular way to increase access to health services , especially in low-re source setting s. Research has demonstrated that task shifting , including the use of community health workers ( CHWs ) to deliver care , can improve population health .
This systematic review investigates whether task shifting in low-income and middle-income countries ( LMICs ) results in efficiency improvements by achieving cost savings .