Search

This paper proposes a taxonomy for Community Health Workers (CHWs) and others engaged in front-line community health activities, encompassing formally-employed workers extending government primary health care (PHC) service delivery as well as a range of other actors with roles at the nexus of government PHC and communities. The taxonomy is grounded in current definitions from the World Health Organization and the International Labor Organization, and proposes some refinements for future iterations of guidance from these agencies. The designation, "Community Health Worker" is currently used to cover a broad range of roles. Furthermore, there are programs engaging workers or community members in roles closely adjacent to those generally recognized as CHWs that use other designations, not commonly included under the rubric of "CHW". This potentially confusing range of roles and nomenclature leads at times to over-generalizations, applying insights and principles relevant for one type of worker or community member that are not necessarily relevant for another. It also leads to a failure to consider occupational groups not commonly thought of as CHWs-but engaged in PHC service delivery at the most peripheral level-in community-based-PHC planning and management arrangements. Building on ILO and WHO classifications and standards, a further clarification of terms and a taxonomy is proposed, with the intention of contributing to clearer communication and shared understanding and, ultimately, sounder community health policy, program planning, and implementation; and more substantial progress towards Universal Health Coverage.

To understand the core aspects of an empowerment-based Community Health Worker (CHW) training program, we studied the model of the Comprehensive Rural Health Project (CRHP) in Jamkhed, India—an organization known for facilitating empowerment of women as Village Health Workers (VHWs) and agents of community change. We define empowerment as a means by which individuals gain health and development-related skills and knowledge to facilitate positive change within their lives and communities. Using VHW training observations and semi-structured interviews with health workers and senior trainers, 6 themes were developed and applied in 4 focus group sessions with 18 multigenerational VHWs trained by the CRHP. Transcripts were qualitatively analyzed under 6 themes—selection, baseline training, continuing education and support, community participation, community empowerment, and commitment and longevity. Empowerment of VHWs was found to be an intentional process involving the creation of safe and supportive environments conducive to long-term participatory and experiential learning with professionals who facilitate and mentor. The impact of the baseline training is maintained through ongoing program-VHW interactions and knowledge reinforcement in both the field and training center. Importantly, these interactions reinforce VHWs’ credibility and confidence in communities served. Community participation was found to be of key importance starting at the selection phase. The methods used for selection, training and ongoing support are critical to developing a cadre of competent, effective and motivated VHWs as well as fostering long-lasting self-development and leadership skills. Downstream effectiveness of community empowerment on health outcomes is demonstrated through indicators such as access to safe deliveries, declining child malnutrition rates, high vaccination rates as well as reductions in stigmatization of illness and caste discrimination.

Abstract Introduction Uganda’s community health worker (CHW), or village health team (VHT), program faces significant challenges with poor retention and insufficient financial and program investment. Adequate compensation comprising financial and non-financial components is critical to retaining any workforce, including CHWs. This study evaluates the impact of a recognition-based non-financial incentives package on the motivation, performance, and retention of VHTs, as well as on the utilization of health services by the community. The incentive package and intervention were developed in collaboration with the district-level leadership and award VHTs who have met predetermined performance thresholds with a certificate and a government-branded jacket in a public ceremony. Methods A two-armed cluster randomized controlled trial (RCT), conducted at the parish level in Uganda’s Masindi District, will evaluate the effects of the 12-month intervention. The cluster-RCT will use a mixed-methods approach, which includes a baseline/endline VHT survey to assess the impact of the intervention on key outcomes, with an expected sample of 240 VHTs per study arm; our primary outcome is the total number of household visits per VHT and our multiple secondary outcomes include other performance indicators, motivation, and retention; VHT performance and retention data will be validated using monthly phone surveys tracking key performance indicators and through abstraction of VHT-submitted health facility reports; and focus group discussions will be conducted with VHTs and community members to understand how the intervention was received. Data collection activities will be administered in local languages. To assess the impact of the intervention, the study will conduct a regression analysis using Generalized Estimating Equations adjusting for cluster effect. Further, a difference-in-differences analysis will be conducted. Discussion This study utilized a cluster-RCT design to assess the impact of a recognition-based incentives intervention on the motivation, performance, and retention of VHTs in Uganda’s Masindi District. Utilizing a mixed-methods approach, the study will provide insights on the effectiveness and limitations of the intervention, VHT perspectives on perceived value, and critical insights on how non-financial incentives might support the strengthening of the community health workforce. Trial registration ClinicalTrials.gov NCT05176106. Retrospectively registered on 4 January 2022.

Background Uganda’s community health worker (CHW) program experiences several challenges related to the appropriate motivation, job satisfaction, and performance of the CHW workforce. This study aims to identify barriers in the effective implementation of financial and non-financial incentives to support CHWs and to strengthen Uganda’s CHW program.Methods The study was implemented in Uganda’s Lira, Wakiso, and Mayuge districts in May 2019. Ten focus group discussions (FGDs) were held with 91 CHWs, 17 in-depth interviews (IDIs) were held with CHW supervisors, and 7 IDIs were held with policy-level stakeholders. Participants included stakeholders from both the Ugandan government and non-governmental organizations (NGOs). Utilizing a thematic approach, themes around motivation, job satisfaction, incentive preferences, and CHW relationships with the community, healthcare facilities, and government were analyzed. Results CHWs identified a range of factors that contributed to their motivation or demotivation. Non-monetary factors included recognition from the health system and community, access to transportation, methods for identification as a healthcare worker, provision of working tools, and training opportunities. Monetary factors included access to monthly stipends, transportation-related refunds, and timely payment systems to reduce refund delays to CHWs. Additionally, CHWs indicated wanting to be considered for recruitment into the now-halted rollout of a salaried CHW cadre, given the provision of payment.Conclusion It is imperative to consider how to best support the current CHW program prior to the introduction of new cadres, as it can serve to exacerbate tensions between cadres and further undermine provision of community health. Providing a harmonized, balanced, and uniform combination of both monetary incentives with non-monetary incentives is vital for effective CHW programs.

Objective We assessed the impact of a digital clinical decision support (CDS) tool in improving health providers adherence to recommended antenatal protocols and service quality in rural primary-level health facilities in Burkina Faso.Design A quasi-experimental evaluation based on a cross-sectional post-intervention assessment comparing the intervention district to a comparison group.Setting and participants The study included 331 direct observations and exit interviews of pregnant women seeking antenatal care (ANC) across 48 rural primary-level health facilities in Burkina Faso in 2021.Intervention Digital CDS tool to improve health providers adherence to recommended antenatal protocols.Outcome measures We analysed the quality of care on both the supply and demand sides. Quality-of-care service scores were based on actual care provided and expected care according to standards. Pregnant women’s knowledge of counselling and satisfaction score after receiving care were also calculated. Other outcomes included time of clinical encounter.Results The overall quality of health service provision was comparable across intervention and comparison health facilities (52% vs 51%) despite there being a significantly higher proportion of lower skilled providers in the intervention arm (42.5% vs 17.8%). On average, ANC visits were longer in the intervention area (median 24 min, IQR 18) versus comparison area (median 12 min, IQR: 8). The intervention arm had a significantly higher score difference in women’s knowledge of received counselling (16.4 points, 95% CI 10.37 to 22.49), and women’s satisfaction (16.18 points, 95% CI: 9.95 to 22.40).Conclusion Digital CDS tools provide a valuable opportunity to achieve substantial improvements of the quality of ANC and broadly maternal and newborn health in settings with high burden mortality and less trained health cadres when adequately implemented.

Abstract Introduction Concerns about SARS-CoV-2 infection risk in health care settings have resulted in changes in prenatal care and birth plans, such as shifts to in-person visits and increased Cesarean delivery. These changes may affect quality of care and limit opportunities for clinicians to counsel pregnant individuals, who are at higher risk of severe COVID-19 disease and adverse pregnancy outcomes, about prevention and vaccination. Methods We conducted a cross-sectional online survey of United States adults on changes in prenatal care, COVID-19 vaccine willingness, and reasons for unwillingness to receive a vaccine. We summarized changes in access to care and examined differences in vaccine willingness between pregnant and propensity-score matched non-pregnant controls using chi-squared tests and multivariable conditional logistic regression. Results Between December 15–23, 2020, 8481 participants completed the survey, of which 233 were pregnant. Three-quarters of pregnant women (n = 186) experienced a change in prenatal care, including format of care (n = 84, 35%) and reduced visits (n = 69, 24%). Two-thirds experienced a change in birth plans, from a hospital birth to home birth (n = 45, 18%) or vaginal birth to a Cesarean delivery (n = 42, 17%). Although 40% of pregnant women (n = 78) were unwilling to receive COVID-19 vaccination, they had higher, though non-significant, odds of reporting willingness to receive vaccination compared to similar non-pregnant women (aOR 1.38, 95% CI: 0.95, 2.00). Conclusion To support pregnant women through the perinatal care continuum, maternity care teams should develop protocols to foster social support, patient-centered education around infection prevention that focuses on improved risk perception, expected changes in care due to COVID-19, and vaccine effectiveness and safety.

Abstract Health-focused apps with chatbots (“healthbots”) have a critical role in addressing gaps in quality healthcare. There is limited evidence on how such healthbots are developed and applied in practice. Our review of healthbots aims to classify types of healthbots, contexts of use, and their natural language processing capabilities. Eligible apps were those that were health-related, had an embedded text-based conversational agent, available in English, and were available for free download through the Google Play or Apple iOS store. Apps were identified using 42Matters software, a mobile app search engine. Apps were assessed using an evaluation framework addressing chatbot characteristics and natural language processing features. The review suggests uptake across 33 low- and high-income countries. Most healthbots are patient-facing, available on a mobile interface and provide a range of functions including health education and counselling support, assessment of symptoms, and assistance with tasks such as scheduling. Most of the 78 apps reviewed focus on primary care and mental health, only 6 (7.59%) had a theoretical underpinning, and 10 (12.35%) complied with health information privacy regulations. Our assessment indicated that only a few apps use machine learning and natural language processing approaches, despite such marketing claims. Most apps allowed for a finite-state input, where the dialogue is led by the system and follows a predetermined algorithm. Healthbots are potentially transformative in centering care around the user; however, they are in a nascent state of development and require further research on development, automation and adoption for a population-level health impact.

BackgroundThe C-Score, which is an individual health score, is based on a predictive model validated in the UK and US populations. It was designed to serve as an individualized point-in-time health assessment tool that could be integrated into clinical counseling or consumer-facing digital health tools to encourage lifestyle modifications that reduce the risk of premature death. ObjectiveOur study aimed to conduct an external validation of the C-Score in the US population and expand the original score to improve its predictive capabilities in the US population. The C-Score is intended for mobile health apps on wearable devices. MethodsWe conducted a literature review to identify relevant variables that were missing in the original C-Score. Subsequently, we used data from the 2005 to 2014 US National Health and Nutrition Examination Survey (NHANES; N=21,015) to test the capacity of the model to predict all-cause mortality. We used NHANES III data from 1988 to 1994 (N=1440) to conduct an external validation of the test. Only participants with complete data were included in this study. Discrimination and calibration tests were conducted to assess the operational characteristics of the adapted C-Score from receiver operating curves and a design-based goodness-of-fit test. ResultsHigher C-Scores were associated with reduced odds of all-cause mortality (odds ratio 0.96, P0.72. A sensitivity analysis using NHANES III data (1988-1994) was performed, yielding similar results. The inclusion of sociodemographic and clinical variables in the basic C-Score increased the AUCs from 0.72 (95% CI 0.71-0.73) to 0.87 (95% CI 0.85-0.88). ConclusionsOur study shows that this digital biomarker, the C-Score, has good capabilities to predict all-cause mortality in the general US population. An expanded health score can predict 87% of the mortality in the US population. This model can be used as an instrument to assess individual mortality risk and as a counseling tool to motivate behavior changes and lifestyle modifications.

BackgroundiDeliver, a digital clinical support system for maternal and neonatal care, was developed to support quality of care improvements in Kenya. ObjectiveTaking an implementation research approach, we evaluated the adoption and fidelity of iDeliver over time and assessed the feasibility of its use to provide routine Ministry of Health (MOH) reports. MethodsWe analyzed routinely collected data from iDeliver, which was implemented at the Transmara West Sub-County Hospital from December 2018 to September 2020. To evaluate its adoption, we assessed the proportion of actual facility deliveries that was recorded in iDeliver over time. We evaluated the fidelity of iDeliver use by studying the completeness of data entry by care providers during each stage of the labor and delivery workflow and whether the use reflected iDeliver’s envisioned function. We also examined the data completeness of the maternal and neonatal indicators prioritized by the Kenya MOH. ResultsA total of 1164 deliveries were registered in iDeliver, capturing 45.31% (1164/2569) of the facility’s deliveries over 22 months. This uptake of registration improved significantly over time by 6.7% (SE 2.1) on average in each quarter-year (P=.005), from 9.6% (15/157) in the fourth quarter of 2018 to 64% (235/367) in the third quarter of 2020. Across iDeliver’s workflow, the overall completion rate of all variables improved significantly by 2.9% (SE 0.4) on average in each quarter-year (P

Objectives Efforts to understand the factors influencing the uptake of reproductive, maternal, newborn, child health and nutrition (RMNCH&N) services in high disease burden low-resource settings have often focused on face-to-face surveys or direct observations of service delivery. Increasing access to mobile phones has led to growing interest in phone surveys as a rapid, low-cost alternatives to face-to-face surveys. We assess determinants of RMNCH&N knowledge among pregnant women with access to phones and examine the reliability of alternative modalities of survey delivery.Participants Women 5–7 months pregnant with access to a phone.Setting Four districts of Madhya Pradesh, India.Design Cross-sectional surveys administered face-to-face and within 2 weeks, the same surveys were repeated among two random subsamples of the original sample: face-to-face (n=205) and caller-attended telephone interviews (n=375). Bivariate analyses, multivariable linear regression, and prevalence and bias-adjusted kappa scores are presented.Results Knowledge scores were low across domains: 52% for maternal nutrition and pregnancy danger signs, 58% for family planning, 47% for essential newborn care, 56% infant and young child feeding, and 58% for infant and young child care. Higher knowledge (≥1 composite score) was associated with older age; higher levels of education and literacy; living in a nuclear family; primary health decision-making; greater attendance in antenatal care and satisfaction with accredited social health activist services. Survey questions had low inter-rater and intermodal reliability (kappa

Systematic reviews of qualitative research (‘qualitative evidence syntheses’) are increasingly popular and represent a potentially important source of information about people’s views, needs and experiences. Since 2013, Cochrane has published qualitative evidence syntheses, and the Cochrane Effective Practice and Organisation of Care group has been involved in the majority of these reviews. But more guidance is needed on how to prepare these reviews in an environment that is more familiar with reviews of quantitative research. In this paper, we describe and reflect on how Cochrane qualitative evidence syntheses differ from reviews of intervention effectiveness and how these differences have influenced the guidance developed by the EPOC group. In particular, we discuss how it has been important to display to end users, firstly, that qualitative evidence syntheses are carried out with rigour and transparency, and secondly, that these quality standards need to reflect qualitative research traditions. We also discuss lessons that reviews of effectiveness might learn from qualitative research.

IntroductionDuring the COVID-19 pandemic, numerous states in the United States instituted measures to close schools or shift them to virtual platforms. Understanding parents' preferences for sending their children back to school, and their experiences with distance learning is critical for informing school reopening guidelines. This study characterizes parents' plans to return their children to school, and examines the challenges associated with school closures during the 2020-2021 academic year.MethodsA national-level cross-sectional online survey was conducted in September 2020. Focusing on a subset of 510 respondents, who were parents of school-aged children, we examined variations in parents' plans for their children to return to school by their demographic and family characteristics, and challenges they anticipated during the school-year using multivariable logistic regressions.ResultsFifty percent of respondents (n = 249) said that they would send their children back to school, 18% (n = 92) stated it would depend on what the district plans for school reopening, and 32% (n = 160) would not send their children back to school. No demographic characteristics were significantly associated with parents plans to not return their children to school. Overall, parents reported high-level of access to digital technology to support their child's learning needs (84%). However, those who reported challenges with distance learning due to a lack of childcare were less likely to not return their children to school (aOR = 0.33, 95% CI: 0.17, 0.64). Parents who reported requiring supervision after school had higher odds of having plans to not return their children to school (aOR = 1.97, 95% CI: 1.03, 3.79). Parents viewed COVID-19 vaccines and face-masks important for resuming in-person classes.DiscussionAbout one-third of parents objected to their children returning to school despite facing challenges with distance learning. Besides access to vaccines and face-masks, our findings highlight the need to better equip parents to support remote learning, and childcare.

Amidst the COVID-19 pandemic and national responses, trust (one’s belief that a system acts in one’s best interest) is important to consider. In community health systems, trust is embedded in relationships between clients, CHWs, and health system stakeholders. This mixed-methods study explores trust through the evolving COVID-19 crisis in Bangladesh, Haiti, and Kenya, where multi-country community health research was underway. We investigate the extent and ways trust between communities, community health workers (CHWs), and health system actors shift, including its relation to community fear and hostility, through self-reported positive and negative experiences of CHWs and policy/program stakeholders on a phone-based survey with 2,025 CHWs and 72 key informant interviews, including CHWs, in late 2020. On surveys, CHWs reported high levels of community trust (8/10 in Bangladesh and Kenya; 6/10 in Haiti) with over 60% reporting client relief in seeing their CHWs. About one-third of CHWs across countries reported experiencing instances of hostility from community members during the pandemic in the form of refused home-entry, ignored advice, or being shouted at. Multivariate analyses revealed that CHWs reporting more positive and fewer negative experiences is consistently associated with continuing routine work, doing COVID-19-related work, and greater community trust. Qualitative interviews showed that existing pre-pandemic trusting relationships withstood the early phase of COVID-19, mitigating negative community reactions toward CHWs and stigma towards COVID-positive individuals, maintaining routine health services, and sustaining appreciation for CHW-provided prevention information and emotional support. CHW-community and CHW-health system actor trust is strengthened when CHWs are well-resourced; CHW-community trust is strained by public frustration at the pandemic, associated restrictions, and sociopolitical stressors. Our study suggests that with adequate institutional support, bonds of trust can promote resilient community health systems during extended public health crises, through CHWs’ commitment to mitigating misinformation, reducing stigma, maintaining routine service provision, and promoting COVID-19 prevention.

Early COVID-19 pandemic data showed a spike in both food insecurity and poor mental health. The purpose of this study was to examine the relationship between food insecurity and mental health outcomes nine months after the start of the COVID-19 pandemic. A national survey of adults 18 years and older was administered in December 2020 (N = 8,355). Multivariable logistic models and post-estimation margins commands were used to show the predicted probability of mental health outcomes (psychological distress, anxiety, and depression) by food security status. The majority of participants (68.5%) reported high/marginal food security, 15.5% had low food security, and 16.0% had very low food security. There was a strong dose response relationship between food insecurity and higher psychological distress, anxiety and depression. Fewer than one in five adults with high/marginal food security screened positive for all three mental health outcomes, while more than two in five adults with low food security screened positive for psychological distress (39.9%), depression (41.7%) and anxiety (41.3%). Among adults with very low food security, nearly half screened positive for psychological distress (47.7%), depression (48.1%) and anxiety (49.4%). Younger adults had higher prevalence of psychological distress compared to older adults regardless of food security status. Food insecure adults, particularly young adults, have higher rates of psychological distress, anxiety, and depression than their food secure counterparts. Facilitating opportunities to connect at risk populations with food assistance and affordable mental healthcare should be prioritized as the pandemic continues and beyond.

In 2019, the World Health Organization (WHO) released the first-ever evidence-based guidelines for digital health. The guideline provides nine recommendations on select digital health interventions that involve the use of a mobile phone or device. It also provides information on implementation considerations, quality and certainty of extant evidence, factors related to acceptability and feasibility of the intervention, and gaps in the evidence that can inform future research. Given the pivotal role digital health can play in supporting health systems, seen especially in light of the COVID-19 pandemic, these guidelines can help provide a roadmap for governments and policymakers in introducing and scaling up digital health interventions to support population health outcomes.

Abstract Background With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. Methods A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. Results Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. Conclusions Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

Abstract Background In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services. Methods We used data from Indian Human Development Surveys done in 2004–2005 and in 2011–2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility. Results Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8–22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI − 1.6–11.1), 26% increase in SBA (95% CI 20–31.1), and 28% increase (95% CI 22.4–32.8) in facility births. Conclusions Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

Abstract Background Evidence is limited on the effectiveness of mobile health programs which provide stage-based health information messages to pregnant and postpartum women. Kilkari is an outbound service that delivers weekly, stage-based audio messages about pregnancy, childbirth, and childcare directly to families in 13 states across India on their mobile phones. In this protocol we outline methods for measuring the effectiveness and cost-effectiveness of Kilkari. Methods The study is an individually randomized controlled trial (iRCT) with a parallel, partially concurrent, and unblinded design. Five thousand pregnant women will be enrolled from four districts of Madhya Pradesh and randomized to an intervention or control arm. The women in the intervention arm will receive Kilkari messages while the control group will not receive any Kilkari messages as part of the study. Women in both arms will be followed from enrollment in the second and early third trimesters of pregnancy until one year after delivery. Differences in primary outcomes across study arms including early and exclusive breastfeeding and the adoption of modern contraception at 1 year postpartum will be assessed using intention to treat methodology. Surveys will be administered at baseline and endline containing modules on phone ownership, geographical and demographic characteristics, knowledge, practices, respectful maternity care, and coverage for antenatal care, delivery, and postnatal care. In-depth interviews and focus group discussions will be carried out to understand user perceptions of Kilkari, and more broadly, experiences providing phone numbers and personal health information to health care providers. Costs and consequences will be estimated from a societal perspective for the 2018–2019 analytic time horizon. Discussion Kilkari is the largest maternal messaging program, in terms of absolute numbers, currently being implemented globally. Evaluations of similar initiatives elsewhere have been small in scale and focused on summative outcomes, presenting limited evidence on individual exposure to content. Drawing upon system-generated data, we explore linkages between successful receipt of calls, user engagement with calls, and reported outcomes. This is the first study of its kind in India and is anticipated to provide the most robust and comprehensive evidence to date on maternal messaging programs globally. Trial registration Clinicaltrials.gov, 90075552, NCT03576157. Registered on 22 June 2018.

A growing number of researchers are preparing systematic reviews of qualitative evidence, often referred to as ‘qualitative evidence syntheses’. Cochrane published its first qualitative evidence synthesis in 2013 and published 27 such syntheses and protocols by August 2020. Most of these syntheses have explored how people experience or value different health conditions, treatments and outcomes. Several have been used by guideline producers and others to identify the topics that matter to people, consider the acceptability and feasibility of different healthcare options and identify implementation considerations, thereby complementing systematic reviews of intervention effectiveness.Guidance on how to conduct and report qualitative evidence syntheses exists. However, methods are evolving, and we still have more to learn about how to translate and integrate existing methodological guidance into practice. Cochrane’s Effective Practice and Organisation of Care (EPOC) ( www.epoc.org ) has been involved in many of Cochrane’s qualitative evidence syntheses through the provision of editorial guidance and support and through co-authorship. In this article, we describe the development of a template and guidance for EPOC’s qualitative evidence syntheses and reflect on this process.

Background Community health volunteers (CHVs) play crucial roles in enabling access to healthcare at the community levels. Although CHVs are considered volunteers, programmes provide financial and non-financial incentives. However, there is limited evidence on which bundle of financial and non-financial incentives are most effective for their improved performance.Methods We used a discrete choice experiment (DCE) to understand incentive preferences of CHVs with the aim to improve their motivation, performance and retention. Relevant incentive attributes were identified through qualitative interviews with CHVs and with their supervisors. We then deployed a nominal group technique to generate and rank preferred attributes among CHVs. We developed a DCE based on the five attributes and administered it to 211 CHVs in Kilifi and Bungoma counties in Kenya. We used mixed multinomial logit models to estimate the utility of each incentive attribute and calculated the trade-offs the CHWs were willing to make for a change in stipend.Results Transport was considered the incentive attribute with most relative importance followed by tools of trade then monthly stipend. CHVs preferred job incentives that offered higher monthly stipends even though it was not the most important. They had negative preference for job incentives that provided award mechanisms for the best performing CHVs as compared with jobs that provided recognition at the community level and preferred job incentives that provided more tools of trade compared with those that provided limited tools.Conclusion A bundled incentive of both financial and non-financial packages is necessary to provide a conducive working environment for CHVs. The menu of options relevant for CHVs in Kenya include transport, tools of trade and monthly stipend. Policy decisions should be contextualised to include these attributes to facilitate CHW satisfaction and performance.

Abstract Background Globally, there is renewed interest in and momentum for strengthening community health systems, as also emphasized by the recent Astana Declaration. Recent reviews have identified factors critical to successful community health worker (CHW) programs but pointed to significant evidence gaps. This review aims to propose a global research agenda to strengthen CHW programs. Methods and results We conducted a search for extant systematic reviews on any intermediate factors affecting the effectiveness of CHW programs in February 2018. A total of 30 articles published after year 2000 were included. Data on research gaps were abstracted and summarized under headings based on predominant themes identified in the literature. Following this data gathering phase, two technical advisory groups comprised of experts in the field of community health—including policymakers, implementors, researchers, advocates and donors—were convened to discuss, validate, and prioritize the research gaps identified. Research gap areas that were identified in the literature and validated through expert consultation include selection and training of CHWs, community embeddedness, institutionalization of CHW programs (referrals, supervision, and supply chain), CHW needs including incentives and remuneration, governance and sustainability of CHW programs, performance and quality of care, and cost-effectiveness of CHW programs. Priority research questions included queries on effective policy, financing, governance, supervision and monitoring systems for CHWs and community health systems, implementation questions around the role of digital technologies, CHW preferences, and drivers of CHW motivation and retention over time. Conclusions As international interest and investment in CHW programs and community health systems continue to grow, it becomes critical not only to analyze the evidence that exists, but also to clearly define research questions and collect additional evidence to ensure that CHW programs are effective, efficient, equity promoting, and evidence based. Generally, the literature places a strong emphasis on the need for higher quality, more robust research.

BackgroundIn 2017, India was home to nearly 20% of maternal and child deaths occurring globally. Accredited social health activists (ASHAs) act as the frontline for health services delivery in India, providing a range of reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) services. Empirical evidence on ASHAs' knowledge is limited, yet is a critical determinant of the quality of health services provided. We assessed the determinants of RMNCH&N knowledge among ASHAs and examined the reliability of alternative modalities of survey delivery, including face-to-face and caller attended telephone interviews (phone surveys) in 4 districts of Madhya Pradesh, India.MethodsWe carried out face-to-face surveys among a random cross-sectional sample of ASHAs (n = 1,552), and administered a follow-up test-retest survey within 2 weeks of the initial survey to a subsample of ASHAs (n = 173). We interviewed a separate sub-sample of ASHAs 2 weeks of the face-to-face interview over the phone (n = 155). Analyses included bivariate analyses, multivariable linear regression, and prevalence and bias adjusted kappa analyses.FindingsThe average ASHA knowledge score was 64% and ranged across sub-domains from 71% for essential newborn care, 71% for WASH/ diarrhea, 64% for infant feeding, 61% for family planning, and 60% for maternal health. Leading determinants of knowledge included geographic location, age ConclusionsOverall results highlight important gaps in the knowledge of ASHAs. Findings on the reliability of phone surveys led to the development of a tool, which can be widely used for the routine, low cost measurement of ASHA RMNCH&N knowledge in India.

Introduction There is a renewed global interest in improving community health worker (CHW) programmes. For CHW programmes to be effective, key intervention design factors which contribute to the performance of CHWs need to be identified. The recent WHO guidelines recommends the combination of financial and non-financial incentives to improve CHW performance. However, evidence gaps remain as to what package of incentives will improve their performance in different country contexts. This study aims to evaluate CHW incentive preferences to improve performance and retention which will strengthen CHW programmes and help governments leverage limited resources appropriately.Methods and analysis A discrete choice experiment (DCE) will be conducted with CHWs in Bangladesh, Haiti, Kenya and Uganda with different levels of maturity of CHWs programmes. This will be carried out in two phases. Phase 1 will involve preliminary qualitative research including focus group discussions (FGDs) and key informant interviews to develop the DCE design which will include attributes relevant to the CHW country settings. Phase 2 will involve a DCE survey with CHWs, presenting them with a series of job choices with varying attribute levels. An orthogonal design will be used to generate the choice sets for the surveys. The surveys will be administered in locally-appropriate languages to at least 150 CHWs from each of the cadres in each country. Conditional and mixed multinomial logit (MMNL) models will be used for the estimation of stated preferences.Ethics and dissemination This study has been reviewed and approved by the Population Council’s Institutional Review Board in New York, and appropriate ethics review boards in Kenya, Uganda, Bangladesh and Haiti. The results of the study will be disseminated through in-country dissemination workshops, meetings with country-level stakeholders and policy working groups, print media, online blogs and peer-reviewed journals.

Objectives Despite the recognised importance of adopting a continuum of care perspective in addressing the care of mothers and newborns, evidence on specific interventions to enhance engagement of women along the maternity care continuum has been limited. We use the example of the Accredited Social Health Activist (ASHA) programme in India, to understand the role of community health workers in retaining women in the maternity care continuum.Methods Using the Indian Human Development Survey data from 2011 to 2012, we assess the association between individual and cluster-level exposure to ASHA and four key components along the continuum of care—at least one antenatal care (ANC) visit, four or more ANC visits, presence of a skilled birth attendance (SBA) at the time of birth and postnatal care for the mother or child within 48 hours of birth, for 13 705 women with a live birth since 2005. To understand which of these services experience maximum dropout along the continuum, we use a linear probability model to calculate the weighted percentages of using each service. We assess the association between exposure to ASHA and number of services utilised using a multinomial logistic regression model adjusted for a range of confounding variables and survey weights.Results Our study indicates that exposure to the ASHA is associated with an increased probability of women receiving at least one ANC and SBA. In terms of numbers of services, exposure to ASHA accounts for a 12% (95% CI: 9.1 to 15.1) increase in women receiving at least some of the services, and an 8.8% (95% CI: −10.2 to −7.4) decrease in women receiving no services. However, exposure to ASHA does not increase the likelihood of women utilising all the services along the continuum.Conclusions While ASHA is effective in supporting women to initiate and continue care along the continuum, it does not significantly affect the completion of all services along the continuum.

BACKGROUND:There is increasing evidence that mobile phone health interventions ("mHealth") can improve health behaviors and outcomes and are critically important in low-resource, low-access settings. However, the majority of mHealth programs in developing countries fail to reach scale. One reason may be the challenge of developing financially sustainable programs. The goal of this paper is to explore strategies for mHealth program sustainability and develop cost-recovery models for program implementers using 2014 operational program data from Mobile for Reproductive Health (m4RH), a national text-message (SMS) based health communication service in Tanzania. METHODS:We delineated 2014 m4RH program costs and considered three strategies for cost-recovery for the m4RH program: user pay-for-service, SMS cost reduction, and strategic partnerships. These inputs were used to develop four different cost-recovery scenarios. The four scenarios leveraged strategic partnerships to reduce per-SMS program costs and create per-SMS program revenue and varied the structure for user financial contribution. Finally, we conducted break-even and uncertainty analyses to evaluate the costs and revenues of these models at the 2014 user volume (125,320) and at any possible break-even volume. RESULTS:In three of four scenarios, costs exceeded revenue by $94,596, $34,443, and $84,571 at the 2014 user volume. However, these costs represented large reductions (54%, 83%, and 58%, respectively) from the 2014 program cost of $203,475. Scenario four, in which the lowest per-SMS rate ($0.01 per SMS) was negotiated and users paid for all m4RH SMS sent or received, achieved a $5,660 profit at the 2014 user volume. A Monte Carlo uncertainty analysis demonstrated that break-even points were driven by user volume rather than variations in program costs. CONCLUSIONS:These results reveal that breaking even was only probable when all SMS costs were transferred to users and the lowest per-SMS cost was negotiated with telecom partners. While this strategy was sustainable for the implementer, a central concern is that health information may not reach those who are too poor to pay, limiting the program's reach and impact. Incorporating strategies presented here may make mHealth programs more appealing to funders and investors but need further consideration to balance sustainability, scale, and impact.

, , In 2010, 7.6 million children under five died globally – largely due to preventable diseases. Majority of these deaths occurred in sub–Saharan Africa. As a strategy to reduce child mortality, the Government of Malawi, in 2008, initiated integrated community case management allowing health surveillance assistants (HSAs) to treat sick children in communities. Malawi however, faces health infrastructure challenges, including weak supply chain systems leading to low product availability. A baseline assessment conducted in 2010 identified data visibility, transport and motivation of HSAs as challenges to continuous product availability. The project designed a mHealth tool as part of two interventions to address these challenges.