A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / This systematic review focuses on improving recognition and treatment of acute medical conditions in pregnant women, infants and children in low and middle income countries by Community Health Workers (CHWs). By examining critically selected articles from different electronic databases, this review seeks to organize and present the important characteristics of a training program aimed at reducing maternal, neonatal and childhood mortality. Data in the form of peer‐reviewed and published articles were collected using three public databases – PubMed, Ovid and EMBASE – using specific search terms. Greater than 300 articles where found using the specific search terms. Those articles were then processed through a series of inclusion and exclusion criteria resulting in a cohort of papers which were then individually analyzed for content. After critical analysis of all 15 publications included in the study, it becomes clear that training programs are incredibly diverse. These four aspects of training programs appear to be the most variable between the studies: size of the training program, length of the training program, training assessment and follow‐up refresher courses. Training programs that are shorter in duration or greater in class number do not seem to be any less effective than longer programs with fewer participants. Future studies should be performed in which one training program with identical training techniques, lengths, and focuses is taught in different regions. The impact that this study has on the literature is as follows: Training programs of shorter duration seem to be as effective as their longer counterparts. Finally, there is a clear need for more robust, standardized and geographically and culturally diverse training programs to more effectively study training methods.

Numerous studies have focused on the effectiveness of community health worker (CHW) programs in producing positive health behaviors and health outcomes for the clients CHWs serve; however, there has been a gap in the literature regarding how the health of HIV + CHWs is impacted by their jobs. A phenomenological design was used to gain insight into the lived experiences of HIV+ CHWs (HIVCHW) who provided services to HIV positive clients. Fifteen HIVCHW were recruited using criteria and snowball techniques. Data were collected via audio recorded personal interviews regarding respondents' perceptions of their work and how it impacted their own health and wellbeing. The data were organized by hand creating charts with pen and paper. Lazarus's theory of stress and coping was used to understand the data and aided in the analysis. The key findings indicated that while the majority of participants had an overall positive perception of the experience of being HIVCHWs, they also indicated that being a CHW impacted their health and well-being. Stress and stressful situations were among the impacts most often referenced by the study participants. The study is socially significant because it may offer the workforce of HIVCHWs empowerment to self-advocate for tools such as stress and time management training and mentors to support healthy work-life balance. In addition, this study may help to prevent or reduce rates of adverse health outcomes such as pain and burnout that HIVCHWs reported experiencing.

INTRODUCTION: Community health workers are a growing and developing portion of the healthcare workforce. They have proven successes in decreasing healthcare inequities for many common chronic medical conditions, such as asthma, and have secured support at the Department of Health and Human Services. One common medical condition for which community health workers have not yet been explored as a resource is pediatric Attention Deficit Hyperactivity Disorder. We sought to investigate what the literature showed on community health workers' involvement in ADHD treatments thus far, and to specifically investigate which ADHD behavioral parent training program could best be adapted to a pilot study where community health workers were the intervention delivery agents. METHODS: We performed a systematic review of the literature on evidence based behavioral parent training programs for children with ADHD. Parent training interventions were compared for ease of application to a community health worker home-visit model. Program ability to successfully reduce child behavior problems and improve parenting practices was analyzed. RESULTS: 8 full text articles were analyzed in depth and grouped by intervention type. 1 article was a sports-based intervention for fathers, 1 was meant to improve attendance rates, 1 was a combined child-targeted and parent-targeted Behavioral Parent Training (BPT) therapy, 2 were based on the "New Forest Parenting Package", and 3 were based on Barkley's 1997 manualized BPT. DISCUSSION: Evidence exists for the ability of community health workers to deliver a behavioral therapy to families of children with ADHD, specifically behavioral parent training. Barkley's manualized BPT had the best combination in our study of positive outcomes for families and ease of adaptability to in-home delivery. We recommend a pilot study be conducted using a modified version of Barkley's BPT and have community health workers as the delivery agents to begin to see what role community health workers can play in the treatment of pediatric ADHD.

Objectifs: Cette étude a documenté la collaboration intersectorielle entre les agents de santé communautaires (ASC) et les enseignants visant à combattre la violence à l’égard des femmes et des filles à Vulindlela, une communauté rurale Sud-Africaine. La collaboration entre ces acteurs, les facteurs qui influencent leur collaboration et les avenues possibles pour une amélioration de cette collaboration ont été explorés. Méthodes: Six ASC et cinq enseignants ont pris part à cette recherche participative qui a inclut l'utilisation du dessin comme méthodologie visuelle. La collecte de données a été réalisée en quatre phases, avec un total de huit entretiens de groupes. La stratégie d’analyse principale a inclus une approche dirigée du contenu narratif et une approche de comparaison constante. Résultats: Le système de collaboration entre les enseignants et les ASC manque de définition et ces acteurs ne peuvent donc en faire l’utilisation. Par conséquent la collaboration actuelle entre ces acteurs a été jugée peu développé, impromptue et informelle. De nombreuses contraintes à la collaboration ont été identifiées, y compris le manque de motivation de la part des enseignants, la nature des relations entre les acteurs, et la capacité individuelle limitée des ASC. Conclusion: Compte tenu des nombreuses contraintes à la collaboration entre ces ASC et les enseignants, il n'est pas évident que cette collaboration conduira aux résultats espérés. Dans l'absence de motivation suffisante et d’une prise de conscience réaliste des défis par les acteurs eux-mêmes, les initiatives externes pour améliorer la collaboration sont peu susceptibles de succès. / Objectives: This study had for objective to document intersectoral collaboration (ISC) between community health workers (CHWs) and teachers aimed at addressing violence against women and girls (VAW/G) in Vulindlela, a rural South African community. The current collaborative paths bringing CHWs and teachers together, the factors that influence their collaboration and potential avenues for future improvement of this collaborative were explored. Methods: A total of six CHWs and five teachers took part in this participatory research which included the use of drawing as a visual methodology. Data collection was divided into four phases and included a total of eight group interviews. The analysis of group interviews utilized a directed approach to narrative data analysis, and a constant comparative approach was used in the analysis of the participants` drawings. Results: There are no well-defined collaborative systems that CHWs and teachers are able to make use of. Consequently teacher-CHW collaboration was found to be poorly developed, unplanned and informal. Numerous barriers were identified as impeding collaboration including the teachers’ lack of motivation to collaborate, the nature of the relationships between these groups of actors and the CHWs’ overall lack of individual capacity. Conclusion: Given the numerous challenges facing collaboration between these CHWs and teacher, it is not clear that such collaboration would necessarily lead to effective outcomes. In the absence of sufficient motivation and a realistic awareness of the challenges from the actors themselves, external initiatives to foster collaboration are unlikely to be successful.

This qualitative study examines the challenges that community health workers or Promotores face when implementing their programs to produce better outcomes in the Latino community. Data collection was derived from five local promotores with an adequate knowledge base of expertise in promotores programs. Study themes focused on how promotores implement their programs, the challenges they face and providing professional and personal insight on working with the Latino community. Present day research emphasizes that promotores or the community health worker model approaches have been promoted as a strategy to address health disparities experienced by Latino communities in the U.S. These programs have been implemented in an effort to improve the health of Latino families and bring awareness to public health issues. However, not much is known about the challenges that they face when implementing these interventions. Study results indicated five emerging themes pertaining to the challenges that promotores face when implementing their programs and include: mental health stigma, recruitment, funding barriers, and lack of evaluation. Finally, suggestions for further research on promotores and the Latino community are discussed.

Objectifs: Cette étude a documenté la collaboration intersectorielle entre les agents de santé communautaires (ASC) et les enseignants visant à combattre la violence à l’égard des femmes et des filles à Vulindlela, une communauté rurale Sud-Africaine. La collaboration entre ces acteurs, les facteurs qui influencent leur collaboration et les avenues possibles pour une amélioration de cette collaboration ont été explorés. Méthodes: Six ASC et cinq enseignants ont pris part à cette recherche participative qui a inclut l'utilisation du dessin comme méthodologie visuelle. La collecte de données a été réalisée en quatre phases, avec un total de huit entretiens de groupes. La stratégie d’analyse principale a inclus une approche dirigée du contenu narratif et une approche de comparaison constante. Résultats: Le système de collaboration entre les enseignants et les ASC manque de définition et ces acteurs ne peuvent donc en faire l’utilisation. Par conséquent la collaboration actuelle entre ces acteurs a été jugée peu développé, impromptue et informelle. De nombreuses contraintes à la collaboration ont été identifiées, y compris le manque de motivation de la part des enseignants, la nature des relations entre les acteurs, et la capacité individuelle limitée des ASC. Conclusion: Compte tenu des nombreuses contraintes à la collaboration entre ces ASC et les enseignants, il n'est pas évident que cette collaboration conduira aux résultats espérés. Dans l'absence de motivation suffisante et d’une prise de conscience réaliste des défis par les acteurs eux-mêmes, les initiatives externes pour améliorer la collaboration sont peu susceptibles de succès. / Objectives: This study had for objective to document intersectoral collaboration (ISC) between community health workers (CHWs) and teachers aimed at addressing violence against women and girls (VAW/G) in Vulindlela, a rural South African community. The current collaborative paths bringing CHWs and teachers together, the factors that influence their collaboration and potential avenues for future improvement of this collaborative were explored. Methods: A total of six CHWs and five teachers took part in this participatory research which included the use of drawing as a visual methodology. Data collection was divided into four phases and included a total of eight group interviews. The analysis of group interviews utilized a directed approach to narrative data analysis, and a constant comparative approach was used in the analysis of the participants` drawings. Results: There are no well-defined collaborative systems that CHWs and teachers are able to make use of. Consequently teacher-CHW collaboration was found to be poorly developed, unplanned and informal. Numerous barriers were identified as impeding collaboration including the teachers’ lack of motivation to collaborate, the nature of the relationships between these groups of actors and the CHWs’ overall lack of individual capacity. Conclusion: Given the numerous challenges facing collaboration between these CHWs and teacher, it is not clear that such collaboration would necessarily lead to effective outcomes. In the absence of sufficient motivation and a realistic awareness of the challenges from the actors themselves, external initiatives to foster collaboration are unlikely to be successful.

Philosophiae Doctor - PhD / Introduction: National community health worker (CHW) programmes are to an increasing extent being implemented in health systems globally, mirrored in South Africa in the ward-based outreach team (WBOT) strategy. In many countries, including South Africa, a major challenge impacting the performance and sustainability of scaled-up CHW programmes is ensuring adequate support from and supervision by the local health system. Supervisory systems, where they exist, are usually corrective and hierarchical in nature, and implementation remains poor. In the South African context, the absence of any guidance on CHW supportive supervision has led to varied practices across the country. Improved approaches to supportive supervision are considered critical for CHW programme performance. However, there is relatively little understanding of how this can be done sustainably at scale, and effective CHW supervisory models remain elusive. Research to date has mostly positioned supervision as a technical process rather than a set of relationships, with the former testing specific interventions rather than developing holistic approaches attuned to local contexts. This doctoral study was exploratory in nature, seeking to generate an in-depth and contextualised understanding of the supervision phenomenon in one specific district in the North West Province (NWP) in South Africa. Using co-production methodology in an iterative approach, the study culminated in the formulation of a supportive supervision framework with CHWs and other frontline actors. Methods: The study was based on a holistic conceptual framework of supportive supervision, which was viewed as comprising three core functions ‒ accountability, development and support ‒ embedded in a complex and multi-level system of resources, people and relationships. To address the study objectives, the research used a mix of qualitative and quantitative methods. Three studies were conducted in a phased process: study 1 comprised a qualitative description of policy and practices in two districts related to the supervision of WBOTs; study 2 identified the main actors and mapped the supervisory system of WBOTs in the district, using social network analysis (SNA); and study 3 involved a qualitative exploration of workplace and interpersonal trust factors in the district and the supervisory system of WBOTs in the district. These three studies provided inputs for a workshop aimed at developing recommendations for a district-level, WBOT supportive supervisory framework. Four published papers reporting on the research conducted are presented in this thesis. It should be noted that the research was conducted during a turbulent political and administrative period in the NWP, when the WBOT programme changed from being a flagship programme for the country to one in crisis. This shifting context needs to be borne in mind when the findings are viewed and interpreted. Results: The study identified weaknesses in both the design and implementation of the supervisory system of WBOTs, with the absence of clear guidance resulting in WBOTs and PHC facilities performing their roles in an ad hoc manner, defined within local contexts. The study documented evidence of high internal cohesion within WBOTs and (where present) with their immediate outreach team leaders (OTLs). However, the relationships between WBOTs and the rest of the primary health care (PHC) and district health system were characterised by considerable mistrust – both towards other workers and the system as a whole. This occurred against a backdrop of increasing OTL vacancies, and the perceived abandonment of WBOT training and development systems and career opportunities. These findings are not dissimilar to those reported previously on the WBOT programme in South Africa and in programmes in other low-resource settings. Nevertheless, through its in-depth, exploratory and participatory approaches, this study provides additional insights into the phenomenon of supportive supervision. Firstly, in conceptualising supportive supervision as a set of ‘bundled’ practices within complex local health systems, the findings reflected the complexity of everyday realities and lived experiences. Secondly, through the embedded nature of the research and the phased data-collection process, the study was able to observe the impact of wider health system contexts and crises on the coalface functioning of the WBOT programme. Thirdly, the study emphasised how supportive supervision depends on healthy relational dynamics and trust relationships, and, finally, how a co-production approach can translate broad guidance, experience and theoretical understanding into meaningful, local practice owned by all the actors involved. Ultimately, the process of engagement, building relationships and forging consensus proved to be more significant than the supportive supervision framework itself. Conclusion: The lack of explicit, coherent and holistic guidance in developing CHW supportive supervision guidance and the failure to address supervision constraints at a local level undermine the performance and sustainability of CHW programmes. Effective supportive supervisory systems require bottom-up collaborative platforms characterised by active participation, sharing of local tacit knowledge and mutual learning. Supervisory systems also need to be designed in ways that promote relationships and generate trust between CHW programmes, other actors and the health system.