A research report submitted to the Faculty of Health Sciences, University of The Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Science Epidemiology in the Field of Implementation Sciences. May 2018 Johannesburg, South Africa. / Background: Surveillance structures for tuberculosis (TB) contact tracing are not well integrated into routine national reporting structures. The implementation of reingineering of primary health care through ward based outreach teams (WBOTs) is a step towards equitable primary health care. Data and information collected by WBOTs for household TB contact tracing is an integral part of the implementation model of primary health care reengineering. The quality of patient record documentation becomes even more vital in light of the increased focus on process and outcome measures in health programmes and as a result, careful consideration be given to the WBOT data collection system used by community health workers (CHWs). In order to contribute to efforts of developing an optimised model for household contact tracing, the acceptability of the current paper-based data collection system needs to be assessed in order to develop a comprehensive monitoring & evaluaiton (M&E) framework for an optimsed model for household tuberculosis contact tracing. Methods: The current cross sectional research project is nested within a project that aims to develop an optimised model for household TB contact tracing. In this nested mixed methods study; the exploratory sequential design was used to explore the facilitators and barriers to completing the current data collection tools used by CHWs. The study had two components, firstly three focus group discussions (FGDs) were conducted in the three Ekurhuleni health sub-districts (Northern, Eastern and Southern) in three purposively selected primary health clinics and secondary data analysis of the main study`s FGDs was also conducted. Manual coding and QDA Miner software was used for coding and all qualitative analysis. Emerging themes were identified through inductive thematic analysis using the constant comparison analysis framework. The results informed the quantitative data collection and analysis. Following qualitative analysis; a close ended questionnaire was refined and informed by the results of the qualitative inquiry. CHWs were recruited using targetted sampling techniques from 6 primary health care facilities located in the different sub-districts in order to administer the questionnaire. The four point Likert Scale questionnaire was developed using theoritical framework for acceptability (TFA) constructs to asses the level of acceptability of the current data collection tools used to document tuberculosis contact tracing activities. Univariate and multivariate linear regression models were fitted to examine significant relationships between the composite acceptability scores and several predictors. All quantitative analysis was perforned on STATA version 14 (StataCorp College Station, Texas 77845 USA). Results: A total of five FGDs were conducted; two that were conducted as part of the main study supplemented the data from the three that were conducted (one in each Ekurhuleni health Sub-district). The total of 54 CHWs participated in all the five FGDs with 89% being female. Average age of all CHWs was 34.41 years [mean (sd): 34.41(8.16)]. Five broad themes emerged including inadequate CHW training, WBOT programme integration with other health and social care service providers, challenges with the WBOT data collection system, community access issues and preference for a digital based data collection system. Data related barriers identified included limitations with the current paper based data collection system such as insufficient competency assessments about the different data collection tools, lack of a specific tool to capture TB contact tracing activities, incomplete referral forms due to clinic staff not completing them, patients providing wrong information, too many papers to complete. Those that were related to the WBOT actvities included lack of community acceptance, resource constraints, violent patients and community members, community members that are not welcoming . Facilitators included motivated CHWs. 94 CHWs were enrolled for the quantitative survey with 90 (95.74%) females. From the total, 35% of the CHWs were from the Ekurhuleni health southern subdistrict, 34% and 31% were from the eastern and northern sub-districts respectively. The overall median (IQR) composite acceptability scores from all sub-districts was 48 (45 51), with the highest scores observed in the Eastern sub-district 49 (45 46) . In the overall study population, the acceptability of the current WBOT data collection tools was low. Conclusions: Main findings pertaining to CHW training indicate that the different phases of the Primary Health Care (PHC) reingeering WBOT trainings were inconsistent. There is also a lack of acknowledgement of attendance as CHW expressed their dissatisfaction in not receiving certifications which resulted in low morale for conducting outreach activities. The sub-optimal integration of the WBOT programme into the primary health care system results in a patchy referral system characterised by incomplete back referrals resulted as referral forms remain incomplete. Communication between the primary health care facility staff and WBOT CHWs needs to be strengthened in order to strengthen the referral linkages with other health and social care service providers. Funding models for WBOT programme need to be reviewed to ensure that resources needed for optimal WBOT functioning are secured. Restricted access to some communities, patients providing wrong addresses, violent and unwelcoming household members and lack of WBOT safety were barriers to accessing TB patients during outreach activities; thus leading to incomplete and innacurate data. The limitations posed by the current paper-based data collection system have been acknowledged and the CHWs preference for a digital based system highlights the need for the evaluation of the current mobile data collection technologies in other regions in order to inform nationwide scale-up. Recommendations: The implementation of the WBOT programme is still in its infancy and in order to improve the data collection processes of the programme, more research on CHW post-training competence is needed to determine the effectiveness of the wide array of training programs. Moreover, the implementation of CHW program should be coordinated among the different training providers including government, civil society organizations and NGOs. To improve the quality of the CHW training delivery and content, CHW feedback should be sought through pre-and post-assessments. There is a need to focus efforts on coordinating and strengthening the different PHC reengineering streams and integrate them into the primary health care system. This will likely strengthen the referral system between the WBOT programme and PHC facilities. The current M&E policy needs to be reviewed and special consideration should be given to TB contact tracing related indicators. This should also be accompanied by an adjustment of the current WBOT data collection tools to better reflect the agreed upon TB contact tracing indicators. The study further recommends further research in the form of economic evaluations to determine the cost effectiveness of scaling up current digital based data collection methods to inform nationwide scale up. Key words: Ward Based Outreach Teams, data collection system, data collection tools, community health workers, TB contact tracing, Community Based Information System, acceptabiltity, mHealth / LG2018

Indiana University-Purdue University Indianapolis (IUPUI) / Community Health Workers (CHW) are trusted frontline members of the public health workforce with a unique understanding of the communities they serve. CHW interventions have been shown effective and economical in improving certain health outcomes, including diabetes-related complications and self-management. The ability of CHWs to relate to patients in a culturally appropriate manner positions them to better address social determinants of health and inequities than many allied health professionals. State-level CHW legislation varies by jurisdiction and can direct CHW processes including definitions, funding, and scope of practice. The Diabetes Project – Indianapolis Neighborhoods (DIP-IN) intervention employs clinic-based CHWs to work with high-risk patients with diabetes in three Indianapolis communities with disproportionately high diabetes prevalence rates. DIP-IN CHWs are based in select Eskenazi Health Federally Qualified Health Centers and deliver services to patients primarily through home visits or phone calls. This dissertation examines CHW policies and the impact of the DIP-IN CHW intervention on patient outcomes in relation to a comparison group. This dissertation includes three studies 1) a state-level policy surveillance exploring legislation that includes best practices for CHW policy, 2) a study using a difference-in-difference approach through the application of generalized linear mixed models to estimate the effect of DIP-IN on A1C and hospital outcomes, and 3) a study using multivariat regression and negative binomial modeling to estimate the impact of DIP-IN on COVID-19 hospitalization and length of stay. As financing influences duration and application of CHW interventions, this dissertation aims to explore the landscape over time of CHW legislation and evaluate a privately funded CHW program model intended to improve health outcome among high-risk patients with diabetes. It also aims to strengthen the knowledge base for CHW involvement in improving clinical-community linkages to support diabetes management. / 2024-07-03

Objectives. A community health worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. While natural leadership may incline individuals to the CHW profession, they do not always have skills to address broad social issues. We describe evaluation of the Women’s Health Leadership Institute (WHLI), a 3-year training initiative to increase the capacity of CHWs as change agents. Methods. Pre-/postquestionnaires measured the confidence of 254 participants in mastering WHLI leadership competencies. In-depth interviews with CHW participants 6 to 9 months after the training documented application of WHLI competencies in the community. A national CHW survey measured the extent to which WHLI graduates used leadership skills that resulted in concrete changes to benefit community members. Multivariate logistic regressions controlling for covariates compared WHLI graduates’ leadership skills to the national sample. Results. Participants reported statistically significant pre-/post improvements in all competencies. nterviewees credited WHLI with increasing their capacity to listen to others, create partnerships, and initiate efforts to address community needs. Compared to a national CHW sample, WHLI participants were more likely to engage community members in attending public meetings and organizing events. These activities led to community members taking action on an issue and a concrete policy change. Conclusions. Leadership training can increase the ability of experienced CHWs to address underlying issues related to community health across different types of organizational affiliations and job responsibilities.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Public Health Johannesburg June 2016 / Background: The work of Community Health Workers is appreciated in most setups in both developing and developed countries. In Zimbabwe there are a number of cadres who are working to bridge the health services and the community. There has however been limited documentation on the perspectives of Community Health Workers on what enables them to do their work and also barriers they face in providing their services. Aim: The study aimed to explore the perceptions of CHWs on the enablers and barriers to providing services in Nyanga district in Zimbabwe. Method: The study used a qualitative methods of in-depth interviews with Community Health Workers and key informants and document reviews. A thematic content analysis was used to identify key themes. The themes were then further analysed to identify the enablers and barriers to community health work. Results and Conclusion: The major enablers of the CHW work were perceived to be the benefits which have accrued to the communities the CHWs were working with, the benefits which the CHWs had gained and the support given by the hospital, NGO and the community leadership. The following were perceived to be the major barriers to CHW work: limited access to health services by the communities from the health facilities driven by the weak macroeconomic conditions in the country, gaps in support services, workload and geographical coverage. The recommendations include improving the motivation of the CHWs through efficient payment system, improving on quality of care and processes in the service provision. The results provide insights into CHW work which can assist policy makers and managers in making informed decisions on the investments they make for the CHW programmes in Nyanga district and Zimbabwe in general. / MT2016

Magister Public Health - MPH / Background: Malnutrition in children under the age of 5 years is a global public Health problem. The UNICEF report states that 10.9 million children under five die in developing countries each year due to malnutrition. According to the Zambia Demographic and Health Survey of 2008 malnutrition is one of the main childhood illnesses in Zambia with almost 50% of the under five children being stunted. The referral system in Zambia is organized in a way that starts at the Primary Health Care (PHC) level within the community and managed by the Community Health Workers (CHW). At this level, Community Health Workers screen and identify children that have childhood illnesses which require treatment and they refer them to the Rural Health Centre (RHC). When the problem cannot be handled at the RHC level the child is referred to the district hospital or provincial hospital level within a particular province. However, most children with malnutrition arrive late at the hospital for treatment. Some of them die soon after admission. It was not clear what prevent the mothers from bringing these children early to the hospital for treatment. Methods: The main aim of the study was to explore factors that are associated with detection and referral of malnourished children from Primary Health Care (PHC) at community level to the Health centres in Kalomo district. The study was conducted in Kanchele community of Kalomo in Southern Province of Zambia. Kanchele is a rural community with most basic services such as health facilities not being easily accessed. The study focused on two PHCs which had the highest prevalence of malnutrition. All participants were asked to sign a consent form after the purpose of study had been explained to them. They were informed that all information would be treated with confidentiality and that participation was voluntary and that they had the right to chose not to participate in the study. Furthermore each participant was asked if they agreed to maintain the confidentiality of the information discussed by participants and researchers during the focus group session. The study was qualitative in nature and focus group discussions were conducted with mothers or caregivers of children under five years, community members who have lived in the community for more than one year and community health workers who have also worked in the community for more than one year. Focus group discussions were used to collect data from mothers and community members. While in-depth interviews were used to collect data from CHWs and nutrition group leaders working at the PHC and community leaders. The data collected from the focus group discussions was analysed using thematic approach. Barriers or hindrances to rehabilitating a malnourished child mentioned by the respondents included lack of knowledge on malnutrition, failure to link malnutrition to poor feeding and bad health seeking habits, poor response to referral as a result of a system which is not supported with adequate resource such as transport, a system that does not support parents with food in-case of the child being hospitalised, the current hospital system only provides food to the patient. The failure by health staff to see that malnutrition is a key childhood disease. Data from this study will be used to develop interventions to improve the management of malnourished children. Conclusion: The study shows that mothers and community members are misinformed about the causes and treatment of malnutrition. It also clearly showed that traditional healers and grandparents played an important role in the diagnosis and treatment of malnourished children in this community. Interventions to improve identification and referral of these malnourished children needs to taken into consideration.

Orientador: Rosana de Fátima Possobon / Dissertação (mestrado profissional) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-08-23T13:29:47Z (GMT). No. of bitstreams: 1 Menassi_AndreiaPerin_M.pdf: 1256716 bytes, checksum: 2be40efeb95b9fd3ca1018e6ca8f6a22 (MD5) Previous issue date: 2013 / Resumo: O aleitamento materno é a estratégia isolada que mais previne mortes infantis, além de promover a saúde física, mental e psíquica da criança e da mulher que amamenta. Desde 1981, o Brasil vem desenvolvendo programas (ex: Programa Nacional de Incentivo ao Aleitamento Materno - PNIAM, Banco de Leite Humano - BLH, Carteiro Amigo, Iniciativa Hospital Amigo da Criança, etc.) e normas como a Norma Brasileira de Comercialização de Alimentos para Lactentes - NBCAL e a Licença Gestante, a fim de garantir estratégias para promoção, apoio e proteção ao aleitamento materno. O Sistema único de Saúde (SUS), por meio das Unidades de Saúde da Família (USF), tem um papel fundamental na promoção do aleitamento materno, por ser uma de suas prioridades de atuação, que é dar assistência às crianças menores de dois anos de vida e a gestantes. Esse estudo propôs-se a identificar o perfil dos Agentes Comunitários de Saúde (ACS) atuantes nas USF da cidade de Piracicaba-SP e verificar seus conhecimentos e práticas em relação ao aleitamento materno. Trata-se de um estudo exploratório de corte transversal, envolvendo todas as USF do município de Piracicaba-SP. Foi utilizado um questionário estruturado, com informações relativas ao perfil sociodemográfico e relativas à atuação dos ACS, por meio de 20 afirmativas relacionadas ao conhecimento e às práticas de promoção e manejo da amamentação. A amostra foi composta por 193 ACS, sendo que 47% tinham mais de 34 anos de idade e atuavam havia menos de três anos na USF do município. A maioria (98%) havia estudado mais do que oito anos, mas somente a metade (49%) relatou possuir treinamento específico em amamentação. E mesmo assim, 94% da amostra, orientavam as mães usuárias das USF sobre a manutenção do aleitamento materno de forma exclusiva até o 6º mês de vida da criança, discorrendo sobre a qualidade do leite, sobre a não necessidade de utilização da chupeta e da mamadeira e sobre o alívio de dor no caso de ingurgitamento mamário e à prevenção de mastite. A maioria dos ACS participantes deste estudo orientava gestantes e puérperas. Dos profissionais com treinamento, 67% tinham conhecimentos insatisfatórios sobre o manejo do aleitamento, embora apresentassem bastante envolvimento em ações de saúde que constituem oportunidades de promoção do aleitamento materno. Houve diferença significativa entre os grupos que receberam e não receberam treinamento em relação ao oferecimento da orientação à gestante e à puérpera, mostrando que há uma maior freqüência de oferecimento de orientação por ACS que recebem treinamento específico sobre lactação / Abstract: Breastfeeding is the single strategy to prevent child deaths, in addition to promoting physical, mental and emotional health of children and breastfeeding women. Since 1981, Brazil has been developing programs (eg the National Breastfeeding Incentive - PNIAM, Human Milk Bank - HMB Friendly Postman, Baby Friendly Hospital Initiative, etc..) And standards such as the Brazilian Standard for Food Marketing for Infants - BNCIF and Pregnant License, to ensure strategies to promote, support and protect breastfeeding. The Unified Health System (SUS), through the Family Health Units (FHU) has a key role in the promotion of breastfeeding, to be one of its priorities for action, which is to care for children under two years Life and pregnant women. This study aimed to identify the profile of Community Health Agents (CHA) operating in the USF in Piracicaba-SP and verify their knowledge and practices in relation to breastfeeding. This is an exploratory cross-sectional, involving all USF from Piracicaba-SP. We used a structured questionnaire with information on the demographic profile and relative to the performance of the ACS through 20 statements related to knowledge and practice in the promotion and management of breastfeeding. The sample consisted of 193 ACS, of whom 47% were over 34 years old and had worked less than three years at USF. The majority (98%) had studied more than eight years, but only half (49%) reported having specific training in breastfeeding. And yet, 94% of the sample, oriented the mothers users of USF on the maintenance of breastfeeding exclusively until the 6th month of the child's life, discussing the quality of milk, about not needing the use of pacifiers and bottle and on the relief of pain in the case of breast engorgement and mastitis prevention. Most ACS study participants guided pregnant and postpartum women. Professionals with training, 67% had poor knowledge about the management of breastfeeding, although showing quite involvement in health activities that provide opportunities for the promotion of breastfeeding. There was significant difference between the groups receiving and not receiving training in relation to offering guidance to pregnant and postpartum women, showing that there is a higher frequency of offering guidance ACS who receive specific training on lactation / Mestrado / Odontologia em Saude Coletiva / Mestra em Odontologia em Saúde Coletiva

Yes / Inequities in access to diabetic retinopathy (DR) services particularly in rural and remote Fiji is concerning. This is because DR when left undiagnosed and untreated for long, can lead to vision loss and permanent blindness. Appropriate channels must be explored to strengthen services and ensure equitable access to healthcare for everyone. This study describes the development and implementation of DR awareness training for community health workers (CHWs) and their subsequent engagement to raise awareness and scale-up DR screening for communities throughout Fiji. As part of a programme to reduce the incidence of avoidable blindness due to diabetes amongst people living in the Pacific, DR training for primary level nurses was developed and implemented. As these primary level nurses were already inundated by clinical duties and competing health priorities, a shifting of the task was proposed to engage the CHWs who would instead educate communities on diabetes and DR and make referrals for DR screening. A one-day DR awareness training was developed and implemented by the Pacific Eye Institute with funding from the Fred Hollows Foundation New Zealand. At the end of the DR programme in 2019, the team had achieved their target and trained a total of 823 CHWs giving an 81.32% coverage of the total 1012 registered CHW in the MHMS register. Anecdotal evidence showed a spike in DR referrals and screenings recorded at health facilities. Three key themes emerged related to the involvement of CHWs which include engagement of CHWs, benefits of the engagement, and health system-related challenges. The use of CHWs who are already integrated into the health system was considered a sustainable intervention to strengthen diabetes and DR services at the primary level of care, particularly if it involves community awareness, health education, and health services facilitation The future of the CHWs will depend on their being integrated more systematically into local health services with strengthened management and supervision. / We acknowledge Fred Hollows Foundation New Zealand for granting this project.

Food systems include food production, processing, distribution, marketing, access, preparation, consumption, and disposal and influences of social, economic, and environmental conditions. Virginia Cooperative Extension (VCE) has professionals, paraprofessionals, and volunteers with expertise in food systems dimensions integrated into Virginia communities. Current VCE programming has unequal reach for Black, Indigenous, and people of color (BIPOC) communities. Community health workers (CHWs) are lay outreach workers who are from the communities they serve and can be effective health educators within BIPOC communities who experience health disparities. The CHW model is underexplored in food systems, despite the importance of food systems for health. A scoping review of United States CHW educational food systems interventions found CHW reach to BIPOC communities primarily through education on food preparation and consumption. Garden-based programming educated on the highest number of food system processes, highlighting a potential role of CHWs within food systems. These results guided development of a feasibility evaluation for the CHW model for garden-based food systems programming for VCE, emphasizing reach to BIPOC communities. Semi-structured interviews were conducted with 29 VCE stakeholders representing several disciplines. The CHW model is feasible for VCE within the current focus on food systems, diversity, and inclusion. Participatory approaches for programming should be used to incorporate the cultural knowledge of the CHW and to create a welcoming environment for BIPOC communities. The CHW model can connect disciplines to provide accessible and culturally relevant programming to BIPOC communities, thus extending the reach of VCE and potentially creating more inclusive community food systems. / Master of Science / Food systems encompass all processes from food production to disposal and are influenced by social, economic, and environmental conditions in which food travels from farm to fork. Virginia Cooperative Extension (VCE) provides outreach to Virginia communities by disseminating research-based information through professionals and volunteers in educational programming for topics that include agriculture, gardening, nutrition, and more. Community health workers (CHWs) are public health educators who serve Black, Indigenous, and people of color (BIPOC) to mitigate health disparities that are exacerbated by unequal distribution of resources within food systems. CHWs are from the communities they serve and thus are uniquely positioned as culturally sensitive educators. This thesis aimed to explore the role of CHWs in food systems education and to evaluate the feasibility of the CHW model for garden-based food systems programming for VCE. A scoping review of U.S.-based food systems interventions found that CHWs have reached BIPOC communities for food systems education that focuses on preparation and consumption of food, but the CHW model has not been widely documented in broad-lens food systems educational programming. Garden-based programs educated on the greatest number of food systems processes. Interviews with 29 VCE stakeholders showed that the CHW model is feasible within the structure and values of VCE. The CHW model can connect traditionally separate disciplines to provide accessible and culturally relevant programming to BIPOC communities, thus extending the reach of VCE and potentially creating more inclusive community food systems.

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.

<p>This research investigates the nature and extent of community participation and involvement in the recruitment and selection processes for Community Health Workers (CHWs), primarily through detailed case studies of three CHW programmes, one in the Western Cape, another in KwaZulu-Natal, and a third which operates in the Western Cape and KwaZulu-Natal. The first utilizes CHWs in health education and home-based care in Khayelitsha and Nyanga. The second specializes in the training, management and supervision of home-based care CHWs in the rural areas of KwaZulu-Natal. The third utilizes CHWs in addressing maternal and child health issues in targeted peri-urban and rural areas in the three provinces. The mini-thesis is organized into five chapters: the first chapter provides the introduction and background as well as the methodological design of the mini-thesis / the second chapter focuses on providing a detailed literature review of relevant materials that cover the subject matter / the third chapter provides the descriptive background of the history of CHWs, CHW policies and community participation in South Africa, as well as a description of the three case study organizations / the fourth chapter describes and discusses the findings and the last and fifth chapter provides a summary of the findings as well as recommendations and conclusions.</p>