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      Realities and experiences of community health volunteers as agents for behaviour change: evidence from an informal urban settlement in Kisumu, Kenya

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          Abstract

          Background

          Community health workers play an important role in health service delivery and are increasingly involved in behaviour change interventions, including for hygiene-related behaviour change. However, their role and capacity to deliver behaviour change interventions, particularly in high-density urban settlements, remain under-researched. This study examines the behaviour change-related activities of community health volunteers (CHVs)—community health workers affiliated with the Kenyan Ministry of Health—in a peri-urban settlement in Kenya, in order to assess their capabilities, opportunities to work effectively, and sources of motivation.

          Methods

          This mixed-methods study included a census of 16 CHVs who work in the study area. All CHVs participated in structured observations of their daily duties, structured questionnaires, in-depth interviews, and two focus group discussions. Structured data were analysed descriptively. Thematic content analysis was followed for qualitative data. Results were synthesized and interpreted using the capability, opportunity, motivation for behaviour change framework, COM-B.

          Results

          In addition to their responsibilities with the Ministry of Health, CHVs partnered with a range of non-governmental organizations engaged in health and development programming, often receiving small stipends from these organizations. CHVs reported employing a limited number of behaviour change techniques when interacting with community members at the household level. Capability: While supervision and support from the MOH was robust, CHV training was inconsistent and inadequate with regard to behaviour change and CHVs often lacked material resources necessary for their work. Opportunity: CHVs spent very little time with the households in their allocated catchment area. The number of households contacted per day was insufficient to reach all assigned households within a given month as required and the brief time spent with households limited the quality of engagement. Motivation: Lack of compensation was noted as a demotivating factor for CHVs. This was compounded by the challenging social environment and CHVs’ low motivation to encourage behaviour change in local communities.

          Conclusions

          In a complex urban environment, CHVs faced challenges that limited their capacity to be involved in behaviour change interventions. More resources, better coordination, and additional training in modern behaviour change approaches are needed to ensure their optimal performance in implementing health programmes.

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          Most cited references19

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          Achieving child survival goals: potential contribution of community health workers.

          There is renewed interest in the potential contribution of community health workers to child survival. Community health workers can undertake various tasks, including case management of childhood illnesses (eg, pneumonia, malaria, and neonatal sepsis) and delivery of preventive interventions such as immunisation, promotion of healthy behaviour, and mobilisation of communities. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers are not a panacea for weak health systems and will need focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. The introduction of large-scale programmes for community health workers requires evaluation to document the impact on child survival and cost effectiveness and to elucidate factors associated with success and sustainability.
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            Rigour and qualitative research.

            N Mays, C Pope (1995)
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              Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review

              Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review. A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.
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                Author and article information

                Contributors
                evalyneaseyo6@gmail.com
                jnmumma@gmail.com
                kerry.e.scott@gmail.com
                damarisnelima@yahoo.com
                EDavis@fhi360.org
                kelly-k-baker@uiowa.edu
                Oliver.Cumming@lshtm.ac.uk
                Robert.Dreibelbis@lshtm.ac.uk
                Journal
                Hum Resour Health
                Hum Resour Health
                Human Resources for Health
                BioMed Central (London )
                1478-4491
                4 October 2018
                4 October 2018
                2018
                : 16
                Affiliations
                [1 ]GRID grid.448911.1, Great Lakes University of Kisumu, ; P O Box 2224, Kisumu, 40100 Kenya
                [2 ]ISNI 0000 0001 2171 9311, GRID grid.21107.35, Department of International Health, , Johns Hopkins Bloomberg School of Public Health, ; 615 N Wolfe St, Baltimore, MD 21205 United States of America
                [3 ]Bangalore, India
                [4 ]ISNI 0000 0004 1936 8294, GRID grid.214572.7, Occupational and Environmental Health, , University of Iowa College of Public Health, ; 145 N Riverside Dr, Iowa City, IA 52246 United States of America
                [5 ]ISNI 0000 0004 0425 469X, GRID grid.8991.9, Department of Disease Control, , London School of Hygiene and Tropical Medicine, ; Keppel Street, London, WC1E 7HT United Kingdom
                Article
                318
                10.1186/s12960-018-0318-4
                6172748
                30286763
                9f2d9262-a86c-4616-aa54-ab7dc40fb8c9
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000278, Department for International Development;
                Categories
                Research
                Custom metadata
                © The Author(s) 2018

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