Greetings from Dhaka! If any of you are at the CHW Symposium this week, please do say hi!
Welcome to the latest edition of the Community Health Research Round-up! The Round-up gives you the key takeaways from important new CHW academic papers every two weeks.
This issue covers papers indexed (largely!) since October 22. Please feel free to reply to the list with anything we may have missed.
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* As always, previous editions of the round-up are available in our archive [here](https://chwimpact.org/research-round-up)
All the best,
HIFA profile: Madeleine Ballard holds a PhD in evaluation science (EBSI) from the University of Oxford as a Rhodes Scholar and was previously the founding Program Manager of Last Mile Health, a Liberian organisation that trains community health workers to provide primary care in remote villages. She is now the Strategic Advisor to CHW 15. [*Note from HIFA moderator (Neil PW): The preceding profile is from 2017 and I note that Madeleine is now the Executive Director for Community Health Impact Coalition https://chwimpact.org/ ]
**Community Health Research Round-Up, Issue 020**
**October 22 - Nov 18, 2019**
1. [ **Discretion, power and the reproduction of inequality in health policy implementation: Practices, discursive styles and classifications of Brazil’s community health workers** ](https://www.sciencedirect.com/science/article/pii/S0277953619305453)
* **Comments:** Interesting ethnography from our colleague, João Nunes + team, questioning the overwhelmingly positive view of the impact of CHWs in terms of promoting social justice and empowerment ([Pérez & Martinez, 2008](https://www.sciencedirect.com/science/article/pii/S0277953619305453#bbib46); [Ingram et al 2008](https://www.sciencedirect.com/science/article/pii/S0277953619305453#bbib25)). Suggests that the picture is more complicated & that the concrete workings of power relations need to be scrutinized when assessing the impact of CHW programmes.
* **Methods:** Ethnography
* **Takeaway:** Implementers are not powerless or apolitical. CHWs’ work is marked by discretion in a context of informality and resource scarcity; it reproduces inequality in terms of how users are received by the health system, and their degree of access to the range of services available.CHWs use unofficial classification schemes based on personal worldviews, their expectations about the profession, their perceptions of how well they are valued by users, their moral conceptions of what is right or wrong, and stereotypes about the poor and vulnerable (even though many CHWs experience the same vulnerabilities). The power of Brazilian CHWs is visible not only in decisions about which practices they will carry out, how and towards whom, but also in constituting individuals as ‘deserving’ or ‘underserving’
2. [ **Expanding the use of community health workers in urban settings: a potential strategy for progress towards universal health coverage** ](https://academic.oup.com/heapol/advance-article/doi/10.1093/heapol/czz13...)
* **Comments:** This is possibly the first review w/geography-stratified findings? (Please reply-all if you know of another one looking at the rural/urban question!)
* **Methods:** Review (Does not follow, e.g. AMSTAR, reporting guidelines terribly well, so hard to tell if it is narrative or systematic)
* **Takeaway:** Considering the substantial global shortage of health workers, the growing trend of urbanization and the effectiveness of CHW programmes, such programmes should be considered as viable approaches for increasing access to health services including in urban settings.
3. [ **Population-based screening for pulmonary tuberculosis utilizing community health workers in Ethiopia** ](https://www.sciencedirect.com/science/article/pii/S1201971219304059#aep-...)
* **Comments:** CHWs have long been involved in TB care, this paper looks at how they might help w/the understanding of the burden of TB in poor rural areas, given the implications this has for TB control. (N.B. This study involved both paid and unpaid CHWs. For more on psychosocial distress among unpaid community health workers in rural Ethiopia, see [this](https://www.sciencedirect.com/science/article/abs/pii/S0277953619302059) paper from RR 010)
* **Methods:** x-sectional survey
* **Takeaway:** Household level symptom screening for active tuberculosis (TB) identified the hidden burden rapidly. Community health workers improved the yield of active TB case finding in rural areas (incl. better access for women). Household level symptom screening for active tuberculosis (TB) identified the hidden burden rapidly.
4. [ **The National Village Health Guide Scheme in India: lessons four decades later for community health worker programs today and tomorrow** ](https://human-resources-health.biomedcentral.com/articles/10.1186/s12960...)
* **Comments:** A welcome profile on a former major national CHW program (India 1977-2002) from our friend Henry Perry & team
* **Methods:** Case Study
* **Takeaway:** Contributors to the failure of the National Village Health Guide Scheme in India included a lack of support from the formal health sector, an overly hasty implementation of the scheme, and poor communication between the government and health centers about the role of the VHGs. The remuneration structure and the VHG selection process were at the root of the program’s shortcomings at the implementation level.
5. [ **Case study of a method of development of a selection process for community health workers in sub-Saharan Africa** ](https://link.springer.com/article/10.1186/s12960-019-0412-2)
* **Comments:** New paper from our colleagues at Warwick, PIH & the Ghana Health Service looking at CHW selection. Pair with their earlier work on the predicitve validity of the Living Goods approach [here](https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3...) (RR 001)
* **Methods:** Case study
* **Takeaway:** Description of the development of a selection process for CHWs in two settings in sub-Saharan Africa using an intensive process, beginning with the identification of which knowledge, skills, and attributes to include and going through to testing the selection process with CHWs
6. [ **Community health workers trained to conduct verbal autopsies provide better mortality measures than existing surveillance: Results from a cross-sectional study in rural western Uganda** ](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211482)
* **Comments:** Interesting methods paper
* **Methods:** x-sectional survey
* **Takeaway:** CHWs are able to conduct high quality verbal autopsy interviews to capture critical information that can be analyzed using standard methodologies to provide a more complete estimate of the burden and causes of mortality. Similar approaches can be scaled to improve the measurement of vital statistics in order to facilitate appropriate public health interventions in rural areas of sub-Saharan Africa.
7. [ **Application of the community health worker model in adult asthma and COPD in the U.S.: a systematic review** ](https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-019-0878-7)
* **Comments:** You all know by now that I appreciate a good systematic review. Very handy overview of CHW care for adult asthma and COPD
* **Methods:** Systematic review
* **Takeaway:** Additional study needed - there were a limited number of fairly small sized asthma studies, the two largest of which showed mixed results regarding CHW effectiveness. CHW interventions demonstrated improvements in some patient reported outcomes, however had no effect on healthcare utilization. There were also no studies on COPD participants.
8. [ **Community drug distributors for mass drug administration in neglected tropical disease programmes: systematic review and analysis of policy documents** ](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790237/)
* **Comments:** Interesting paper relevant to both practitioners and policymakers (& the gap between them…)
* **Methods:** Review of WHO global and WHO-AFRO regional documents and select national NTD programme master plans in Africa
* **Takeaway:** Mass drug administration programmes for NTDs depend on community drug distributors to deliver drugs. Global and African WHO policy documents assume the implementation of community drug distributors but provide little guidance for their roles and how to prepare and utilise them within integrated programmes and changing contexts (e.g. there is almost no clear delineation of responsibilities, nor is there up-to-date practical guidance for implementers)
9. [ **Development of a Framework to Describe Functions and Practice of Community Health Workers** ](https://journals.lww.com/jcehp/Abstract/publishahead/Development_of_a_Fr...)
* **Comments:** A necessary piece given the insanity of the US healthcare system, but conceptually interesting for those who care about accreditation and work elsewhere
* **Methods:** Rapid review
* **Takeaway:** A framework is proposed to inform decisions regarding certification, education, and payment for CHW services in the United States. Four categories of CHW practice are developed from the evidence: peer CHW, general CHW, clinical CHW, and health navigator.
10. [ **Analysis of the quality of seasonal malaria chemoprevention provided by community health Workers in Boulsa health district, Burkina Faso** ](https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-4...)
* **Comments:** Rare example of a quality of care assessment on CHWs in a *national* program under *routine* conditions.
* **Methods:** Mixed: non-participant observation & one-on-one interviews
* **Takeaway:** Despite the difficulties faced by community health workers, they manage to deliver acceptable quality of care.
1. [ **mHealth tool to improve community health agent performance for child development: study protocol for a cluster-randomised controlled trial in Peru** ](https://bmjopen.bmj.com/content/9/11/e028361.abstract)
* **Objective:** Experimental cluster randomised controlled trial to evaluate the implementation and impact of a tablet-based application that intends to improve the performance of CHAs, thus improving the child-rearing practices of caregivers and ultimately child health and development indicators.