COMMUNITY HEALTH WORKER IMPACT DURING COVID-19

COMMUNITY HEALTH WORKER IMPACT DURING COVID-19

In South Africa, more than 28,000 community health workers move from house to house in vulnerable communities to screen and test the members for COVID-19 while in Kenya, 63,350 CHWs have received sensitization and awareness on COVID-19 and “they have reached over 5.5million households with COVID-19 prevention messages, conducting contact tracing, and reporting new cases to the authorities for further health action.” We have provided the impact of community health workers during COVID-19 and their impact on essential services including under 5s, mother and child health, HIV, TB, malaria, vaccine-preventable diseases.

Impacts of Community Health Workers (CHWs) With regard to COVID-19

CHWs Are Instrumental in Contact Tracing and Behavior Change

  • In Kenya, community health workers have played a critical role in the country’s fight against the COVID-19 crisis. According to the African Medical and Research Foundation (AMREF), “the emergence of COVID-19 globally has refocused attention to CHWs as the most easily accessible and available workforce to step in to turn off the tap of community transmission.”
  • Since community transmission has been seen to exacerbate the social and economic effects of COVID-19, CHWs are instrumental in household to household contact tracing and referring the contacts for testing with the help of local administrations and the national surveillance teams.
  • In South Africa, more than 28,000 community health workers move from house to house in vulnerable communities to screen and test the members for COVID-19 while in Kenya, 63,350 CHWs have received sensitization and awareness on COVID-19 and “they have reached over 5.5million households with COVID-19 prevention messages, conducting contact tracing, and reporting new cases to the authorities for further health action.”
  • The government of Kenya has developed protocols for CHWs during this pandemic that puts them at the center of the fight. The community health workers follow up everyone who has come into contact with the patient’s body fluids, have had direct physical contact with the patient, has touched the patient’s clothes, has been breastfed by the patient, has slept or eaten in the same household as the patient, or healthcare workers who suffered needle-stick injuries while attending to probable or confirmed COVID-19 patients.
  • In Liberia, the country is leveraging its extensive track record of disease surveillance and expanding routine healthcare delivery to strengthen COVID-19 preparedness.

CHWs as Agents Counter Stigma and Depression and Offer Mental Support

  • Throughout the world, community health workers have been helping patients, and their close contacts navigate the stigma, depression, and mental instability that comes with the health and economic effects of the pandemic.
  • In the United States, community health workers have been helping their patients stay sane and navigate the unprecedented landscape occasioned by the virus. They do this by offering a listening ear, helping them overcome trauma, and even assisting those in low-income areas get access to food.

Community Awareness, Engagement, and Sensitization to Prevent, Detect, and Respond to the Virus

  • Another impact that CHWs have had in the fight against COVID-19 is bringing awareness and COVID-19 prevention resources to the grassroots in an effort to curb community transmission.
  • In Liberia, community health workers are helping prevent the spread of the virus by:
    • conducting infection prevention and control measures
    • explaining and promoting social distancing
    • organizing hand hygiene stations
    • educating their neighbors about interrupting disease transmission
    • distributing buckets and soap for handwashing
  • The government of Liberia is also engaging community health workers in the detection of the virus in the community by:
    • engaging CHWs, under the supervision of nurses, to identify the signs and symptoms of COVID-19 among community members
    • coordinating testing, including collecting sample swabs for suspected or probable cases.

Other Impacts

  • According to a white paper titled “Global and Local Community Health Workers as a lifeline for communities facing inequities in the midst of COVID-19 and beyond,” some other impacts that community health workers have had in combating COVID-19 include:
  • According to a study by BMJ Health Global, community health workers can help fight the pandemic by achieving the following goals: “protect healthcare workers, interrupt the virus, maintain existing healthcare services while surging their capacity, and shield the most vulnerable from socioeconomic shocks.”

Impacts of Community Health Workers (CHWs) With regard to Children Under the Age of Five

Remarkable Reduction in Under-5 Mortality Rates in Developing Countries

  • Several case studies exist for countries with national CHWs programs that have significantly contributed to the remarkable reduction in under-5 mortality and impressive improvements in the nutritional status of children in the countries. These countries include Ethiopia, Malawi, and Brazil.

1. Ethiopia

  • By incorporating community health workers into the health care systems, Ethiopia has achieved an impressive reduction in the mortality rates of children under the age of five. As per the 2015 UN Inter–Agency Group for Child Mortality Estimation (IGME) report, Ethiopia hit its target for Millennium Development Goal 4 for child survival, recording an estimated under–five mortality rate of 59 per 1000 live births in 2015, a sharp decline from 205 in 1990.
  • This means that Ethiopia achieved an average mortality rate reduction by 5% every year, 2.1% higher than the sub-Saharan average of 2.9%.
  • The major contributing factor to the reduction of under-5 mortality rates in the country was “a decrease in stunting prevalence amongst children under-5 from 67% in 1992 to 40% in 2014.” These achievements are primarily attributable to Ethiopia’s Health Extension Programme, which was launched in 2003 to provide universal healthcare through 34,000 government-trained and salaried health extension workers (HEWs).
  • A community-based nutrition program run by the health extension workers led to “substantial changes in infant and young child feeding (increased exclusive breastfeeding) and reductions in underweight of 2ppts/ year.”

2. Malawi

  • Malawi was among the first sub-Saharan African countries to achieve MDG goal number 4 by reducing live births from 245 to 68 deaths per 1000 live births between 1990 and 2013.
  • Malawi’s community health workers (known as health surveillance assistants, HSAs) have been key in the delivery of health services in Malawi since the 1960s. In 2011, Malawi had more than 10,000, “3,800 of which had received training to diagnose and treat children with malaria, pneumonia, and diarrhea.
  • The HSAs have been instrumental in the significant decline of child mortality in Malawi.

3. Brazil

  • Brazil is another country with a significant network of CHWs (locally known as Community Health Agents). The roles of these community health agents in their community include “conducting home visits, promotion of healthy practices, linking families to health services, expanded vaccination coverage, promotion of breastfeeding, increased use of oral rehydration salts, management of pneumonia and growth monitoring.”
  • Brazil’s CHWs have played a critical role in achieving the country’s remarkable reductions in under-5 mortality and stunting. The prevalence of stunting in children under the age of 5 in Brazil reduced from 37% in 1974/75 to 7% in 2006/07.

CHWs Offer Better Quality Health Services

  • According to studies that have been conducted in Kenya, analysts have concluded that community health workers are perceived by caregivers to offer better services than facility-based health workers.
  • As per the research, “caregivers of children under the age of five perceived CHWs to provide higher quality of care in terms of accessibility and patient relationships, compared to facility-based health workers and equal quality of care on clinical aspects.”

Other Impacts of CHWs on Children Under the Age of Five

  • In other different developing nations, CHWs’ impact s felt in the following ways:
  • In Pakistan, “the lady health workers’ home visit package includes counseling mothers on responsive stimulation. A randomized cluster trial of this intervention reported significantly higher net development scores on cognitive, language, and motor scales at 12 and 24 months of age, and on a social–emotional scale at 12 months of age.”
  • In Cape Town, South Africa, The Philani Maternal Child Health and Nutrition Project “also reported positive effects of a mentor mother home visit programme, including training on responsive stimulation, on underweight and on severe underweight amongst children 0-6 years old.”
  • In Bangladesh, research “found that CHWs can effectively screen (using mid-upper arm circumference) and treat uncomplicated cases of severe acute malnutrition (SAM) with ready to use therapeutic food (RUTF), showing a high degree of compliance with case management guidelines.”
  • In Ethiopia, “a study conducted amongst health extension workers (HEWs) included observation of consultations with sick children and gold standard re-examinations. The study found that HEWs were able to correctly manage 72%, 79% and 59% of children with pneumonia, diarrhea, and malnutrition, respectively.”
  • In Kenya, “CHWs conduct home visits to check on families; educate households on essential behaviors, like optimal breastfeeding practices and nutritional guidelines; diagnose and treat childhood illnesses, including malnutrition; and more.” CHWs have led to the reduction of under-five mortality rates by 27%.

Impacts of Community Health Workers (CHWs) With regard to Maternal and Child Health

Declined Maternal and Neonatal Morbidity and Mortality

  • Studies have revealed than community health workers have contributed to declined rates of maternal and neonatal (deaths during the first 28 days of life) mortality rates in developing nations.
  • According to recent systematic reviews, “community-based interventions and strategies can improve maternal and newborn outcomes, including morbidity and mortality of women, mortality and morbidity of neonates, and care-related outcomes in low and middle-income countries.”
  • Recent studies have found out that community health workers in developing countries have had positive impacts on:
  • Scaling up community-based healthcare programs, including involving community health workers, has been identified as the key success factor in the reduction of maternal and child mortality in Ethiopia, Nepal, and Rwanda.
  • According to a meta-analysis of nine trials in Africa and Asia, neonatal mortality declined by 21% due to antenatal and postnatal home visit interventions by CHWs.
  • In some countries, there is another rapidly developing community-based concept called “women groups” that is facilitated by a female community health worker. A systemic review and meta-analysis of seven trials of pregnant women participating in such groups found out that “when at least 30% of pregnant women participated in the groups, run by local female facilitators, there was a 49% reduction in maternal mortality and a 33% reduction in neonatal mortality.”
  • A “systematic review and meta-analysis of RCTs of CHW-led women’s groups practicing participatory learning and action in Bangladesh, India, Malawi and Nepal has demonstrated a 37% reduction in maternal mortality.”

CHWs Impact on HIV in Developing Countries

CHWs Help Expand Access to and Increase Coverage of ART programs in Resource-Limited Settings

  • According to scientific studies conducted in different communities in developing countries, community health workers perform the following functions in the communities they serve in:
    • referring community members for HIV testing.
    • linking community members to care.
    • accompanying them to clinic appointments.
    • providing psychosocial support.
    • making referrals to other services.
  • Many other studies have proven that community health workers play a critical role in expanding access to and increasing coverage of ART programs.
  • According to a study that was conducted in sub-Saharan Africa on the role of CHWs in HIV care, it was established that the CHWs play critical roles among them “patient support (counseling, home-based care, education, adherence support and livelihood support) and health service support ​(screening, referral and health service organization and surveillance)
  • According to the study, “CHWs were reported to enhance the reach, uptake and quality of HIV services, as well as the dignity, quality of life and retention in care of people living with HIV. The presence of CHWs in clinics was reported to reduce waiting times, streamline patient flow and reduce the workload of health workers. Clinical outcomes appeared not to be compromised, with no differences in virologic failure and mortality comparing patients under community-based and those under facility-based care.”

CHWs Contribute to Increased ART Adherence Levels

  • Several studies have indicated the following outcomes when CHWs are incorporated into grassroots healthcare systems:
    • In Uganda, researchers found good adherence to highly active antiretroviral therapy (HAART), which can be attributed to a strong community health workers system called TASO.
    • In Sub-Saharan Africa, HIV/AIDS patients supported by community health workers “experienced a more rapid and greater overall increase in CD4 cell counts than unexposed patients, higher levels of adherence, and showed greater improvements in selected health-related QOL indicators.”

Community Health Programs help improve Virological and Immunological Outcomes and Lower Death Rates

  • Studies have concluded that patients with support from community health workers “achieved higher rates of virological suppression and immune restoration than patients lacking this support.”
  • In Uganda, “PHW (peer health workers) intervention was associated with decreased virologic failure rates occurring 96 weeks and longer into ART.”
  • In Malawi, “community support is associated with a considerably lower death rate and better overall ART outcomes.”

CHWs Impact on Tuberculosis in Developing Countries

CHWs Improved TB Treatment Adherence in Kenya

  • A study was conducted in rural and urban Kenya to measure the effectiveness of using community health workers for the treatment of TB among the populations.
  • The study concluded that CHWs were instrumental in enhancing TB treatment adherence and the best effects were in urban areas. According to the study, “adherence among patients who had utilized CHWs was 83% compared to 68% among those that did not utilize CHWs.”
  • Other findings of the research were:
    • “New TB patients utilizing CHWs were significantly likely to be adherent (p = 0.032) than those not utilizing CHWs.”
    • “There was a higher proportion (94% p = 0.472) of the patients utilizing CHWs who accepted HIV screening compared to those not utilizing CHWs (79% p = 0.179).”
    • “Among the patients who were adherent to TB treatment and utilizing CHWs, 75% (p<0.001) were residing in the urban set-up compared to the 25% from the rural set up.”

CHWs Improved Contact Tracing Among Immigrants with TB in Barcelona

  • Another study conducted among immigrants with TB in Barcelona found out that community health workers proved effective in contact tracing among immigrants in Barcelona.
  • According to the study, “the effectiveness of contact tracing for TB control in areas with high immigration can be improved by incorporating CHWs who act as translators, cultural mediators and facilitators who accompany cases and contacts through treatment and follow-up.”

CHWs in Ethiopia Detect TB Cases and Refer Them

  • Ethiopia has made massive and impressive strides in managing TB, and part of its success is attributable to the country’s health extension officers.
  • According to statistics, 77% of tuberculosis cases in Ethiopia were first referred by health extension officers. WHO’s Esther Aceng explains that “the workers are positioned in the lowest administrative unit—they would not see more than five to six cases of tuberculosis, so patients are easy to follow. That is why you see these tremendous results.”

CHWs Contribute to Improved TB Diagnosis in Malawi

  • According to Dr. Katie Simon of the Baylor College of Medicine Children’s Foundation Malawi, incorporating community health workers led to a twenty-fold increase in the Intensified tuberculosis case finding (TB ICF) at a busy ART clinic in rural Malawi.
  • The CHWs intervention also “led to the detection of more pediatric TB, which previously was not being diagnosed at the facility.”

CHWs Impact on Malaria in Developing Countries

CHWs Deliver Malaria Interventions

  • One of the barriers to controlling malaria globally is delivering interventions to the most vulnerable communities. This barrier is being navigated by utilizing community health workers to deliver the interventions to the people and demographics that need them the most.
  • CHWs are an attractive option since they require minimal training, are readily available, and are cost-effective. According to this study, which summarizes 28 other studies on the same issue, “the community-delivered model is effective in improving the coverage of malaria interventions and reducing malaria-associated mortality.”
  • Some of the malaria interventions delivered by CHWs include “conducting rapid diagnostic tests, malaria treatment, community sensitization for IRS, and distribution of insecticide-treated nets.”
  • CHWs play a critical role in distributing bed nets and promoting their appropriate use.

CHWs Are Instrumental in Reducing Malaria Morbidity and Mortality

  • According to the World Bank, the incidence and mortality rates of malaria have declined by 37% and 70%, respectively, between 2000 and 2015. Community health workers have played a key role in this decline.
  • In Ethiopia, local mother coordinators who are community health workers contributed to a 40% reduction in mortality rate among under-5 children by teaching mothers to provide home treatment of malaria.
  • “With the emergence of rapid diagnostic tests for malaria, studies have shown that CHWs achieved clinical cures in 98% of childhood cases and adherence to medication treatment in 83% of patients.”
  • According to the World Health Organization, “CHWs can provide prompt and adequate treatment to fever cases within 24 h to help reduce morbidity and mortality associated with malaria among under-five children in Africa.”

CHWs Impact on Vaccine-Preventable illnesses

Improved Immunization Uptake

Better Surveillance of Vaccine-Preventable Illnesses in the Community

  • A study conducted in the Obala health district of Cameroon found out that CHWs played a pivotal role in controlling vaccine-preventable diseases by using community-based surveillance.
  • The CHWs were looking out for “simple case definitions of priority diseases and unexpected events or unusual conditions” and made home visits to detect vaccine-preventable diseases early.

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