Module 7: Community Health Workers Outcomes
Critical Outcome Measurements
Evaluation is necessary to determine whether CHW programs are statistically contributing to improved health. Research is needed to determine whether the use of CHWs is a cost-effective way to accomplish a certain goal so that financial resources are not wasted, but are instead strategically invested. When examining CHW programs in the United States, research findings on efficacy vary. The Viswanathan et al. (2010) systematic review of the literature concerning outcomes and costs of CHW programs in the U.S. determined that the programs have only improved the health outcomes of underserved populations in some contexts and for some health conditions. For example, while change was found in participant behavior and health outcomes in some CHW interventions, no change was found in about half of the papers. The review found that CHW programs were oftentimes not statistically more effective than alternatives, including no intervention, community intervention, media, print, or a combination of interventions. However, the authors concluded that “For other outcomes, the absence of statistically significant differences…may favor the use of CHWs from a cost or resource perspective when the comparator is a high-resource alternative, such as health care professionals.” Not only must outcomes be measured, but cost-effectiveness must be examined as well. Research on both of these metrics is necessary to guide future policy and program design.(1)
Brownstein (2008) contends that “A lack of comprehensive evidence-based research demonstrating that community health workers (CHWs) can improve health outcomes may contribute to the lack of momentum for policies and systems changes needed to support the role of CHWs in public health programs. As the authors note, challenges still exist in evaluating the effectiveness of CHWs, and additional research is warranted. However, recent scientific literature supports that CHWs positively affect health outcomes and access to and use of medical and other services by community members—especially among those from vulnerable and diverse populations.”(2) Not only is reliable data important to guide program design, but also for the continuation of CHW programs. Brownstein (2008) notes that information on return-on-investments (i.e., outcomes from CHW programs) is necessary to build political will, garner continued financial support, and ensure the long-term sustainability of effective CHW programs.(3)
While Brownstein’s findings differ from those of Viswanathan et al. (2010), both Brownstein (2008) and Viswanathan et al. (2010) acknowledge methodological limitations in existing studies, implying that past research may not be entirely credible and that further research with reliable data must be conducted.(4) Rosenthal et al. (2008) explain that “Research articles describing community health worker (CHW) programs often focus on program activities and short-term outcomes, failing to assess CHWs’ long-term contributions to improving individual and community health.” In response to this problem, the authors developed a research agenda for future key areas of research: “CHW impact on health status, CHW cost effectiveness, building CHW capacity and sustaining CHWs on the job, funding options, CHWs as capacity builders, and CHWs promoting real access to care.” With these outcome measurements, the CHW field can be drastically improved and further developed.(5)
It is especially important to measure outcomes since some programs may have no statistically significant impact on a community’s health. For example, Norris et al. (2006) examined the effectiveness of CHW care for diabetic patients and found that, although patient knowledge increased and their satisfaction with the program was high, changes in physiological measurements and health behaviors of the patients were mixed. The authors noted that “There are some data to support their [CHWs’] effectiveness in improving participant knowledge levels and satisfaction, but data on health, quality-of-life and economic outcomes are sparse. Much additional research, however, is needed to understand the incremental benefit of CHWs in multicomponent interventions, and to identify appropriate settings and optimal roles for CHWs in the care of persons with diabetes.” Thus, further research is needed to determine which models of CHW programs work best for specific populations and to determine the most replicable and successful strategies for recruitment, training, and supervision of CHWs. Moreover, the authors acknowledge that while CHW programs may contribute to diabetes health literacy, the knowledge must translate to improved physiological measures, health behaviors, and quality of life.(6) This point illustrates the distinction between outputs and outcomes.
Outputs are different from outcomes. For example, an output is the number of people enrolled in a job training program, while the outcome is the number enrolled in the job training program who now have a job due to the job training program. Outcome refers to the actual impact and end goal of an intervention. As an example of an output, an intervention in Bangladesh found that CHWs were able to classify very severe diseases of neonates with 73% sensitivity, 98% specificity, a positive predictive value of 57%, a negative predictive value of 99%, and upon identification, CHWs referred patients to higher level care.(7) While this evaluation provides a useful first step, it does not determine the outcome. Was there a change in neonatal mortality due to the CHWs’ identification of severe illness, referral, and facilitation of transportation? Outcomes are essential to measure. In Zaire, two years after the implementation of a CHW program for malaria, 65% of malaria cases were being treated by CHWs and the morbidity of malaria had decreased by 50%.(8) This is an example of an outcome. For more information on the distinction between outputs and outcomes, see Outcomes are Essential in Global Health.
Case Studies: HIV Care
The Celletti et al. (2010) study, which compiled data from Brazil, Ethiopia, Malawi, Namibia, and Uganda, found that 39% of HIV-positive patients’ first contacts with the healthcare system were with CHWs, and only 24% of patients’ first contacts were with doctors. In Ethiopia, the number of people being tested and counseled rose from 500,000 in 2006 to 1,600,000 in 2007 due to the training of CHWs on the provision of these services. In Namibia, after only having 2,000 total patients on antiretroviral therapy (ART) since 2002, the number of patients starting ART increased to 160 per month after the CHW program was implemented (i.e. close to 2,000 new patients in a single year). Moreover, out of 200 people surveyed regarding the CHW program, 90% reported being satisfied or extremely satisfied with their assigned CHW. This study concluded that “the inclusion of CHW in health teams allows frequent service-user interaction at the community level, which improves adherence, patient follow-up and psychosocial support. They therefore contribute to better outcomes than can be achieved through services delivered only by doctors and nurses.”(9)
In Haiti, Partners in Health - also known as Zanmi Lasante in Haitian Creole - has implemented an HIV-PHC (primary health care) integrated model of care. CHWs supervise ART patients, conduct outreach to communities with a focus on marginalized populations, and actively seek out patients suspected of having HIV/AIDS and tuberculosis (TB) to bring to clinics. Mukherjee and Eustache (2007) explain that “While initially trained to identify and treat patients with HIV and TB, CHWs have become an important part of the provision of PHC. They support a range of health promotion, disease prevention and treatment services, including infant vaccination and prenatal care, treatment of diarrhoeal disease and acute respiratory infection and the diagnosis and treatment of tuberculosis.” The aim of this integrated model was to increase the uptake of primary health care services through HIV and TB outreach by CHWs. The program was able to significantly increase voluntary counseling and testing (VCT), and over half of the patients diagnosed with HIV after the implementation of the program were referred by a CHW or knew of one. The referral by CHWs is important not only to identify those positive patients in need of prophylaxis for opportunistic infections, but it also provides an opportunity for prevention in seronegative patients. Moreover, the clinics saw more children with malnutrition because of the CHW program. At one clinic, the utilization of PHC services increased from 20 to 380 ambulatory visits per day at the clinic. Even though the CHWs were only trained in regards to HIV/AIDS, they were able to increase the uptake of primary health care services through their outreach, their role as liaisons between communities and health centers, and their emotional, physical, and logistical support they provided their patients.(10) The program improved outcomes for the use of HIV/AIDS services, as well as the primary health care services. This study demonstrates the importance of not only evaluating the intended outcomes of a project, but adjunct consequences such as use of other services.
Case Studies: Neonatal Care
According to Baqui et al. (2010), an estimated 9.7 million children under the age of five die each year, and 38% of those deaths occur during the neonatal period. Infections contribute to a large portion of these deaths. In a cluster-randomized controlled trial, Baqui et al. (2010) evaluated home-care and community-care for maternal and neonatal health interventions in rural Bangladesh. In the home-care intervention, CHWs assessed neonates for infection and referred sick neonates to higher levels of care. For the 34% of caretakers who did not comply with the referral, but consented to home treatment, CHWs administered injectable antibiotics. As a result of this intervention, neonatal mortality decreased from the initial state of 46.9 deaths per 1,000 live births to 29.2 per 1,000 live births in the last six months of the 30-month program. Moreover, the case fatality rates for very severe diseases were 4.4% for neonates treated by CHWs, 14.2% for those treated by medically qualified practitioners, 32.0% for those treated by other providers (including unqualified providers), and 27.6% for those who received no care. Those treated by unqualified providers had the highest fatality rates. The intervention not only introduced more accessible and effective care, but also decreased the number of patients undergoing potentially harmful care by unqualified providers; the proportion of neonates treated by unqualified providers or having no treatment decreased from 28% to 16% during the last six months of the intervention. This measure of output indicates that CHWs may divert patients from harmful practices, thereby contributing to better health outcomes for neonates.(11)
The design of this intervention is noted to be similar to that of the Gadchiroli study of NGO SEARCH in India. In this study, CHWs treated 91% of suspected sepsis cases of neonates with injectable antibiotics. The case fatality rate resulting from this intervention was low at 6.9%, with rates of the Baqui et al. (2010) study even lower at 3.1%; however, the identification protocols for sepsis differed slightly.(12) The SEARCH CHW model for neonatal care has been highly effective. In this model, one literate woman in every village is trained to become a “barefoot neonatologist”, equipped to provide home-based newborn care. This model is not costly since it does not use high-tech equipment, facilities, or healthcare professionals. Between 1995 and 1998, this model of home-based neonatal care resulted in a 62% decrease in newborn mortality in 39 villages in Gadchiroli. In 2003, the infant mortality rate had decreased to 30 deaths out of 1,000 live births from 121 deaths per 1000 in 1995. Due to the numerous studies on this model that have demonstrated significant positive outcomes, the model has been endorsed by the World Health Organization (WHO) and UNICEF.(13) Evaluation and dissemination of outcomes not only benefits the program itself in terms of continued financial support, but also benefits other health programs worldwide by demonstrating effective models.
(1) Viswanathan, Meera, Jennifer Kraschnewski, Brett Nishikawa, Laura Morgan, Amanda Honeycutt, Patricia Thieda, Kathleen Lohr, Daniel Jonas. “Outcomes and Costs of Community Health Worker Interventions: A Systematic Review.” Medical Care 48(2010): 792-808.
(2) Brownstein, J. Nell. “Charting the Course for Community Health Worker Research.” Progress in Community Health Partnerships: Research, Education, and Action 2(2008): 177-178.
(4) Viswanathan, Meera, Jennifer Kraschnewski, Brett Nishikawa, Laura Morgan, Amanda Honeycutt, Patricia Thieda, Kathleen Lohr, Daniel Jonas. “Outcomes and Costs of Community Health Worker Interventions: A Systematic Review.” Medical Care 48(2010): 792-808.
(5) Rosenthal, E. Lee, Hendrik de Heer, Carl H. Rush, and Lisa-Renee Holderby. “Focus on the Future: A Community Health Worker Research Agenda by and for the Field.” Progress in Community Health Partnerships: Research, Education, and Action 2(2008): 225-235.
(6) Norris, S.L., F.M. Chowdhury, K. Van Le, T. Horsley, J.N. Brownstein, X. Zhang, L. Jack Jr., D.W. Satterfield. “Effectiveness of community health workers in the care of persons with diabetes.” Diabetic Medicine 23(2006): 544-556. Accessed on 16 February 2011.
(7) Darmstadt, Gary L., Abdullah H Baqui, Yoonjoung Choi Sanwarul Bari, Syed M Rahman, Ishtiaq Mannan, ASM Nawshad Uddin Ahmed, Samir K Saha, Radwanur Rahman, Stephanie Chang, Peter J Winch, Robert E Black, Mathuram Santosham, Shams El Arifeen. “Validation of community health workers’ assessment of neonatal illness in rural Bangladesh.” Bulletin of the World Health Organization 87(2009). Accessed on 16 February 2011. <http://www.scielosp.org/scielo.php?pid=S004296862009000100009&script=sci_arttext&tlng=en>
(8) Celletti, Francesca, Anna Wright, John Palen, Seble Frehywot, Anne Markus, Alan Greenberg, Rafael Augusto Teixeira de Aguiar, Francisco Campos, Eric Buch, and Badara Samb. “Can the deployment of community health workers for the delivery of HIV services represent an effective and sustainable response to health workforce shortages? Results of multicountry study.” AIDS 24(2010): 45-57.
(10) Mukherjee, J. S. and FR. E. Eustache. “Community health workers as a cornerstone for integrating HIV and primary healthcare.” AIDS Care 19(2007): 73-82.
(11) Baqui, Abdullah H., Shams E. Arifeen, Emma K. Williams, Saifuddin Ahmed, Ishtiaq Mannan, Syed M. Rahman, Nazma Begum, Habibur R. Seraji, Peter J. Winch, Mathuram Santosham, Robert E. Black, , and Gary L. Darmstadt. “Effectiveness of Home-based Management of Newborn Infections by Community Health Workers in Rural Bangladesh.” Pediatric Infectious Disease 28(2009): 304-310.
(13) Bang, Abhay. “Dr. Abhay Bang: Research with the People.” Forbes India Magazine 04 June 2010. Accessed on 17 February 2011. <http://business.in.com/article/ideas-to-change-the-world/dr-abhay-bang-research-with-the-people/13742/1>