Abstracts from the 1st International Symposium on Community Health Workers

s from the 1st International Symposium on Community Health Workers Kampala, Uganda. 21–23 February 2017 Published: 19 September 2017 Introduction David Musoke, Rawlance Ndejjo, Trasias Mukama, Solomon Tsebeni Wafula, Charles Ssemugabo, Linda Gibson School of Public Health, Makerere University, Kampala, Uganda School of Social Sciences, Nottingham Trent University, Nottingham, United Kingdom Email: [email protected] Community health workers (CHWs) are recognised globally as part of human resources for health due to the increasing evidence of their role in delivering preventive and curative services particularly in low and middle income countries. CHWs contribute significantly in attainment of the Sustainable Development Goals (SDGs) especially SDG 3 (good health and well-being) since they are at the forefront of improving health in the community. It is against this background that Makerere University School of Public Health, Uganda in collaboration with Nottingham Trent University, UK and the Ministry of Health, Uganda organised the 1 International Symposium on Community Health Workers held from 21 to 23 February 2017 at Hotel Africana in Kampala, Uganda. The symposium, which had the theme: Contribution of Community Health Workers in attainment of the Sustainable Development Goals, was attended by over 450 participants from 22 countries around the world who included researchers, policy makers, funders, implementers, civil society, students and other stakeholders from national and international organisations. The symposium participants shared evidence and experiences on the value and contribution of CHWs to national health systems as well as the achievement of the 2030 agenda for sustainable development enshrined in the SDGs. Furthermore, the symposium enhanced greater interdisciplinary collaboration and learning globally across sectors and initiatives. The symposium received funding support from the UK Department for International Development (DFID) through Tropical Health and Education Trust (THET). Other symposium partners and co-funders included UNICEF, USAID, Pathfinder International, AMREF Health Africa, World Vision, Malaria Consortium, Harvest Plus, Healthy Child Uganda, Healthcare Information For All (HIFA), CHW Central, Health Systems Global Community Health Workers thematic working group, Advancing Partners and Communities (APC), Makerere University Centre of Excellence for Maternal Newborn Health Research (CMNHR), Living Goods, FHI 360, BRAC, REACHOUT consortium, and The AIDS Support Organisation (TASO). This supplement is constituted of 100 abstracts which were among those presented at the symposium. Session 1: History and current state of CHW programmes O1: Community Health Workers around the World: policy findings from the community health systems catalog Kristen Devlin, Kimberly Farnham Egan, Tanvi Pandit-Rajani JSI Research & Training Institute, Inc., 44 Farnsworth Street Boston, MA 02210, USA Correspondence: Kristen Devlin ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O1: © The Author(s). 2017 Open Access This artic International License (http://creativecommons reproduction in any medium, provided you g the Creative Commons license, and indicate if (http://creativecommons.org/publicdomain/ze Background: In 2012, the Advancing Partners & Communities (APC) project developed the Community Health Systems Catalog, a resource providing information on community health policies and programs in 25 countries. Recognizing a shift toward increased harmonization of community health programs, APC is updating the Catalog, which provides detailed information on community health worker (CHW) cadres, including scope of work, coverage, selection, training, supervision, reporting, and motivation, per documented guidance. Methods: APC developed and conducted a community health survey in each country and verified data in national and sub-national policies, strategies, and curricula. To date, APC has updated data for 15 countries: Afghanistan, Ghana, Haiti, India, Liberia, Madagascar, Malawi, Mali, Nepal, Nigeria, Pakistan, the Philippines, Senegal, South Sudan, and Zambia. Results: Across these 15 countries, policy information was available for a total of 44 CHW cadres – typically two to three per country. Data show diversity in all CHW aspects: job description; supervision and reporting structure; coverage area and ratio; selection; data collection; training curricula; and incentives. Findings also highlight commonalities: for instance, many CHWs report to multiple supervisors (75%); most CHWs access clients on foot (84%), but many CHW clients also travel to them (61%) or CHWs access clients by bike (43%); and CHW selection criteria most commonly stipulate community residence (52%), age (50%), education (41%), and literacy (32%). Data further reveals that CHW information is often absent, limited, unclear, and contradictory in policy. Conclusions: The Catalog documents policy related to CHWs and related operational aspects. Both the commonalities and the diversity across countries may inform, reinforce, and expand the growing body of knowledge of CHWs – and their relationship to the health system more generally – for researchers, policymakers, and program implementers. Further, findings highlight policy gaps and areas where additional guidance to better align and scale up CHW programs may be needed. O2: Achieving Sustainable Development Goals: a case study of Community Health Workers in working class communities in Gauteng Province, South Africa Maria van Driel, Juliet Kabe Khanya College, Johannesburg, South Africa Correspondence: Maria van Driel ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O2: Background The South African government’s neoliberal policies over the past 20 years of democracy together with the HIV/AIDS pandemic, has deepened poverty, unemployment and social inequality. Consequently, the Community Health workers (CHWs) play a critical role delivering healthcare services and supporting communities. Methods The case study draws on the daily work and experience of CHWs in Gauteng Province, South Africa, from 2012 to 2016. Methods used le is distributed under the terms of the Creative Commons Attribution 4.0 .org/licenses/by/4.0/), which permits unrestricted use, distribution, and ive appropriate credit to the original author(s) and the source, provide a link to changes were made. The Creative Commons Public Domain Dedication waiver ro/1.0/) applies to the data made available in this article, unless otherwise stated. BMC Proceedings 2017, 11(Suppl 6):10 Page 2 of 36 include in-depth interviews, focus group discussions and desktop research. The study focuses on two inter-related aspects facing CHWs in their daily work: i) The context and content of delivery of health services focusing on the nature of CHWs daily work with communities with respect to health care systems and health services delivery; and ii) As the agents of delivery of community health care services, the nature of CHWs’ work contributes integrally to daily social reproduction within working class family/households and communities. Results The paper argues that the CHWs do not only provide important services to communities within the failing healthcare system, but contribute substantially towards the social reproduction of large sections of the working class. While seemingly contradictory: the CHWs work within the public sphere and their work is social, but the modality of their work in working class communities is a form of privatisation, where predominantly women, provide ‘care work’ and subsidise the state and society with their labour. Conclusion While the CHWs provide important support to communities, their full potential contribution to sustainable development is weakened objectively on several levels: the nature of the healthcare provided, the nature of social reproduction of working class communities and the continued exploitation of black women’s labour and confinement to ‘care work’. O3: Living on the Frontline: Community Health Work in rural South Africa Alexandra Plowright, Gillian Lewando Hundt, Richard Lilford, Celia Taylor, David Davies, Jo Sartori Warwick Centre for Applied Health Research and Delivery (W-CAHRD), Warwick Medical School, University of Warwick, Coventry, UK Correspondence: Alexandra Plowright ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O3: Background Community Health Workers (CHWs) provide health support and basic level care to large numbers of rural populations, particularly in subSaharan Africa. The World Health Organization has formally recognised their work and acknowledges their potential to make a substantial contribution to the achievement of the Sustainable Development Goals. This study was a pilot of a training intervention for CHWs in South Africa, and this paper presents findings that report on the qualitative exploratory phase of the study. Methods CHWs were invited to share their perspectives on their role: Semistructured interviews with 48 CHWs explored their motivation, as well as the barriers preventing them from doing their job well. Each CHW was also shadowed, which gave insight into the practical dayto-day activities that they engage in. Results Participating CHWs identified that the key motivation was elevating their status in their community, whilst the main barrier was a lack of confidence resulting from sub-standard training and supervision. Shadowing revealed that CHWs, contrary to literature, are the ‘front line’ for health issues far removed from basic level care, which extend much wider than the provision of basic level healthcare. Complex health issues that were addressed by CHWs included provision of care for medication defaulters, ante natal care and being ‘first responder’ for emergencies. Conclusions CHWs are key health professionals who shoulder a significant burden of care at community level. In practice, CHWs provide more than basic care and patient support. An absence of training and support means that CHWs do not feel well-equipped to deal with the challenges that they encounter daily while living on the frontline, delivering healthcare services in rural South Africa. O4: Assessing successes and challenges in the scale-up of a national, public sector community health worker cadre in Zambia: A qualitative study Sydney Chauwa Phiri, Margaret Lippitt Prust, Caroline Phiri Chibawe, Ronald Misapa, Jan Willem van den Broek, Nikhil Wilmink Clinton Health Access Initiative, Lusaka, Zambia; Clinton Health Access Initiative, Boston, MA, USA; Ministry of Health, Lusaka, Zambia; Office of the President, Public Service Management Division, Lusaka, Zambia Correspondence: Nikhil Wilmink ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O4: Background In 2010, a public-sector cadre of Community Health Workers (CHWs) called Community Health Assistants (CHAs) was created in Zambia through the National Community Health Worker Strategy to expand access to health services. This cadre continues to be scaled up to meet the growing demands of Zambia’s rural population. To foster continuous learning, evaluation and innovation, a study was conducted in 2015 to understand the successes and challenges of introducing and institutionalizing the CHA cadre within the Zambian health system. Methods Semi-structured, individual interviews were held across 5 districts with 16 CHAs and 6 CHA supervisors, and 10 focus group discussions (FGDs) were held with 93 community members. Audio recordings of interviews and FGDs were transcribed and thematically coded using Dedoose web-based software. Results The study showed that the CHAs play a critical role in providing a wide range of services at the community level, as described by supervisors and community members. Some challenges remain that may inhibit the CHAs ability to provide health services effectively. The respondents highlighted infrequent supervision, lack of medical and non-medical supplies for outreach services, and challenges with the mobile data reporting system. Conclusions The study shows that to optimize the impact of CHAs or other CHWs system-level, support systems need to be functioning effectively, including supervision, community surveillance systems, supplies, and reporting. This study contributes to the evidence base on the introduction of formalized of CHW cadres in other countries. O5: Challenges of Community Health Workers in sustaining maternal and child health program in Indonesia Ralalicia Limato, Sudirman Nasir, Patricia Tumbelaka, Din Syafruddin, Rukhsana Ahmed Eijkman Institute for Molecular Biology, Jakarta, Indonesia; Hasanuddin University, Makassar, Indonesia; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK Correspondence: Ralalicia Limato ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O5: Background Community Health Workers (CHWs) locally called kader play a crucial role in the delivery of maternal and child health services in Indonesia. Kader are trained to work in the Posyandu, a community-integrated service, and perform the tasks of registration, weighing women and children, health counselling and report writing. In addition, they do referral of pregnant women to the village midwife. We explored the challenges they face while voluntarily contributing to the Posyandu services. Methods Data was collected in Southwest Sumba and Cianjur district using semi-structured interviews and focus group discussions (FGDs) in three time periods: 1) September to November 2013 in both districts; 2) November 2014 and September 2015 in Cianjur district only. A total of 185 semi-structured interviews and 13 FGDs covering village BMC Proceedings 2017, 11(Suppl 6):10 Page 3 of 36 midwives, kader, community (men and women), and key district health and community stakeholders were conducted. All interviews were recorded, transcribed, translated into English, coded and analysed using NVivo10. Results The kader indicated several challenges they faced in delivering their work: 1) the strong cultural belief that women must obey their husbands disempowered women to make decisions about their pregnancy and delivery, and it hindered kader’s referral of women for facility delivery; 2) limited training opportunities for kader lead to suboptimal quality of service; 3) favouritism in kader’s recruitment and retention deterred the continuity of their work in the Posyandu. Conclusions Even though kader have a vital role in sustaining the maternal and child health program, their services are challenged by gender inequality influences on decision making, and training and recruitment limitations. These conditions indicate less responsiveness of the issues facing by kader. Greater recognition of kader competencies and interest on kader’s work by the local government and community leaders has potential to improve their services as CHWs. O6: Functionality assessment of selected community health units across ten counties in Kenya Miriam Karinja, Doreen Kudwoli, Anthony Gitau, Mourice Rawago, Colin Pillai, Marcel Tanner, Bernhards Ogutu Swiss Tropical and Public Health Institute, Basel, Switzerland; Center for Research in Therapeutic Sciences (CREATES), Strathmore University, Nairobi, Kenya; Familia Nawiri Novartis Pharma, Nairobi, Kenya; Scientific Capabilities Center of Excellence, Novartis Pharma, Basel, Switzerland Correspondence: Miriam Karinja ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O6: Background In seeking to improve health outcomes in Kenya, the government developed the community health strategy (CHS) which aims to develop linkages between the households and the peripheral healthcare system. Through the implementation of the strategy, community health units (CHUs) are established to serve a catchment population of 5000 people. Service provision within a CHU is undertaken by community health volunteers (CHVs), supervised by community health extension workers (CHEWs) and governed by community health committees (CHC). A total of 48 CHUs across ten counties in Kenya were assessed. The purpose of the assessment was to obtain baseline data on the functionality of the CHUs in order to track their performance upon partnering with Familia Nawiri, a Novartis social venture in Kenya. Methods The assessment of the CHUs was done using an AMREF functionality scorecard with 17 key elements (performance and process indicators and cardinal elements) needed for a functional CHU. CHUs scoring 049% were graded as non-functional, 50% to 79% semi-functional and 80% and above as functional. In addition, CHUs had to meet three cardinal elements to be graded as functional (reporting rate >80, holding dialogue and action days). The CHUs assessed were selected from Familia Nawiri program sites. The assessment team comprised of sub county CHS representative, a CHEW, a CHV and a Familia Nawiri representative. Results Overall only 15% of the 48 CHUs assessed were found to be functional, 42% were rated as semi functional and 44% non-functional. 94% of the CHUs reported having trained CHVs, 70% had trained CHEWs, 54% had trained CHCs, 67% had reporting tools, and 67% reported getting supervision by the district health management team during the past 6 months. Only 23% of the CHUs were providing stipends to the CHVs and 20% had provided bicycles for CHVs transport. Conclusion Only 15% of the CHUs assessed were found to be functional. This highlights gaps in the implementation of community health strategy across different regions. Interventions are required to improve the functionality of the CHUs. O7: Close-to-community health providers in the complex adaptive health system in Bangladesh Tahmina Afroz, Sushama Kanan, Sabina F Rashid, Irin Akhter, Tamanna Majid, Sumona Siddiqua, Mahfuza Rifat, Malabika Sarker James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh Correspondence: Sushama Kanan ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O7: Background Close-to-community (CTC) health providers play an important role in providing sexual and reproductive health services to women of Bangladesh through bridging the community to health facilities. REACHOUT is a five-year multi-country implementation research project which aims to understand the role of CTCs. In this project, the Bangladesh team led by James P. Grant School of Public Health (JPGSPH), BRAC University, is focusing on CTC providers involved in menstrual regulation (MR). MR is manual vacuum aspiration to safely establish non-pregnancy up to 8-10 weeks after a missed menstruation period. Partners of REACHOUT consortium reviewed the complex adaptive health system in which CTCs perform, aiming to identify inter-dependent actors and possible interactions at multiple levels which shape health outcome. Method Policy makers, researchers and professionals participated in the review held in 2016, in Bangladesh. Complex adaptive health system was reviewed through literature review and participatory workshop. Result A range of health service providers including government, nongovernment organization (NGO) and private providers co-exist in Bangladesh. CTC providers may be formally affiliated to institutions and have recognized qualification; or informal such as drug seller or traditional birth attendants with or without formal training or institutional affiliation operating outside the formal rules regulating the practice. Formal CTC providers are trained to refer clients to low cost appropriate health facilities. Informal CTC providers often refer clients to private sectors. Moreover, informal CTCs driven by financial interest refer women to unsafe services provided by clandestine operators. Inter-facility referrals also take place across public, private and NGO facilities. Pluralistic nature of health system makes the health sector complex for women to choose appropriate service. Contextual factors such as regulation, policies, social & cultural norms, economics and politics, affect this complex adaptive health system. The interaction between multiple actors affects the health outcome. Conclusion CTC providers can act as referral hub and play a critical role in appropriate and safe referral. Coordination among different health professionals is critical. Access to information is crucial to ensure equity for poor women. Session 2: Training models for CHW programmes O8: Open Deliver: a mobile digital content management system providing an equitable approach to achieve universal Community Health Worker training Mike S. Bailey, Edward Kakooza, Sean Blaschke, Carolyn Moore, Alex Little mPowering Frontline Health Workers/Jhpiego, Washington DC, USA; College of Health Sciences, Makerere University, Kampala, Uganda; UNICEF, Kampala, Uganda; mPowering Frontline Health Workers/ Jhpiego, Washington DC, USA Correspondence: Mike S. Bailey ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O8: Background The Ministry of Health acknowledges that 75% of the disease burden in Uganda is preventable and it is the Village Health Teams (VHTs) BMC Proceedings 2017, 11(Suppl 6):10 Page 4 of 36 that are primarily responsible for addressing this burden. In Uganda, there is a shortage of health workers that perform per expectations because they lack the skill mix to effectively respond to the country’s health needs. Approach Digital resources providing the basis for high impact health interventions and responses to epidemics can be organized within a single digital content management system designed for rapid publication to mobile devices for VHT access. Use of mobile devices for instruction is consistent with recognition that traditional techniques involving a single exposure to content to improve provider performance “result in very low effect size” and fail to address Sustainable Development Goals related to equitable access to training. Conclusion Open Deliver is a proven process for adapting, storing and delivering multimedia digital content onto mobiles. The principle component of this process is Orb the content sharing platform that will allow NGOs and Governments alike to store, share and coordinate digital resources for programs such as FamilyConnect and mTrac. Scaling proven technologies to create a centralized content delivery and data collection system in Uganda will help ensure that services, content and functions are implemented in accordance with international standards and result in savings through the elimination of duplicate systems. O9: Cascading Training Model for scaling up access to community based family planning services through Village Health Teams in Iganga and Kumi districts of Uganda Beatrice Bainomugisha, Laura C. Wando, Laura Ehrlich Sanka WellShare International. Kampala, Uganda; 2 WellShare International, Minneapolis, MN, USA Correspondence: Beatrice Bainomugisha ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O9: Background Various models of engaging and training Village Health Teams (VHTs) have been used by implementing partners in Uganda. WellShare International used a Cascading Training Model (CTM) in training VHTs in Iganga and Kumi districts. WellShare engaged Ministry of Health approved master trainers to train the District Health Team (DHT) and Health Workers, who in turn trained the VHTs to offer Community Based Family Planning (CBFP) Services. The purpose of the study was to document and inform implementing partners about the success of the model. Methods In 2015, WellShare collected qualitative data through purposively sampled key informant interviews with stakeholders (6 DHT, 8 health workers and 16 VHTs) to document processes and inputs needed for implementation, identify advantages and challenges of the model, and document lessons learned and recommendations for scale up. Assessment reports from project start-up, district-level Health Management Information System (HMIS) data, and projectlevel databases over the life of project were also reviewed. Qualitative data was synthesized thematically and by stakeholder group. Results Key informants perceived CTM to be more cost-effective, efficient, and sustainable compared to other training models. Informants felt VHT performance increased due to close working relationships between health worker supervisors and VHTs. The health workers perceived VHTs as partners who greatly reduce their workload, while the supervision approach improved communication and quality of services. The cost of training and ongoing supervision of VHTs is substantial (around $200 per person) and would require allocation in district health budgets. The model requires a substantial time commitment from the DHT. Conclusions The CTM, requires initial investment in funding and time, but is more sustainable, inclusive, and strengthens communication between providers and quality of VHT services. This model enables direct ownership of the districts of CBFP services and was highly recommended for use in other districts. O10: Cascade training model: a sustainable village health team training approach to increase uptake of modern family planning methods Deborah Musedde, William Mugeni, Lisa Firth, and Leigh Wynne The Salvation Army Uganda, Mbale, Uganda; The Salvation Army Uganda, Kampala, Uganda; Salvation Army World Service Office, Arlington, Virginia, USA; FHI 360, Durham, North Carolina, USA Correspondence: Deborah Musedde ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O10: Background The Salvation Army Integrated Family Planning (SAIFaP) Project integrated family planning services into the existing Sustainable, Comprehensive Responses for vulnerable children and their families (SCORE) Project in Eastern and North Eastern Uganda. SAIFaP used a cascade training model to train 280 of SAIFaP’s 378 village health team members (VHTs) to provide injectable contraception or community-based access to injectables (CBA2I). This model has contributed to the sustainability of CBA2I services in the seven project districts. Methods After visiting WellShare International Uganda’s CBA2I project in Iganga district, the SAIFaP project replicated WellShare’s cascade training model. Using this model, Ministry of Health master trainers and District Health Team members worked together to train two midwives from each district for five days to become trainers of trainers in CBA2I. These fourteen midwives went back to their respective districts and trained 24 midwives from 16 health facilities across the seven project districts, who in turn trained VHTs affiliated with their health facilities for ten days. Following this training, midwives have continued to provide supportive supervision for the VHTs’ CBA2I. VHTs receive their resupply of methods and safety boxes from the midwives who trained them and bring back monthly community-based family planning (CBFP) service delivery reports to include in the general HMIS reporting to the district. Results As of May 2016, the project achieved more than 7,500 couple-years protection. This included 7,139 new acceptors of modern contraception, of which 3,685 were CBA2I clients. Midwives feel confident to provide refresher training to VHTs and to train new VHTs when there is VHT turnover. Midwife turnover has been inconsequential. Conclusion The cascade training model strengthens midwife-VHT rapport and the sustainability of CBFP and CBA2I services. After the SAIFaP project ended in May 2016, VHTs continued to provide CBFP services in their homes and the midwives continued to provide supportive supervision. O11: Community health workers’ training in Uganda: The Living Goods model Sharon B. Amanya ([email protected]) Department of Health and Government Relations, Living Goods LTD, Kampala, Uganda BMC Proceedings 2017, 11(Suppl 6):O11: Background The critical shortage of qualified health workforce for the growing population with diverse health care needs continues to pose a great challenge to developing countries. Community Health Workers (CHWs) serve as a good alternative to improve health care access and outcomes, and enhance quality of life for people in diverse communities. CHWs’ ability to achieve this depends on the training, continuous monitoring and support provided. In this paper, we present the training model used for Living goods community health promoters (CHPs). BMC Proceedings 2017, 11(Suppl 6):10 Page 5 of 36 Training model Living Goods uses a highly-selective screening process that includes references, tests, and role-playing to choose candidate trainees for the CHP’s role. Once selected, the trainees undergo a one month intensive training. The training includes: integrated Community Case Management (iCCM), maternal and new-born care, use of android phones in health care reporting and business skills. Various methods are incorporated in the training including: lecture presentations, role plays, group discussions, and practical sessions both in class and hospitals. Trainees undergo certification, with a required passing score of 75% and above. Successful candidates graduate, in presence of officials from the district health office, Living Goods and local community authorities. Once the CHPs commence their duties, they are given monthly in service trainings as well as an annual exam which they should pass with a minimum score of 85%. On average, over 95% of the trainees achieve the required passing scores. Post training evaluation usually shows that the course content and experience is well perceived, with over 98% of the trainees rating it as very good. Consequently, our CHPs usually conduct their duties in a professional manner, with less chances of dropout. Conclusion Our training model is practical and effective. This makes it replicable especially for CHW training programs in rural communities. O12: Timed and Targeted Counselling A village health team model for Maternal new-born and child Health Richard Muhumuza, Heechan Roh, Mark Lule, Agnes Namagembe, Christine Oseku, Irene Auma Integrated programs Division, Department of Health Nutrition and HIV, World Vision, Kampala Uganda Correspondence: Richard Muhumuza ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O12: Introduction World Vision is implementing Maternal Newborn and Child Health (MNCH) projects using a system strengthening approach with an aim of contributing to the continuum of care. One of the core models used is timed and targeted Counselling (ttC) where village health teams (VHTs) play a fundamental role in conducting household visits during which all the pregnant women and children under 2 years are mapped out. The Model ttC is a community based MNCH model aimed at extending primary health care, behavioral change communication counselling to the household level through the 1000 days (from conception to the time the child is two years). After obtaining updated village maps, VHTs follow up all the pregnant women and children under 2 years in their catchment areas. Specific messages depending on the gestation period are passed on during counseling session to ensure that pregnant, breastfeeding mothers and key decision makers in the households receive essential health and nutrition information to influence sustainable behavioral change at specific timelines till the child makes 2 years. Furthermore, before another counselling session is conducted, previous action points are first reviewed to ensure they were worked upon by the mothers. Timeliness being key in this model, messages are carefully delivered so that a woman has sufficient time to act on the given messages. It is targeted because each message is delivered at a particular time and space. In addition, the information is individualized, with messages focusing on the circumstances of each specific family. It is Counselling because VHT engages in a discussion with the family to identify barriers to preferred health practices after which feasible shifts are negotiated towards these preferred practices based on individual circumstances. Conclusion ttC as a model has shown great potential in contributing towards the improvement of MNCH mainly through behavior change and it sits well in the existing VHT structure. O13: Enhancing Village Health Teams’ knowledge and skills through radio distance learning: experience of World Vision in Amuru district, Uganda Benon Musasizi, Lorna Barungi Muhirwe, Nathan Isabirye World Vision, Kampala, Uganda; School of Public Health, Makerere University, Kampala, Uganda Correspondence: Benon Musasizi ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O13: Background Ministry of Health with financial Support from World Vision Uganda (WVU) developed 12 timed and targeted counseling (ttC) audio dramatic but educative episodes. The episodes were run through radio. The major objective of radio distance learning (RDL) for ttC was to provide refresher training for VHTs on a regular, sustainable and cost effective way. ttC is a package of key health and nutrition messages that is disseminated by VHTs to pregnant and breastfeeding mothers to cause sustainable behavioral change at specific timelines in the first 1,000 days of life. ttC contributes to ending of preventable deaths of newborns and children below 5 years which is a focus of the Sustainable Development Goals. Methods RDL program in Amuru was implemented by WVU through a wellestablished VHT structure. Overall leadership was the responsibility of the District Health Office. Three hundred VHTs were formed into 26 groups of 5 members. Gulu FM was contracted to run the 12 episodes every Sunday at 4:00pm to 4:30pm with a repeat on Wednesday. Each group was given a radio while each VHT was given a Listener’s guide and Handbook. Health Assistants provided regular technical support supervision and mentoring. The results presented here were extracted from the RDL assessment for ttC, April, 2016. Results RDL was well received by the district health team and VHTs. The findings indicated that VHT knowledge for ttC improved from 53.4% to 85.4%. Episode 3 (malaria during pregnancy), 9 (baby supplementary feeding) and 12 (managing diarrhea) were best performed while episode 10 (baby immunization) and 11 (balanced diet) were least known by VHTs. The assessment conducted in 2015 indicated that VHTs had more knowledge on episode 2 at 77% which improved to 95.8% by 2016. VHTs had least knowledge on episode 11 (balanced diet) at 21% and episode 6 (care for newborn babies) at 36%, which improved to 64.0% and 77.1% respectively. Conclusions RDL is one of the most cost effective capacity building models that can be utilized to enhance VHT’s knowledge in basic primary health care. Session 3: Performance, motivation and satisfaction of CHWs O14: Recruiting, training and retaining of Community Volunteers: Experience from rural Bangladesh Nakul Kumar Biswas, Afsana Karim, Jatan Bhowmick, Joby George Save the Children, Dhaka, Bangladesh Correspondence: Nakul Kumar Biswas ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O14: Background USAID supported MaMoni Health Systems Strengthening Project deployed 24,000 unpaid Community Volunteers (CVs) in 4 districts to support the Ministry of Health and Family Welfare’s (MOHFW) health promotion activities. They were trained for 8 days with on job feedback and support. Annual dropout rate was 19% during pilot phase. BMC Proceedings 2017, 11(Suppl 6):10 Page 6 of 36 Methods The study examined the causes of dropout/retention of CVs. It analyzed routine Management Information System (MIS) data from January 2014 – December 2016 and conducted unstructured interviews with key stakeholders (MOHFW staff, elected representatives, project staff and dropout CVs). It also analyzed the process of CV recruitment, deployment, their monthly participation in group meetings, and Expanded Program on Immunization (EPI) sessions, and inquired about satisfiers/ dissatisfiers. The analysis was fed into modifications of the project interaction with the CVs. Results Local government representatives and MOHFW staff were involved in selecting and recruiting CVs. All CVs participated in community group meeting and EPI sessions in their assigned areas. In qualitative interviews, factors for becoming a CV cited were diverse and not related to income. Thus, several project initiatives were introduced (providing registers, bags, and job aids, formalizing their role in the community). The main factors for attrition were: migration to other places (for job opportunity, marriage, and higher education) and involvement in other business. They also cited initial family opposition that they gradually overcame. In 2014, annual dropout rate of CVs was around 12%, it increased to 34% as the project matured in 2015. However, in 2016, the annual rate was close to 8%, and less than 1% in the final three months. Conclusion The retention rate compared to other studies in Bangladesh is high. The project has shown that it is possible to retain completely unpaid volunteers by focusing on well-being of the community, desire for self-development, contribution in betterment of health, better utilization of free time, acceptance/honor of CV position and future career advancement. O15: Factors influencing motivation of health extension workers in Sidama zone, south Ethiopia: A qualitative study Aschenaki Z. Kea, Daniel G. Datiko, Maryse C. Kok REACH Ethiopia, Hawassa, Ethiopia; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom; Royal Tropical Institute, Amsterdam, The Netherlands Correspondence: Aschenaki Z. Kea ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O15: Background In 2004, Ethiopia introduced the health extension program (HEP), comprising a package of basic community health services. A perennial challenge in community health worker (CHW) programs is the question of how to motivate CHWs. This study explored factors that influence motivation and performance of the Health Extension Workers (HEWs). Methods The study was conducted in six districts of Sidama Zone, South Ethiopia, employing focus group discussions (FGDs) and in-depth interviews (IDIs). FGDs and IDIs were tape recorded and transcribed verbatim into English. The transcripts were independently read in pairs by four researchers to identify key themes and develop a coding framework. Transcripts were coded using Nvivo (v.10) software, analyzed and summarized in narratives for each theme and sub-theme. Results Factors influencing the motivation of HEWs interplay at individual (interest to the profession, sense of belongingness, positive changes, and worthiness of the service), community (trust of the community, community satisfaction, recognition from community volunteers), organizational and administrative or political level. De-motivators from community side were lack/minimal support from village administrators and expectation of curative services. Organizational demotivators: unsupportive supervision, rude behavior of health workers, low salary, workload, lack of career advancement, educational opportunities, opportunities to transfer, favoritism, inadequate pre-service and in-service training, lack of logistics and basic facilities. Support from district health office was mentioned as a motivator. Little or preferential support from political leaders/administrators and engagement of HEWs on political matters/affairs (de-motivators) were observed at administrative/political level. Conclusions Multiple factors influence motivation of HEWs. Supportive supervision, referral and community engagement were the priority areas identified for the introduction of quality improvement intervention to improve motivation and performance of HEWs. The health system needs to address context based de-motivators as the HEWs are the first point of contact for community based health services. O16: High retention of Community Health Workers in a rural district in Southwestern Uganda Amy J. Hobbs, Eleanor Turyakira, Jerome K. Kabakyenga, Alberto Nettel-Aguirre, Teddy Kyomuhangi, Jennifer L Brenner Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Alberta, Canada; Cumming School of Medicine, Department of Paediatrics, University of Calgary, Alberta, Canada; Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda Correspondence: Eleanor Turyakira ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O16: Background Despite evidence suggesting the effectiveness of community health worker (CHW) programs in improving maternal, new-born, and child health (MNCH) in low-to-middle-income countries, attrition of CHW is a global problem. We aimed to evaluate the characteristics and retention of volunteer CHWs who were trained and supervised in Bushenyi district, rural Uganda. Methods Between July 2012 and August 2014, Healthy Child Uganda facilitated a district-led scale up and training of CHWs in Bushenyi district. CHW demographics was collected at enrolment and ongoing participation monitored through CHW quarterly meetings. Existing project databases were analyzed. Retention rates and reasons for exiting the CHW program were presented by demographic variables. A multivariable logistic regression model was created to examine predictors of two-year retention. Results A total of 1,669 CHWs in all 64 parishes (563 villages) were selected and supervised in Bushenyi district. The majority of CHWs were female (75%); mean age was 38 years (SD: ±9.7). Retention was high, with 97% and 95% of CHWs being active after one and two years respectively. Of the 84 CHWs who exited the program, approximately 70% left for logistical reasons including moving to a new village (n = 20) and being offered a new job (n = 18). In unadjusted analysis, being male (OR = 1.66; 95% CI: 1.04-2.64) and having completed secondary education (O-Level) or more (OR = 1.77; 95% CI: 1.10-2.85) were associated with exiting the CHW program before two years. Sex (OR = 1.57; 95% CI: 0.95-2.60) and education (OR = 1.61; 95% CI: 0.97-2.65) remained significant predictors of 2-year retention in multivariable modelling, controlling for age at enrolment. Conclusions In our study, most reported attrition was due to logistical reasons that were unrelated to the CHW role or selection/program factors. Addressing CHW attrition, particularly for males and those with higher education, may improve retention for CHW programming over the longer term. O17: Evaluation of the effectiveness of community based health services in the North West Province, South Africa Tumelo Assegaai, Helen Schneider, Gavin Reagon School of Public Health, University of the Western Cape, School of Public Health, Cape Town, South Africa Correspondence: Tumelo Assegaai ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O17: BMC Proceedings 2017, 11(Suppl 6):10 Page 7 of 36 Background South Africa faces a high burden of avoidable mortality but has weak preventive and promotive strategies to address this burden. In response, government is strengthening community based health services through primary health care (PHC) Ward Based Outreach Teams (WBOTs). This team includes trained Community Health Workers (CHWs) providing basic services at household level. The North-West Province (NWP) was an early adopter of, and had the highest coverage by teams by the end of 2015. This presentation describes a mixed method evaluation of the WBOTs in NWP conducted in 2015/16. Methods The performance of PHC facilities with and without WBOTs was compared using routine facility indicators, comparing changes from before (2010/2011) to four years after implementation (2014/2015). Indicators identified as sensitive to WBOT activity included: couple year protection rate (CYPR); antenatal care coverage; childhood immunization and Vitamin A coverage; under-5 (U5) diarrhoea with dehydration rate; and U5 healthcare utilisation rates. In-depth interviews and focus-group discussions were conducted with a purposeful sample of 60 participants, representing stakeholders from provincial to local levels. Results Measles coverage, CYPR and severe diarrhoea rates showed significantly greater improvement, and U5 utilisation and antenatal coverage declined at lower levels, in facilities with WBOTs compared to those without WBOTs; Vitamin A coverage improved equally in all facilities. On qualitative analysis, persistent weaknesses include integration into and acceptance of CHWs by PHC clinic staff. Enabling factors include strong stewardship by provincial and district management, and the positive role of retired nurses as team leaders. Conclusion WBOTs appear to have had effects on some PHC indicators, suggesting population level impacts of South Africa’s CHW programme. However, these need to be confirmed in repeat assessments over time. Structured systems of supervision that involve both communities and facilities, and the integration of the community based health services with the formal PHC system remain key challenges and need to be addressed as priorities. O18: Recognition and sustained support of Community Health Workers in Sierra Leone, Lesotho, Malawi and Mozambique Marielle Bemelmans, Amanda Banda, Esther van Adrichem, Mit Philips Médecins Sans Frontières Operational Centre Brussels, Analysis & Advocacy Unit, Brussels, Belgium; Médecins Sans Frontières Operational Centre Brussels, Johannesburg, South Africa Correspondence: Marielle Bemelmans ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O18: Background Responding to staff shortages in sub-Saharan Africa, task shifting occurred at different levels. Most clinical care in the countries studied is provided by mid-level cadres. Specific tasks including malaria diagnosis and treatment, HIV-testing and treatment support are often delegated to lay providers or CHWs, but there are concerns around recognition and sustainability. Methods Review of role, level of recognition and sustained support of CHW or lay provider cadres in Sierra Leone, Malawi, Mozambique, Lesotho and analysis of context specific factors; where available, effects on health service provision at community and health facility level was included. Results non-communicable diseases. Often compensating for critical health staff shortages, improved access to and quality of care was noted. However, these lay cadres face similar problems as regular qualified health staff: inadequate remuneration, lack of supervision and support, lack of harmonized training packages and job profiles. While some differences exist in levels of recognition, overall absorption of health workers into formal health system is slow, leading to many unpaid volunteers running the health services. Conclusion The renewed interest in CHWs should include efforts to formalize their role and accredited training packages. Moreover, recurring obstacles to absorption in the public health system and to adequate financial and technical support need to be tackled. Donors increasingly defer funding of staff remuneration to rely on domestic resources. However, in most countries this is not a realistic option; wage bill restrictions won’t allow pay adjustments or staff expansion necessary to fill vacancies in staff establishment. Without a significant shift in mindset and practical measures to allow absorption and adequate support of CHWs in the public sector, reaching adequate service provision and health Sustainable Development Goals will remain out-of-reach for most communities. O19: Exploring factors that motivate Palliative Care Volunteers and their experiences as they carry out this role Ivan Onapito, Florence Nalutaaya, Elizabeth Namukwaya, Mhoira Leng Makerere Palliative Care Unit, Department of Medicine Makerere University, Kampala, Uganda; University of Edinburgh, Edinburgh, UK; Cairdeas International Palliative Care Trust, Glasgow, UK Correspondence: Ivan Onapito ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O19: Background Goal number 3 of the Sustainable Development Goals (SDGs) is to improve Health and Well-being with one of the targets being the recruitment, development, training and retention of the health workforce in developing countries. With the rising incidence of noncommunicable disease (NCDs), there is an increasing need for good palliative care services. Holistic care involves the community even when delivered within the hospital setting because hospitals become communities of care for short or long term stay. Since 2011, Makerere Palliative Care Unit (MPCU) has recruited and trained 25 volunteers, and integrated them into palliative care service provision. Between 2012 and 2015, volunteers have offered pastoral and social services to 1007 patients and made 4532 patient visits. However, less is understood about what motivates them in their role, hence the need to explore these factors. Methods A qualitative exploratory study using semi-structured interviews was used with the 11 MPCU volunteers to collect data. Results Volunteers felt motivated by good teamwork, a chance for career development through acquiring new skills, compassionate/humanitarian contribution, training, and mentorship. Despite this, volunteers identified several challenges within their work that included high level of expectation from patients and families, as well as lack of mutual respect. Conclusion For them to perform their role well and remain motivated, volunteers should be appreciated, have good relations with all staff involved in patient care, and start income generating activities to sustain their valuable service to patients. Many of the volunteers have used this experience to move on to other roles in their communities. BMC Proceedings 2017, 11(Suppl 6):10 Page 8 of 36 Session 4: Delivery of health services O20: Human Centered Design for rapid results: improving quality in close to the community health systems in four villages in Kenya Mary B. Adam, Angie Donelson, Simon Mbugua, Joram Ndungu, Carolyne Waithera, Jacob Chege AIC Kijabe Hospital, Maternal Newborn Community Health Program, Kijabe, Kenya; Donelson Consulting LLC, London, England; Strathmore University, Nairobi, Kenya Correspondence: Mary B. Adam ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O20: Background Health professionals have struggled to create systems-level quality improvement to influence household interactions that improve population health. We show how a Human Centered Design stakeholder-driven quality improvement process has made rapid change within a complex system across four Kenyan villages. Methods Our process, SALT (Stimulate-Appreciate-Learn-Transfer), begins with community health workers (CHWs) who have a critically-important “bridging” role to households. SALT (3 day workshop and follow-up) involves intensive coaching, helping CHWs uncover unarticulated needs and assumptions of communities to engage households in behavior change. One community health unit with 27 CHWs formed four groups in four villages to address diverse public health issues (immunization, composting toilets, neonatal health, and public gardening). They achieved process and impact results over 7 months (March September 2016) for projects they conceived, with no external funding for implementation. Results All groups achieved process goals (planning stage, assigned roles, innovated to solve problems, tracked to work plan, created independently functioning teams and documented improvements) and developed and implemented action plans with at least partial completion of desired impact goals. Two developed an additional PlanDo-Study-Act (PDSA) cycle and one moved to scale. Moreover, all four groups also implemented both a household and community teaching component. Group A created 11 kitchen gardens, engaging 174 households and 2 churches. Group B visited all households with pregnant and postnatal women in their geographic region (N = 35) and continued home visits while adding education/demonstration kitchen gardens (cross learning from colleagues). Group C consistently increased targets, resulting in composting toilets (N = 4) and hand wash facilities (N = 120). Group D mobilized intensive community resources toward immunization defaulters (N = 6). Conclusions CHWs can design, lead and implement community driven PDSA cycles and iterate to achieve positive health gains. O21: Low utilization and service delivery challenges: results from a qualitative study of Mali’s Community Essential Care Package Karen Z. Waltensperger, Yordanos B. Molla, Serge Raharison, Mouhamadou Gueye, Mamadou Faramba Camara Aissatou Aida Lo, Eric Swedberg, Drissa Bourama Ouattara, Binta Keita, Mieko McKay Maternal and Child Survival Program (USAID)/Save the Children, Washington, DC, United States; Maternal and Child Survival Program (USAID)/JSI, Washington, DC, United States; Centre d'Etude et de Recherche sur l'Information en Population et en Santé, Bamako, Mali; Services de Santé de Grand Impact (USAID)/Save the Children, Fairfield, CT, United States; Services de Santé de Grand Impact (USAID)/Save the Children, Bamako, Mali; Ministry of Health, National Health Directorate, Bamako, Mali Correspondence: Karen Z. Waltensperger ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O21: Background Community health services in Mali are delivered through a decentralized network of ~900 health centers (CSCom), owned and operated by Associations de Santé Communautaire. As a pro-equity strategy, the Ministry of Health and partners held a national forum in 2009 to define a package of high-impact services for mothers, newborns, and children living more than 5km from a CSCom. Known as Soins Essentiels dans la Communauté (SEC), the package is delivered by a new cadre of community health worker (CHW), the Agent de Santé Communautaire. To explore challenges of service delivery and low SEC utilization, we conducted a qualitative study in four districts of Southern Mali. Methods The study applied three qualitative data collection methods: focus group discussions, triads/dyads, and one-on-one interviews. We summarized the data collected thematically and presented it based on components of the Phase 4 Ronald M. Anderson Health Utilization Model. Results SEC users appreciated improved access and availability of curative services provided close to home but expressed preference for an expanded package that offered injections and care for adult family members. Non-users included families where illness recognition was poor and/or mothers disempowered to make care-seeking decisions. CHWs reported feeling demotivated by poor working conditions, erratic supervision, weak community and health system support, and a low stipend paid irregularly. Housing, healthcare and livelihood options in remote communities were limited. Female CHWs reported widespread psychological and sexual harassment that contributed to attrition and went unexamined and unpunished. CHWs were outfitted with bicycles unsuited to difficult road conditions. Chronic stock outs of essential drugs and supplies threatened the failure of the entire SEC strategy. Conclusions Poor CHW working conditions, weak motivation, low job satisfaction and erratic supervision challenge delivery of quality services. Factors related to illness recognition, care-seeking, household decisionmaking, and user preferences constitute barriers to full utilization of high-impact services. O22: Referral to health facilities in Kenya: factors that support community health volunteers in linking the community and health systems Maryline Mireku, Nelly Muturi, Robinson Karuga, Rosalind McCollum, Miriam Taegtmeyer, Lilian Otiso LVCT Health, Nairobi, Kenya; Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK Correspondence: Maryline Mireku ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O22: Background The Kenyan Community Health Strategy outlines referral as a core function of Community Health Volunteers (CHVs) under direct supervision of Community Health Extension Workers (CHEWs). We sought to find out the factors influencing CHV referral from community to health facility level following a supportive supervision intervention that aimed at improving performance of CHVs and CHEWs in Nairobi (urban) and Kitui (rural) region. Methods Qualitative and quantitative data was collected before and after the intervention through eight programme assessment workshops, twelve focus group discussions, 92 interviewer-administered questionnaires and 98 in-depth interviews with the community, CHVs and CHV supervisors. Qualitative data was coded and analyzed using Nvivo while quantitative data was analyzed in MS Excel. Results CHVs reported they knew how to refer but only 2% of them reported having all items required in their work. Qualitative data noted BMC Proceedings 2017, 11(Suppl 6):10 Page 9 of 36 persistent stockouts of standardized CHV referral forms which tracks referrals. Community members identified factors promoting referral uptake as recognition of the importance of the referral, belief that by attending the health facility they can be helped and treated, and expectation of quality low cost services. Barriers to uptake of referral included distance to facility, lack of funds for transport, lack of drugs at health facility, poor attitude of health workers and long queues. Health facility staff who were not aware of the referral form, either lost or ignored it making it difficult for CHVs to obtain feedback. The community expected monetary support and preferential treatment following a CHV referral. Conclusions CHVs need relevant tools to refer appropriately. Health centres need to provide quality care to patients and feedback to CHVs in addition to working in partnership with CHVs and CHEWs to address barriers to referral uptake. CHVs and CHEWs should clarify community expectations to enhance uptake of referrals. O23: Perceptions of communities and health workers on the role of Community Health Workers screening and referring children with suspected tuberculosis and HIV infection, using the WHO/UNICEF Integrated Management of Childhood Illness guidelines, in three rural communities Uganda Jesca Nsungwa-Sabiiti, Fred Kagwire, Morrine Sekadde, Mugabe Frank, Gorretti Nalwadda, Vanessa Kabarungi, Josephine Kyaligonza, Maureen Namanya, Ann Dete Jen, Flavia Mpanga Child Health Division, Ministry of Health, Kampala, Uganda; UNICEF, Kampala, Uganda; TB/Leprosy Program, Ministry of Health, Kampala, Uganda; UNICEF, New York, NY, USA Correspondence: Jesca Nsungwa-Sabiiti ([email protected]) BMC Proceedings 2017, 11(Suppl 6):O23: Background Over the past century, community health workers (CHWs) have been identified as a growing platform for improving the survival of children under five. The potential for CHWs to improve pediatric tuberculosis and HIV care in sub-Saharan Africa is not well understood. Before introducing the recently launched WHO/UNICEF integrated community case management (ICCM) guidelines, which includes tuberculosis (TB) and HIV, we conducted a study to assess provider and community perceptions regarding the role of CHWs. Methods In 2016, four focus group discussions with female and male caregivers, 46 key informant interviews with CHWs, health facility staff and management committee members, community leaders, mothers who previously consulted a CHW for sick child illness were conducted in Kayunga, Sheema and Wakiso district in Uganda. Data was analyzed for content in respect to acceptability and capability of CHWs to implement ICCM/TB/HIV guidelines. Results Overall, TB and HIV are perceived as rare and checking for these diseases would not affect iCCM. Varied views however emerged regarding the ability and role of CHWs. Mothers with previous experience with CHWs felt that, if trained properly CHWs are capable of implementing ICCM/TB/HIV guidelines and caregivers are willing to be referred to health facilities. CHW viewed TB/ HIV as complicated problems requiring “very good” training. Most CHWs had little previous encounter with referrals. Health workers (HWs) considered CHWs of lower skills mostly meant to promote prevention of these diseases. Both CHWs and HWs thought facilities may not handle the additional patient load. Lack of incentives and facilitation such as gloves, torches, gumboots to provide better services, stigma associated with HIV and TB were some of the constraining factors for CHWs. Conclusions This study highlights the potential of CHWs integrated into a functioning local health system in TB/HIV care. Efforts are needed to ensure competencies of CHW, facilitated referral system and motivating CHWs. O24: Development of community skilled birth attendants in hard-toreach areas of Bangladesh Marufa A. Khan, Manirul Islam, Sabbir Ahmed, Imteaz I. Mannan, Joby