Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers

Primary prevention of cardiovascular disease (CVD),by identifying individuals at risk is a well-established, but costly strategy when based on measurements that depend on laboratory analyses. A non-laboratory, paper-based CVD risk assessment chart tool has previously been developed to make screening more affordable in developing countries. Task shifting to community health workers (CHWs) is being investigated to further scale CVD risk screening. This study aimed to develop a mobile phone CVD risk assessment application and to evaluate its impact on CHW training and the duration of screening for CVD in the community by CHWs.A feature phone application was developed using the open source online platform, CommCare(©). CHWs (n=24) were trained to use both paper-based and mobile phone CVD risk assessment tools. They were randomly allocated to using one of the risk tools to screen 10-20 community members and then crossed over to screen the same number, using the alternate risk tool. The impact on CHW training time, screening time and margin of error in calculating risk scores was recorded. A focus group discussion evaluated experiences of CHWs using the two tools.The training time was 12.3h for the paper-based chart tool and 3h for the mobile phone application. 537 people were screened. The mean screening time was 36 min (SD=12.6) using the paper-base chart tool and 21 min (SD=8.71) using the mobile phone application, p

Use of m-Health Technology for Preventive Interventions to Tackle Cardiometabolic Conditions and Other Non-Communicable Diseases in Latin America- Challenges and Opportunities

In Latin America, cardiovascular disease (CVD) mortality rates will increase by an estimated 145% from 1990 to 2020. Several challenges related to social strains, inadequate public health infrastructure, and underfinanced healthcare systems make cardiometabolic conditions and non-communicable diseases (NCDs) difficult to prevent and control. On the other hand, the region has high mobile phone coverage, making mobile health (mHealth) particularly attractive to complement and improve strategies toward prevention and control of these conditions in low- and middle-income countries. In this article, we describe the experiences of three Centers of Excellence for prevention and control of NCDs sponsored by the National Heart, Lung, and Blood Institute with mHealth interventions to address cardiometabolic conditions and other NCDs in Argentina, Guatemala, and Peru. The nine studies described involved the design and implementation of complex interventions targeting providers, patients and the public. The rationale, design of the interventions, and evaluation of processes and outcomes of each of these studies are described, together with barriers and enabling factors associated with their implementation.Fil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Diez Canseco, Francisco. Universidad Peruana Cayetano Heredia; PerúFil: Irazola, Vilma. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Miranda, Jaime. Universidad Peruana Cayetano Heredia; PerúFil: Ramirez Zea, Manuel. Institute of Nutrition of Central America and Panama; GuatemalaFil: Rubinstein, Adolfo Luis. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

A systematic review of digital health tools used for decision support by frontline health workers (FLHWs) in low- and middle- income countries (LMICs)

In in low-and middle-income countries (LMIC), where there are very few trained physicians and nurses, community health workers (CHWs) are often the only providers of healthcare to millions of people. Such LMIC are countries that are classified, based on their geographic region and Gross National Income (GNI), as low-middle income by the World Bank Group, the worlds largest development bank. Research has shown digital health tools to be an effective strategy to improve the performance of frontline line health workers. The aim of this review was to systematically examine the literature on digital health tools that are used for decision support in LMIC and describe what we can learn from studies that have used these tools. As part of a larger parent study the following databases were searched: PubMed, Embase, Scopus, CINAHL, Global Health Ovid, Cochrane and Global Idex Medicus, to find ariticles in the following domains: training tools, decision support, data capture, commodity tracking, provider to provider communication, provider to patient communication and alerts, reminders, health information content. These domains were selected based on the World Health Organisation (WHO) framework for classifying digital health interventions. Content from all seven of these domains informed a series of reviews however this review focuses on how digital tools are used to provide decision support to FLHWs. Included studies were conducted in LMIC in Africa, Asia, North America and South America with the most common users of the tools being CHWs. Most tools for FLHW decision-support used in the interventions described in included articles were in either the pilot or prototype phases, and offered maternal and child health care services. Although decision support was the primary digital health function of all these studies, there was considerable variation in the number of digital health functions of each tool with most studies reporting decision support and data capture as their primary and secondary functions respectively. All the studies found their intervention to have beneficial effects on one or more of the following outcomes: beneficiary engagement, provider engagement, health effects and process/outputs. These findings show great potential for the use of decision support digital health tools as a means of improving the outcomes of health systems through; reducing the work load of FLHWs, reducing the costs of health care, improving the efficiency of service delivery and/or improving the overall quality of care

Utilizing mHealth to increase follow-up in Latinx adults with hyperlipidemia.

Background: Management of hyperlipidemia (HLD) is crucial to the prevention and management of cardiovascular disease cardiovascular disease (CVD), a leading cause of death in the United States (US) and Latinx adults (Centers for Disease Control and Prevention (CDC), 2019). The main difficulty affecting monitoring of lipid levels in patients diagnosed with HLD is lack of adherence to follow-up appointments. Purpose: The purpose of this Quality Improvement (QI) project is to evaluate the impact of culturally competent translated short message service (SMS) texts to increase adherence follow-up on a Latinx population served at the Kentucky Racing Services Health Center (KRSHC). Intervention: This project utilized the rapid plan, do, study, act (PDSA) cycle for quality improvement to evaluate the impact of culturally competent SMS texts appointment reminders. A retrospective review identified patients requiring intervention. Rate of change and two proportion z test was used to calculate follow-up rates and statistical significance between pre- and post-intervention groups. Results: Although not statistically significant, the rate of change was 2.7%. More than 50% of patients in both groups were male. Gender assigned at birth and age distribution were similar between both groups. Discussion: SMS text reminders are a quick and cost-effective method to communicate with Latinx patients. mHealth as a form of communication may prove to be a more effective means of communication as the population becomes more familiar with it

Challenges facing successful scaling up of effective screening for cardiovascular disease by community health workers in Mexico and South Africa: Policy implications

The integration of community health workers (CHWs) into primary and secondary prevention functions in health programs and services delivery in Mexico and South Africa has been demonstrated to be effective. Task-sharing related to adherence and treatment, from nurses to CHWs, has also been effectively demonstrated in these areas. HIV/AIDS and TB programs in South Africa have seen similar successes in task-sharing with CHWs in the areas of screening for risk and adherence to treatment. In the area of non-communicable diseases (NCDs), there is a policy commitment to integrating CHWs into primary health care programs at public health facilities in both Mexico and South Africa in the areas of reproductive health and infant health. Yet current programs utilizing CHWs are not integrated into existing primary health care services in a comprehensive manner for primary and secondary prevention of NCDs. In a recently completed study, CHWs were trained to perform the basic diagnostic function of primary screening to assess the risk of suffering a CVD-related event in the community using a non-laboratory risk assessment tool and referring persons at moderate to high risk to local government clinics, for further assessment and management by a nurse or physician. In this paper we compare the experience with this CVD screening study to successful programs in vaccination, reproductive health, HIV/AIDS, and TB specifically to identify the barriers we identified as limitations to replicating these programs in the area of CVD diagnosis and management. We review barriers impacting the effective translation of policy into practice, including scale up issues; training and certification issues; integrating CHW to existing primary care teams and health system; funding and resource gaps. Finally, we suggest policy recommendations to replicate the demonstrated success of programs utilizing task-sharing with CHWs in infectious diseases and reproductive health, to integrated programs in NCD

WHAT DO COMMUNITY HEALTH WORKERS NEED TO PROVIDE COMPREHENSIVE CARE THAT INCORPORATES NON-COMMUNICABLE DISEASES?

Non-Communicable Diseases (NCDs) such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes are the leading cause of premature death and disability worldwide, accounting for 60% of all deaths globally and 80% of NCD related mortality occurring in low and middle-income countries (LMICs). Health systems in LMICs have been oriented toward maternal and child health, and infectious illnesses as these were the main causes of morbidity and mortality until recently. Over the last decade, health systems in LMICs have recognized the need to address NCDs, and have restructured health services to include relevant prevention and control strategies. Health workforce is one of the key building blocks of health systems; however, most LMICs have a shortage of physicians. In addition, the available health care providers are unevenly distributed within countries with the majority concentrated in urban regions compared to rural regions where large proportions of the population reside. This poor distribution and shortage of physicians has led some countries to rely on task shifting, where tasks normally performed by qualified health professionals are transferred to other health providers with a lower level of education and professional training. In 1978, the Declaration of Alma-Ata included trained community health workers (CHWs) and traditional medical practitioners as part of the health team as a fundamental step towards comprehensive primary care. Since then, CHWs have been a cornerstone of health systems in several countries with over 26 different CHW programs identified in the literature across more than 24 LMICs. Traditionally, CHWs do not hold formal professional certification but receive job-related pre-service training. However, there is a lot of variation across countries where some countries require CHW certification before they can start performing their roles. CHWs reside in the community where they work, and are usually volunteers and sometimes receive financial compensation for receiving training and performance-based incentives for health related activities. CHWs can enable essential health care services to be provided in a cost-effective manner. They have been instrumental in reducing maternal and neonatal mortality rates through their presence for home births and making referrals for emergency obstetric care, and by promoting vaccination uptake, breastfeeding, and education about infectious disease. More recently, CHWs have been useful in HIV/AIDS prevention and control, educating communities and performing tasks such as screening, counselling and supplying antiretroviral drugs. With the increasing prevalence of NCDs and to meet changing community health needs, CHWs are sought to provide a similarly appropriate care for NCD risk factors control. While CHWs may not replace qualified health providers, they can play a considerable role in improving health outcomes by educating, screening, referring and following-up individuals at high risk of NCDs. CHWs have been trained in some settings to screen, educate and follow-up patients with NCDs or people at increased risk of NCDs. However, there is a need to better understand how to support CHW programs to be more effective and sustainable. There is knowledge gap in terms of the CHWs current capacity, working conditions, training provided for NCD prevention and control, remuneration, supervision and other upstream challenges facing CHWs and the health systems. The literature suggests that the there is a range of context-specific factors which can have an impact on the performance of CHWs and the quality of the care they provide. Some of these factors include the remuneration schemes employed, the workload, task complexity, lack of clarity in job description, and other essential factors such as interpersonal relationships between CHWs and other members of the primary health care team. CHW programs operate differently across and within countries. Evidence-based policy interventions are required to inform policy decision to ensure effective CHW program implementation. This thesis applies a mixed-methods approach to explore the capacity of the CHWs and the system support necessary to facilitate the CHW’s role in providing comprehensive, community-oriented, continuous primary health care which includes prevention and control strategies for NCDs. Part One provides an insight into the historical background of CHWs and how their role has evolved due to global health needs. With the expanding role of CHWs to incorporate NCDs, part two throws light on training of CHWs for NCDs in LMICs. Chapter two presents results of a systematic review about the effectiveness of training CHWs for cardiovascular disease prevention and management in LMICs. The chapter findings demonstrate the importance of having interactive and culturally adapted training sessions to make the training easier to follow and understand by the CHWs. The findings also highlight the need for evaluating the knowledge and skill-set of the CHWs to capture the training impact; and the necessity of scheduling refresher training at regular intervals to ensure knowledge retention. Chapter three demonstrates the importance of using an evaluation framework such as Kirkpatrick’s evaluation model to evaluate the effectiveness of training among CHWs. Using an evaluation framework, not only assesses the knowledge change but rather employs multiple measures to assess knowledge, skills and behaviour change of the CHWs. This allows for a more comprehensive interpretation of the training outcomes. The qualitative data involved in Chapter three provided insight on the low morale and discontent of the CHWs with their working conditions. In part three, I use a discrete choice experiment (DCE) to provide evidence of effective interventions that can keep the CHWs motivated and retain them in the workforce. Chapter Four explains the process of designing a DCE for Accredited Social Health Activists (ASHAs), who are CHWs in India. It also provides evidence of the feasibility of using Android computer tablets to display the DCE for the CHWs. In chapter five, I examine the relative importance of stated preferences of ASHAs to remain in service using a DCE survey. Career progression was found to be the main influencing factor for ASHAs in addition to fixed salary and other non-financial factors such as priority free family health-check and reduced workload. The findings demonstrated that the ASHAs sociodemographic characteristics such as their education level plays a key role in shaping their preference profile. These findings can inform future policy decisions of evidence-based recruitment and retention strategies that are applicable to the local context. CHWs have proven to be effective in providing a wide range of services including NCDs care. However to optimize the performance of CHW programs, we need to understand the system level support needed and the strategies necessary to be considered in the design and operation of CHWs’ programs. Part four, investigates the policy and implementation elements and system level support needed to enable the CHWs in rural India to provide comprehensive primary health care that incorporates NCDs. Chapter six uses policy review and qualitative research to understand the policy and implementation gaps, current capacity, working conditions and challenges faced by ASHAs in providing NCDs care to their community. It provides an overview of the perspectives of the key stakeholders of the ASHA program including ASHAs, ANMs, primary care doctors, community members, and district medical officers. Findings revealed that ASHAs are unrecognised as formal members of the NCDs delivery team, however they are overburdened with extensive NCDs tasks without receiving training or remuneration for these tasks. ASHAs remain to be volunteers that receive performance based remuneration and are not covered by any of the workers’ rights or laws. However, ASHAs remain enthusiastic about helping their communities and aspire to be recognised as formal employees of the health system with a potential career progression pathway. The concluding chapter summarises the key findings, discusses the main themes emerging from the thesis and outlines the future research directions and policy recommendations

Complex Care Management Program Overview

This report includes brief updates on various forms of complex care management including: Aetna - Medicare Advantage Embedded Case Management ProgramBrigham and Women's Hospital - Care Management ProgramIndependent Health - Care PartnersIntermountain Healthcare and Oregon Health and Science University - Care Management PlusJohns Hopkins University - Hospital at HomeMount Sinai Medical Center -- New York - Mount Sinai Visiting Doctors Program/ Chelsea-Village House Calls ProgramsPartners in Care Foundation - HomeMeds ProgramPrinceton HealthCare System - Partnerships for PIECEQuality Improvement for Complex Chronic Conditions - CarePartner ProgramSenior Services - Project Enhance/EnhanceWellnessSenior Whole Health - Complex Care Management ProgramSumma Health/Ohio Department of Aging - PASSPORT Medicaid Waiver ProgramSutter Health - Sutter Care Coordination ProgramUniversity of Washington School of Medicine - TEAMcar

Homelessness and Public Health in Los Angeles

Los Angeles faces a housing crisis of unprecedented scale. After years of underinvestment, in 2016/2017 LA County voters approved Measures H and HHH, which provided an infusion of resources for homeless services, permanent housing, and integrated outreach through the LA County Homeless Initiative (HI). An estimated 58,936 individuals in LA County remain homeless as of January 2019, 75% of them unsheltered and living on streets, in tents, or encampments. Our best estimates suggest that the homeless population has grown since 2017.HI takes a Housing First approach to homelessness, with the largest amount of total funds allocated to housing solutions. However, rehousing is often subject to delays in construction and case management. These delays, combined with persistent market forces driving new homelessness, have left the county well short of its targets. While no forecasts were issued, the initial gap analysis for HI had assumed a 34% reduction in the total homeless count from 2016 to 2019. The count has in fact increased by 26% over that period, meaning 28,000 more homeless clients than anticipated on any night. Whereas cities with comparable homeless crises such as New York have focused on increasing the availability of emergency shelters and safe havens in addition to permanent housing, LA County’s relatively low investment in transitional options has resulted in persistent levels of unsheltered homelessness.Research has shown that homelessness has severe health consequences. Homeless individuals have a high risk of mortality, with a recent LA County Medical Examiner report finding an average age of death of 48 for women and 51 for men. Homeless individuals have much higher risks of mental illness, substance abuse, infectious disease, chronic illness, violence, and reproductive health risks than the general population. Much less is known about the health burdens associated with being unsheltered, but most evidence points to substantially greater health risks given the more intense exposures to violence, weather, pollution, poor sanitation, and behavioral risk. Research is just beginning to quantify the burdens of living on the streets.Our analysis of the LA County homelessness response drew on expert interviews, data analysis, and document review. Beyond the growing numerical gap between HI’s targets and actual trends, we identified five critical service gaps that require immediate attention: Taking a person-centered approach that recognizes both the diversity of client needs and the limitations of existing resources, yet honors the principle that everyone deserves housing; Improving access to emergency shelters by reducing legal and political barriers to construction and adopting “low barrier shelters” that facilitate entry; Delivering comprehensive street medicine and other services to unsheltered homeless populations using evidence-based models that support the path to housing and recovery Adopting more extensive outreach models that engage citizens, empower homeless clients and leverage mobile technology so that case workers can focus on clients most in need; Strengthening data collection and research methods to understand the consequences of unsheltered homelessness, pilot new service models, and evaluate rehousing efforts

An examination of the ability of community health workers to effectively conduct community-based screening for cardiovascular disease in South Africa, Guatemala, and Mexico

BACKGROUND: This study explored training effectiveness for community health workers (CHWs) in a successful intervention in which they conducted primary screening for cardiovascular disease (CVD) in low resource settings. Implementation challenges related to scaling were explored with key informants. METHODS: A multiple methods assessment was conducted to: (1) quantitatively assess training effectiveness; (2) qualitatively capture the CHWs’ experience of training; (3) gather feedback from key stakeholders about factors anticipated to impact scaling the intervention to the population level. Change in knowledge levels at three different time points was determined through comparison of group means (ANOVA). The Consolidated Framework for Implementation Research (CFIR) guided the qualitative data collection and analyses, using nVIVO® and Atlas.ti® software, combined with manual coding. RESULTS: Training was effective at increasing content knowledge of CVD and the effect persisted for 3-6 months after completion of field work. CHWs felt empowered by the training and the acquisition of new skills but some expressed their reservations about written tests being used to accurately capture their capabilities. Some supervisors (nurses) perceived CHW training as a threat to their own professional standing while also acknowledging the value CHWs added to health services through their expert community knowledge and connections. CHWs remained frustrated by inadequate and irregular compensation, disrespect from formally trained health professionals, lack of career development pathways, and failure to account for the influence environmental factors – safety, extreme weather, and infrastructure – in workload planning. Key informants raised additional concerns about the negative impact of ineffective government communication regarding CHW programs and policies to communities and key actors in the health care system, including failure to consult key stakeholders, lack of clear role definitions, setting standards for training and performance evaluation, and lack of supervisory mechanisms. The issue of financing for CHW programs was not raised by key informants. CONCLUSIONS: Scaling strategies for successful interventions using CHWs need to be guided by well-designed implementation plans that include proactive, multi-level engagement with communities and health systems, and appropriate evaluation measures tied to health outcomes. Training effectiveness should be evaluated and linked to well-defined outcome measures in CHW’s programs that involve task-shifting