Policy options for improving the performance of community health workers (CHWs) in maternal and child health in Brazil: analysis of barriers and facilitators to CHW national programme and evaluation of a community-based trial in Recife

Background and objectives. Studies and international agencies\u2019 policy documents, while acknowledging the potential of Community Health Worker (CHW) programs in improving reproductive maternal newborn and child health (RMNCH) outcomes, underline the scarcity of strong evidence of effectiveness and solicit more in-depth investigations on the implementation process of such programs. Recent developments about how to improve service quality in RMNCH emphasize the need of a system approach, according to which any attempt to evaluate and improve the overall system, or part of it, should take into account the overall complexity and interdependency across actors and components. Moving from the intersection between the current debate on CHWs, the emphasis on quality improvement and system approaches to health systems, the research is aimed at developing analytical and policy tools that may be used to improve the performance of CHWs in Brazil, a country whose CHW program is considered among the most valuable models globally. Methods. A three step process has been envisaged. The first step, through a systematic review of qualitative studies conducted in Brazil on CHWs and building on concepts driven from the international literature, develops a logic model to describe factors influencing CHWs\u2019 performance in Brazil and their underlying mechanisms. The second step, moving from a case study built around the impact evaluation of an intervention trial targeting CHWs in the city of Recife and aimed at supporting quality home visits to pregnant women and mothers, is aimed at providing further insights on barriers and facilitators to interventions designed to improve CHWs\u2019 performance, and at further validating the model. The third step uses the logic model to identify and systematize policy options, contextualized to the Brazilian system, to improve the performance of CHWs across all their attributions and tasks as well as in a specific area such as RMNCH. Results. The systematic review, confirming the findings of international literature, showed that, although the main factors influencing CHWs\u2019 performance reside in the formal health system components and in the sub-system elements of the CHW program, the community system is a powerful source of complex interactions that may act either as facilitators or as barriers of CHWs\u2019 performance. A logic model was developed to facilitate the identification, analysis and visualization of these factors and their dynamics. The case study confirmed the validity of the model for analyzing and interpreting the results of the intervention and, by explaining the reasons for its partial failure, provided hints about how interventions and policies aimed at improving CHWs\u2019 performances should be conceived. Using the model as the reference framework, policy options were systematized according to the health and community system components and proposed as a comprehensive compendium and as policy packages according to the various levels of responsibility regarding CHW program in the Brazilian health system. A model for prioritization criteria was also proposed. Conclusions. The analytical and policy tools that were developed may be useful for a more systematic and evidence-based approach to improving the performance of CHWs in Brazil. The systematization of influencers of CHWs\u2019 performance and their mediators can be used to describe the institutional and stakeholders\u2019 response to CHW program. The logical model, populated with institutional and behavioral facilitators and barriers, can serve to identify areas that requires action for program strengthening. The policy compendium can facilitate, at various levels of the system, the development and prioritization of policy packages aimed at improving RMNCH-related tasks of CHWs in a broader systemic perspective, recognizing that most factors influencing specific tasks of CHWs are cross-cutting and need to be addressed as such

Innovating home visiting to mothers and infants by community health workers: an action-oriented guide

Abstract Objectives: to describe the process of development and the structure of an action-oriented guide for home visits (HVs) to mothers and infants by Community Health Workers (CHWs). The guide was adopted in a controlled trial aimed at assessing its efficacy in improving CHWs' performance. Methods: steps to develop the guide included: 1) Review of international and national standards and recommendations for community interventions for maternal and child care; 2) Assessment of perceived needs of CHWs and other Family Health professionals regarding prenatal and postnatal HVs; 3) Identification of elements to construct the guide. Results: the Guide provides action-oriented instructions for 10 HVs during prenatal and postnatal period up to 9 months instead of the 18 HVs currently recommended by Ministry of Health. Specific tasks for each visit including assessment and promotion of early child development (ECD) and an action-oriented risk classification are introduced as standardized operational practice. Conclusions: the described approach to guide construction allows adapting the guide contents to the health system context in Brazil and other countries interested in improving quality of HVs by CHWs. The guide, by identifying tasks to be carried out and actions to be taken at each HV, provides an innovative approach and represents a requisite for a more efficient and effective use of their time

Visitas domiciliares inovadoras e a saúde materno‑infantil

Objetivo: Avaliar o efeito de um programa de Visitas Domiciliares Inovadoras (VDI), que é baseado em um guia de orientação, nos conhecimentos e práticas de saúde das mães em relação aos cuidados da criança e durante os períodos pré/pós-natal, e indicadores de saúde materno-infantil (ISMI). Métodos: Estudo transversal e analítico que comparou 195 gestantes e mães que receberam VDI (grupo 1) com o grupo 2, de visitas domiciliares convencionais (VDC), realizado em Unidades de Saúde da Família (USF) de Recife, Pernambuco, entre 2015 a 2016. Dividiram-se 16 equipes de saúde da família em dois grupos: oito equipes receberam treinamento para VDI e oito não receberam. Houve dez VDI com a utilização do guia, durante a gestação e durante os nove meses da criança. As VDC ocorreram uma vez/mês, durante o mesmo período das VDI, mas sem o guia. Após nove meses, as participantes foram entrevistadas através de questionário com conteúdos relacionados à saúde materno-infantil. Resultados: 93 gestantes (49 do grupo 1 e 44 do 2) e 102 mães de crianças (57 do grupo 1 e 45 do 2) responderam aos questionários. Os resultados mostraram melhores indicadores de pré-natal (p=0,005), melhor conhecimento sobre métodos contraceptivos (

Innovating home visiting to mothers and infants by community health workers: an action-oriented guide

Abstract Objectives: to describe the process of development and the structure of an action-oriented guide for home visits (HVs) to mothers and infants by Community Health Workers (CHWs). The guide was adopted in a controlled trial aimed at assessing its efficacy in improving CHWs' performance. Methods: steps to develop the guide included: 1) Review of international and national standards and recommendations for community interventions for maternal and child care; 2) Assessment of perceived needs of CHWs and other Family Health professionals regarding prenatal and postnatal HVs; 3) Identification of elements to construct the guide. Results: the Guide provides action-oriented instructions for 10 HVs during prenatal and postnatal period up to 9 months instead of the 18 HVs currently recommended by Ministry of Health. Specific tasks for each visit including assessment and promotion of early child development (ECD) and an action-oriented risk classification are introduced as standardized operational practice. Conclusions: the described approach to guide construction allows adapting the guide contents to the health system context in Brazil and other countries interested in improving quality of HVs by CHWs. The guide, by identifying tasks to be carried out and actions to be taken at each HV, provides an innovative approach and represents a requisite for a more efficient and effective use of their time

Effectiveness of an action-oriented educational intervention in ensuring long term improvement of knowledge, attitudes and practices of community health workers in maternal and infant health: a randomized controlled study

Abstract Background The potential role of Community Health Workers (CHWs) in improving maternal and child health outcomes, particularly in low and middle-income countries and in disadvantaged communities, is receiving increased attention. Adequate and focused training is among the key requisites for enhancing CHWs performances and research is necessary to identify effective training methods. Methods A randomized controlled study was designed to assess the effectiveness of a training course in improving knowledge, attitudes and practices (KAP) of CHWs regarding maternal and infant health. Seventy-eight CHWs belonging to Family Health Units in the city of Recife, Brazil were randomly allocated to intervention and control groups. The intervention group took part in a four-day interactive training course based on an action-oriented guide to perform home visits to pregnant women and their infants throughout pregnancy and infancy until 9 months of age. KAP in intervention group after training and after 1 year were compared to control group and to baseline. Results Fifty-nine CHWs completed all KAP assessments (31 in intervention and 28 in control group). Baseline characteristics were similar in both groups. At 1 year from training, the intervention group had higher overall KAP score (120.65 vs. 108.19, p <  0.001) as well as knowledge (47.45 vs. 40.54, p <  0.001), practice (53.45 vs. 49.11, p <  0.001) and attitudes scores (19.74 vs. 18.81, p = 0.047) than the control group. Moreover, at 1 year from training, the intervention group maintained significant improvements in overall KAP score (120.65 vs. 106.55, p <  0.001) as well as in knowledge (45.45 vs. 42.13, p <  0.001), and practice (53.45 vs. 45.29, p <  0.001) scores with respect to baseline. In the control group, overall KAP (106.59 vs. 108.19, p = 0.345) as well as separate knowledge, attitudes and practices scores remained unchanged. Conclusions A four-day interactive training course on action-oriented home visits to pregnant women and infants produced a sustained improvement of CHWs’ KAP and may represent a model to ensure retention of acquired competences. Trial registration RBR-9gchqr. Date registered: July 21, 2018 (Retrospectively registered)

Innovating home visiting to mothers and infants by community health workers: an action-oriented guide

Abstract Objectives: to describe the process of development and the structure of an action-oriented guide for home visits (HVs) to mothers and infants by Community Health Workers (CHWs). The guide was adopted in a controlled trial aimed at assessing its efficacy in improving CHWs' performance. Methods: steps to develop the guide included: 1) Review of international and national standards and recommendations for community interventions for maternal and child care; 2) Assessment of perceived needs of CHWs and other Family Health professionals regarding prenatal and postnatal HVs; 3) Identification of elements to construct the guide. Results: the Guide provides action-oriented instructions for 10 HVs during prenatal and postnatal period up to 9 months instead of the 18 HVs currently recommended by Ministry of Health. Specific tasks for each visit including assessment and promotion of early child development (ECD) and an action-oriented risk classification are introduced as standardized operational practice. Conclusions: the described approach to guide construction allows adapting the guide contents to the health system context in Brazil and other countries interested in improving quality of HVs by CHWs. The guide, by identifying tasks to be carried out and actions to be taken at each HV, provides an innovative approach and represents a requisite for a more efficient and effective use of their time