Question & problem
Community Health Workers (CHWs) are first line community-based health care workers in many low- and middle-income countries (LMIC) contexts, particularly rural ones. They are lay paid workers or volunteers who undergo relatively short training on specific health services. CHW roles can include building relationships between health services and communities, conducting health promotion activities, providing clinical services, and supporting access to specialized care. In LMIC contexts, where diagnosis of disability is often delayed, CHWs can play a key role in screening and linking individuals with disability to care. In addition, they can provide basic disability related community health education and counselling. There is evidence that CHWs can effectively provide services for dementia, and depression (including perinatal depression), and conduct screenings for developmental disabilities and hearing loss. However, CHW programs are often over extended and face conflicting health challenges and priorities, including issues of incentivisation, supervision and program financing.
Quote
Recommendations
Key recommendation
Action
Identification of context-specific disability care needs by conducting needs assessments, stakeholder engagement and collection of routine data to culturally adapt training (focusing on knowledge and skills) for CHWs. Before implementing training it is wise to pilot test of the capacity-building curricula to inform its feasibility and effectiveness through feedback from CHWs, people with disabilities and other relevant stakeholders responsible for implementation
Strengthening supervision through continuous learning opportunities, performance improvement indicators and fidelity measures, including training supervisors on soft skills.
Incorporating disability care into CHW mandates and job descriptions to ensure the smooth integration of disability care in CHW roles.
Key recommendation
Action
Development of locally contextualized screening tools by working alongside people with disabilities, local stakeholders, familities, healthcare providers to ensure that the tools are sensitive to users’ needs and easy to administer by CHWs. Usability can be enhanced by developing local care standards with short texts, practical guidelines and pictorial content and by incorporating these tools into CHW training
After the initial training, it is important to ensure continued access to screening tools and other disability care material for continuous learning of CHWs and making appropriate updates and revisions to the curriculum
Key recommendation
Action
To produce the evidence for the integration and sustainability of CHW training programs, it is crutial to conduct localized implementation research through pilot and feasibility projects comparing different models of CHW integration and sustainability to advise policymakers on the cost effectiveness and scalability of approaches
Implementation research should identify and test methods to improve CHW services including incentivization strategies based on workload, motivation, supervision and remuneration to inform performance based incentives and professional development opportunities that can mitigate high levels of attrition in the workforce
Key recommendation
Action
Development of a local CHW national policy that advises organisations on standardised incentives, defined roles and responsibilities, guidelines for services, coverage indicators and integration into the broader health system. The policy should also focus on sustaining CHW programs through quality mechanisms for funding, capacity-building, supervision and support for CHWs by engaging with governmental agencies, community bodies and funders to secure reliable resources for programs.
Challenges
Challenge #1: There are a range of disability care services, ranging from screening to care and referral, that CHWs are ideally placed to provide. However, they lack the mandate and training to do so.
- Children and elderly people with disabilities can face difficulties in reaching healthcare facilities. CHWs can bridge this gap by providing home-based care. They can also be trained to screen for developmental disabilities and peri-partum depression and psychosis as part of their work providing maternal and child health services. However, only a few pilot programs have as yet utilized CHWs in this way.
- There is significant evidence for the role CHWs can play in autism screening, developmental delay screening, and dementia screening, mental health education, treatment and referrals. CHW services can improve symptoms of depression (including peri-partum depression), anxiety, and post-traumatic stress disorder. CHWs may provide basic ear related treatments such as washouts or ear drop instillation; but such interventions need to be further tested via pilot studies.
- Inadequate CHW training and/or poor supervision reduces their motivation and erodes community trust in CHWs. Training on disability care needs to utilize knowledge and skill-based learning, be tied to ongoing support/mentorship and address social and rights-based perspectives. Regular care supervision is better than longer or more frequent trainings. However quality of supervision may not be emphasized enough by CHW programs.
Challenge #2: Lack of availability of locally adapted, easy to use evidence-based disability screening tools, testing devices and community health education materials for use by CHWs due to evidence gaps or supply chain issues.
- While they cannot make a formal diagnosis, there is evidence that trained CHWs can effectively screen children for developmental delay (DD). There are a number of DD screening tools that have been successfully used by CHWs in South America, Asia and Africa but these need to be scaled. Autism screening tools have been proven effective in LMIC, but they have not been delivered by CHWs, which is a gap in research. For other disabilities that are diagnosed in infancy or childhood, there is a need to develop or adapt screening tools. For dementia screening programs, it is important to use tools that take into account potentially lower literacy levels in LMIC settings. Disability health education materials for CHWs use also needs to be further developed.
- Lack of availability of devices, health education materials and medicine due to supply chain failure can erode community trust in CHWs, as well as cause demotivation among CHWs and is cited as one of the key challenges faced by CHW programs.
Challenge #3 There is lack of evidence available on the provision of services by CHWs for a range of disabilities. Efforts to generate this evidence need to be supported by advocacy, governance, research and health sectors.
- While evidence is available for autism or developmental delay screening, mental health, dementia and peripartum depression care there is limited evidence on the effectiveness of CHWs for a wider net of common disabilities.
- The broad range of disabilities brings with it its own unique needs and challenges. CHWs require special training and skills to support individuals with different types of disabilities, however this also makes it challenging to develop standardised interventions or approaches
Challenge #4 Existing challenges with CHW programs, particularly relating to workload, task prioritization and reimbursement need to be addressed so that new disability programs can be successful.
- Many countries lack CHW policies, causing CHW role limitation and confusion. Conflicting/poorly defined roles force CHWs to prioritize among health services. High work-loads worsen program quality. Programs embedded within health systems with well-defined roles and fewer tasks are more successful.
- CHW dissatisfaction with existing payment models, especially volunteer models, is documented and lowers motivation and care quality.
- There is abundant disease specific research on CHW effectiveness, but more research on how CHWs can form a part of the health system and provide broader care is missing.
Finding the answers
Six databases (PubMed, Global Health, Cochrane Reviews, Taylor and Francis Online, Campbell and Google Scholar) were searched for meta-analyses, systematic reviews, and scoping and narrative reviews. After reviewing these databases, five articles were selected for inclusion in the review. All of these articles documented evidence from both high- and low-income countries. As CHW skills are transferrable across health conditions, one review of reviews highlighting learnings from various CHW programs was also included.
Recommendations & actions
Key recommendation
Action
Identification of context-specific disability care needs by conducting needs assessments, stakeholder engagement and collection of routine data to culturally adapt training (focusing on knowledge and skills) for CHWs. Before implementing training it is wise to pilot test of the capacity-building curricula to inform its feasibility and effectiveness through feedback from CHWs, people with disabilities and other relevant stakeholders responsible for implementation
Strengthening supervision through continuous learning opportunities, performance improvement indicators and fidelity measures, including training supervisors on soft skills.
Incorporating disability care into CHW mandates and job descriptions to ensure the smooth integration of disability care in CHW roles.
Key recommendation
Action
Development of locally contextualized screening tools by working alongside people with disabilities, local stakeholders, familities, healthcare providers to ensure that the tools are sensitive to users’ needs and easy to administer by CHWs. Usability can be enhanced by developing local care standards with short texts, practical guidelines and pictorial content and by incorporating these tools into CHW training
After the initial training, it is important to ensure continued access to screening tools and other disability care material for continuous learning of CHWs and making appropriate updates and revisions to the curriculum
Key recommendation
Action
To produce the evidence for the integration and sustainability of CHW training programs, it is crutial to conduct localized implementation research through pilot and feasibility projects comparing different models of CHW integration and sustainability to advise policymakers on the cost effectiveness and scalability of approaches
Implementation research should identify and test methods to improve CHW services including incentivization strategies based on workload, motivation, supervision and remuneration to inform performance based incentives and professional development opportunities that can mitigate high levels of attrition in the workforce
Key recommendation
Action
Development of a local CHW national policy that advises organisations on standardised incentives, defined roles and responsibilities, guidelines for services, coverage indicators and integration into the broader health system. The policy should also focus on sustaining CHW programs through quality mechanisms for funding, capacity-building, supervision and support for CHWs by engaging with governmental agencies, community bodies and funders to secure reliable resources for programs.
Policy priorities
There is a need to develop national CHW policies specifying their mandates as well identifying sustainable strategies for increasing range of services to include disability care. It is by explicitly investing in the welfare and professional development opportunities that the CHW workforce can be encouraged to adopt new populations and diverse support roles into their routine care provision. Governments should be responsible for engaging with a wide range of stakeholders to ensure sustainable and ongoing funding and transparent quality standards for CHW programs that focus on disability care, including disabled peoples organizations (DPOs), provincial civil bodies, community organizations and professional healthcare associations. A national policy for CHWs will be essential for advising integration into different healthcare priorities as well as establishing mechanisms for the monitoring and evaluation of the policy impact.
Conclusion
CHWs can be utilized for education, screening and care for common disabilities and are ideally placed to reach these harder to access populations. In addition, evidence exists for effective disability service provision by CHWs for a range of tasks. However, in order for disability care to be successfully incorporated into CHW programs, there is a need to research strategies for expansion of these programs, as well as of sustaining them by incorporation into the wider health system. There is also a need to minimise conflict of health priorities within CHWs by expanding this workforce.
Gaps & research needs
- Screening tools developed in high-income countries are often copy-righted with prohibitive costs and can not be used by health care providers or scientists in LMICs. While selecting tools to evaluate, researchers should focus on building an evidence base for tools that are available free of cost and can be used by CHWs in LMICs.
- There is a need to pilot test delivery of autism screening tools by CHWs in LMICs.
- Caution needs to be used by dementia researchers to select standards and tools that adjust for lower literacy levels in LMICs.
- There is a need for studies evaluating efficacy of clinical history of ear and hearing taking by CHWs, as well as for provision of basic hearing related treatment.
- There is a need to pilot test interventions delivered by CHWs for a broader range of disabilities.
- There is a need to study methods for increasing CHW coverage and program scalability.
- There is a need to study how to maintain adequate quality supervision and program quality in the process of transition to scale
Acknowledgements
Peer Review: This evidence brief has been reviewed by Sarah Marks, Research Fellow at the International Centre for Evidence in Disability and Onaiza Qureshi, Knowledge Exchange Officer at the Disability Evidence Portal.
Publication details: © London School of Hygiene & Tropical Medicine, April 2023.
Suggested citation: Maria Iqbal. Evidence Brief: What role can community health workers play in disability services in LMICs? Disability Evidence Portal, April 2023.
Disclaimer: The views expressed in this publication are those of the author/s and should not be attributed to Disability Evidence Portal and/or its funders