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TABLE OF CONTENTSACRONYMS .2EXECUTIVE SUMMARY .3INTRODUCTION .4METHODOLOGY .6KEY FINDINGS .7Knowledge and Competency Barriers .7Structural and Contextual Barriers .10Attitudinal Barriers .15CONCLUSION .17REFERENCES .181

CCUSAID2Anti-retroviral therapyAccredited social health activistJohns Hopkins Center for Communications ProgramsCommunity health agentCommunity health extension workerCommunity health workerDirectly Observed Treatment, Short-CourseHealth Communication Capacity CollaborativeHuman Immunodeficiency Virus/Acquired Immune Deficiency SyndromeIntrauterine deviceTuberculosisSocial and behavior change communicationUnited States Agency for International Development

EXECUTIVE SUMMARYSocial and behavior change communication (SBCC),which uses communication to positively influencethe social dimensions of health and well-being,is an important strategy for improving healthservices at the provider level. As community healthworkers (CHWs) play an increasingly importantrole in providing health services, there is also anincreasing focus on to how to use SBCC strategiesto build CHWs’ capacity to offer quality services tothe community members they serve. A key stepin designing and implementing effective SBCCprograms for CHWs is understanding the barriersand facilitators that effect CHWs in providingthese services. The aim of this literature review isto examine the barriers and facilitators to CHWservice provision in three areas: knowledge andcompetency barriers in which CHWs lack the skillsand knowledge to provide services, structuraland contextual barriers in which systemic andenvironmental factors influence CHWs’ abilityto provide services, and motivational barriers inwhich social norms and attitudes that effect CHWswillingness to provide services. In all three areas,findings revealed that CHWs face significant barriers,ranging from lack of materials and high workloadsto ingrained attitudes and insufficient training. Theresults and recommendations in this paper can beused to anticipate and respond to potential barriersand promote facilitators to service provision throughSBCC programs for CHWs.3

INTRODUCTIONThe Health Communication Capacity Collaborative(HC3) is a five-year global project funded by theUnited States Agency for International Development(USAID), designed to strengthen the capacity ofmiddle- and low-income countries to develop andimplement state-of-the-art health communicationprograms. HC3 is led by the Johns Hopkins Centerfor Communication Programs (CCP) and addressesimportant health issues, such as child survival, familyplanning, Ebola, HIV/AIDS and malaria.An important focus of this project is to determinehow to maximize the effectiveness of SBCCprograms within the context of low- and middleincome countries. While SBCC programming canbe influential at all levels of the health system, itsimpact within these countries’ contexts is particularlyimportant at the service provision level. Communitylevel providers represent the final link betweencommunities and the essential health services uponwhich they rely. In many cases, this responsibilityfalls upon CHWs, who are increasingly becomingprimary service providers in low-resource settings.HC3 aims to examine how SBCC programs thatfocus on improving CHW service provision can inturn strengthen CHWs’ ability to effectively deliverquality health care by developing provider-centeredstrategies that identify challenges to changingprovider behavior within these contexts.CHWs play a crucial role within health systemswhere geography, a lack of resources or a lack oftrust make providing health education and servicesthrough the more formal sector challenging. Theterm “community health worker” can apply to a widerange of health workers at the local level. However,for the purposes of this paper, a CHW is defined asa health worker who receives standardized trainingoutside of the formal nursing or medical curriculato deliver a range of basic health, promotional,educational and mobilization services, and has adefined role within the community system and largerhealth system.1 It should be noted, however, thatsome studies cited in this paper include CHWs withinthe broader category of local health workers. Thesepapers still present information that is representativeof and relevant to the CHW experience.Adopted from the USAID CHW Evidence Summit Steering Committee14As an increasingly significant component ofthe health system, CHWs present an importantopportunity to use SBCC strategies to improvehealth education and services. CHWs fulfill a broadscope of responsibilities within a community, fromproviding family planning education, and detectingand referring serious illnesses in remote areas todispensing anti-retroviral treatment (ART) andadministering immunizations. SBCC programmingcan improve the effectiveness and quality of theseservices through positively influencing the socialdeterminants that influence the CHWs’ work,such as knowledge, attitudes, norms and culturalpractices. Through identifying and addressingthese issues, CHWs can become more competentand conscientious in addressing the needs of theircommunities.Within community health work, numerous factorsexist that impede or improve CHWs’ ability toeffectively provide services to beneficiaries.Understanding these factors and how they may beinfluenced by a social behavior change programallows SBCC programs to anticipate and respond tobarriers through program objectives and design.HC3 conducted a literature review to identify barriersand facilitators to service provision commonlyexperienced by CHW programs. Specifically, thepaper presents barriers within three categories: Knowledge and Competency Barriers—CHWsdo not know how to perform assigned tasks. Structural and Contextual Barriers—CHWs arenot able to perform assigned tasks. Attitudinal Barriers—CHWs are not willing toperform assigned tasks.The aim of this paper is to serve as a tool toassist SBCC programs in recognizing potentialfactors that may influence CHWs, therebyhelping program designers, managers and otherstakeholders to better tailor their SBCC programsto meet these challenges. This paper also presentsrecommendations based on the findings from theliterature to guide stakeholders in conceptualizingand designing SBCC programs that can create

substantial and sustainable change. While thisliterature did seek to identify both facilitators andbarriers, the body of evidence provided moreinformation on challenges faced by CHWs thanon factors that increased effectiveness. This paperreflects the findings of literature and therefore,has a greater emphasis on barriers to, rather thanfacilitators of, effectiveness. Program designersshould also keep in mind that these findings andrecommendations are based on a broad analysis ofCHW programs in multiple countries, and that localcontexts should be evaluated and incorporated inthe design of specific programs.5

METHODOLOGYThe literature search included both peer-reviewedjournals and grey literature on the topic ofCHWs (with a particular focus on CHWs’ abilities,performance and attitudes), limited to resourcespublished in the last 10 years, which focused onmiddle- and lower-income countries. The databasesearch strategy included relevant terms from the6controlled vocabularies of the databases consulted(PubMed, SocINDEX and ERIC)—”community healthworkers,” “home health aid,” “home health provider,”“community health assistants,” “lay health worker,”“health extension worker” and “village health team,”supplemented with country terms, thesaurus termsand limits from each database as appropriate.

KEY FINDINGSKnowledge and Competency BarriersAs CHWs increasingly play a more prominent rolein providing health services in low- and middleincome countries, there is an increasing need toensure that CHWs possess the necessary knowledgeand competencies to satisfactorily perform theirexpanding roles. Effective training of new CHWs, aswell as training for existing CHWs in new topics andskills, ensures that health workers have the capacityto provide quality health education and services totheir target populations.Several studies note that CHWs’ level of knowledgeis an important factor in determining the successof a CHW program. A study of CHWs and auxiliarynurse midwives in India, for example, foundthat after adjusting for socio-demographicfactors, the knowledge level of CHWs was themost important factor in adherence to essentialnewborn care practice by new parents (Agrawalet al., 2012). Mothers who had been visited by ahighly knowledgeable CHW were twice as likelyto adhere to essential newborn care practices ascompared to those who were visited by CHWshaving less knowledge. A study of community-basedreproductive health agents in Ethiopia determinedthat the competency of CHWs also contributes to thesuccess of CHW service provision (Prata, Weirdert,Fraser & Gessessew, 2013). The study determinedthat successful uptake of contraception among thetarget population was a result of CHWs who hadbeen trained and, in turn, provided the most popularcontraception method, injectable contraceptives,rather than only condoms or pills.Despite the importance of CHWs as frontlineworkers in health care provision, evaluations of CHWprograms show that these health workers often lackthe knowledge necessary to safely and effectivelyperform their responsibilities. An evaluation ofcommunity health extension workers (CHEWs)tasked with providing family planning educationin Nigeria found that most CHEWs did not knowabout several family planning methods, such asintrauterine devices (IUDs) (Onwuhafua, Kantiok,Olafimihan & Shittu, 2012).Insufficient training leads to poor service qualityWhile knowledge and competency among CHWsis acknowledged as central to the success of CHWprograms, research shows that many programscontinue to provide training that is insufficient or ofpoor quality, resulting in knowledge gaps amonghealth workers. A study evaluating accreditedsocial health activists (ASHAs) in India found thatdespite training, there were still significant gaps intheir knowledge in child morbidity and mortality(Shrivastava & Shrivastava, 2012). Kalyango etal. compared post-training knowledge gainsbetween CHWs in Uganda who were trained in themanagement of both malaria and pneumonia withknowledge gains of CHWs trained exclusively inmalaria case management. While 88 percent of CHWstrained in the dual case management and 94 percentof those trained in malaria-only managementreported the training as sufficient, knowledgeassessments found that both groups scored anaverage of only 70 percent on malaria knowledgeand the dual case management group scored only60 percent on the pneumonia assessment (Kalyango,Rutebemberwa, Alfven, Ssali, Peterson & Karamagi,2012). The study demonstrates not only that bothCHW groups could benefit from additional training,but also that CHW perceptions of the quality of thetraining and their own knowledge and competencylevel do not necessarily align with actual knowledge.However, some studies show that CHWs canrecognize gaps in their knowledge base. Communityreproductive health workers tasked with providingfamily planning education in Uganda claimedthat additional training and factual informationwere necessary for them to effectively resolvemisconceptions about family planning amongcommunity members (Martinez, Vivancos, Visschers,Namatovu, Nyangoma & Walley, 2008). Successfultraining programs can lead to increased effectivenessand confidence among CHWs. Lay health workers inCambodia reported that their training, particularlythe discussion sessions, were helpful in increasingtheir knowledge, skills and confidence (Vichayanrat,Steckler & Tanasugarn, 2013).7

Improving the quality of training is not necessarilysufficient to improve long-term knowledge amongCHWs. The routine provision of refresher trainingsis also important in reinforcing and updating skillsand knowledge. A study in Madagascar found thatin a CHW contraceptive knowledge assessment,additional refresher courses were associated witha 13.2 percent increase in a CHW’s score (Gallo etal., 2013). A similar study in Kenya also showed thatrefresher courses led to increased adherence totreatment guidelines among CHWs (Rowe, Olewe,McGowan, McFarland, Rochat & Deming, 2007).Investment in ongoing training can lead to the longterm success of a CHW program. Nxumalo, Goudgeand Thomas compared three CHW programs inSouth Africa and found that the program that was byfar the most successful invested significantly moreresources in ongoing training than the other twoprograms (2013).One potential cause of unsuccessful trainingis when courses do not allot sufficient time forcontent mastery. This is particularly true whentrainings cover more complex or technical topics.For example, Chinbuah et al. found that CHWs inGhana successfully adhered to dosing guidelinesfor simple childhood illnesses, but did not adhere toreferral guidelines (2013). The study identified thecomplicated referral algorithms and guidelines asa possible cause of the sub-optimal performance.Similarly, in evaluating a CHW training course inthe use of rapid diagnostic malaria tests in the field,Blanas et al. found that shortly after the training, onlyhalf could correctly explain the program’s referralalgorithm, even when showed a visual depictionof it, and almost half could not prescribe first-linetreatment correctly (Blanas, Ndiaye, Nichols, Jensen,Siddiqui & Hennig, 2013).Research in India is consistent with the findingsof Blanas et al., showing that learning dosage andtreatment regimens can pose a challenge for CHWs.A report assessing the feasibility of using villagehealth workers to control visceral leishmaniasisfound that while the village health workersdemonstrated good knowledge of the presentingsymptoms, mode of transmission and diagnostictools, they showed poorer knowledge of treatmentregimens and few knew the specific drugs thatwere recommended as first-line medications andtheir specific durations (Malaviya, Hasker, Singh, vanGeertruyden, Boelaert & Sundar, 2013). Identifying8potentially challenging topics or skills and designingeffective training with sufficient time allocated tomaster these areas is essential for ensuring qualityservice provision.The knowledge barriers faced by CHWs extendbeyond technical topics. Research suggests thatCHWs would benefit from training on non-technicaltopics that would facilitate their effectiveness incarrying out their responsibilities. Nxumalo, Goudgeand Thomas (2013) found that training whichenhanced problem-solving skills helped CHWs torespond more efficiently to complex challenges.A study of CHWs in India found that those CHWsthat demonstrated better time management skillsscore higher on performance evaluations, leadingresearchers to suggest that additional trainingshould not be limited to subject matter topics, butalso should include training in managerial skills(Maji, Hutin, Ramakrishnan, Hossain, De 2010). Whencommunity reproductive health workers in Ugandawere struggling to overcome community barrierstoward family planning, researchers suggestedthat training in communication strategies mighthelp to overcome these barriers (Martinez, et al.,2008). Training in “soft” skills, such as problemsolving, management and communication, canprovide CHWs with the tools to address some of thechallenges they face within their work.Expanding roles and responsibilities requireongoing trainingOften, CHWs’ lack of knowledge stems from eithera formal or informal expansion of the CHWs’responsibilities without corresponding training.Increasingly, struggling health systems are shiftingtasks formerly performed by clinic staff to CHWs asa strategy to resolve human resources shortages(Smith et al. 2014; Tantchou & Gruenai 2009;Alamo, Wabwire-Mangen, Kenneth, Sunday, Laga,Colebunder 2012). While the initial orientationand training may properly address the anticipatedactivities of a CHW, over time, the increasing scopeof these activities can lead to gaps in knowledge andcompetency.A recent situational analysis of task-shifting toCHWs in Malawi found that instead of training allCHWs in a new task, clinics trained only one or twoCHWs and expected the remaining CHWs to learnthe new task on the job through informal peer-topeer instruction (Smith et al. 2014). CHWs felt that

this type of training was insufficient for some ofthe more complicated new responsibilities, suchas tuberculosis (TB) medication and ART. Similarly,lay health workers in Uganda were expected to addART services for children to their ART responsibilitieswithout receiving any training on counseling ortreatment for children (Rujumba, Mbasaalaki-Mwaka,Ndeezi 2010). The study found that 24 percent ofhealth workers were constrained by inadequateknowledge about pediatric HIV care and lack ofpediatric counseling skills. The consequences ofthe lack of training are compounded when CHWslack on-site support of health professionals. Aninvestigation into the high incidence of facilitybased obstetric hemorrhage in Malawi found thatthese facilities were being manned by local nursemidwives, who never received training in respondingto complicated situations, such as hemorrhages,and lacked the support of trained health personnel(Beltman, et al., 2013).Community demands of and expectations for CHWscan extend beyond the scope of CHWs’ knowledgeand competencies. Given CHWs’ role as local healthrepresentatives, community members often expectadditional assistance that CHWs are not equipped toprovide. Community health agents (CHAs) in Brazilwere called upon by community members to providesocial support, in addition to health education, suchas facilitating access to social services (Zanchetta,Salami, Perreault, & Leite, 2012). A study examiningthe use of CHWs for community-based distributionof a specific fever medication in Uganda foundthat community members were disappointed thatCHWs were only trained in treating a single illnessinstead of in an integrated approach to managingmultiple conditions (Nsabagasani, Sabiiti, Kallander,Peter

to examine the barriers and facilitators to CHW service provision in three areas: knowledge and competency barriers in which CHWs lack the skills and knowledge to provide services, structural and contextual barriers in which systemic and environmental factors influence CHWs’ ability to provide services, and motivational barriers in

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