Huyen Vu, MPH
Community health workers (CHWs) serve an increasingly important role as intermediary between patients and health services. In low-income and middle-income countries, where healthcare systems often face resource shortages, CHWs find themselves taking on a wide range of tasks and responsibilities. In these settings, providing strong supervision for CHWs is vital to ensuring consistent quality of care.
Studies suggest that effective supervision of CHWs can motivate them, create a sense of legitimacy for both CHWs and the community they serve, identify and correct poor CHW practices, and help resolve challenges unique to CHWs (Jenkins R et al., 2013; Ledikwe J et al., 2013; and Colvin C et al., 2013). In practice, however, the quality of CHW supervision is highly variable due to lack of skills and tools, limited transportation resources, financial obstacles, and cultural factors in the local health systems.
In an effort to help improve the quality of CHW supervision, Zelee Hill and her colleagues recently conducted a systematic review to identify different CHW supervision strategies that have been applied in low- and middle-income countries, along with implementation issues of those strategies. Below are some key findings from the review.
Gold-standards for CHW supervision
Supportive/facilitative supervision is considered the gold-standard practice in CHW supervision.
- Description: This approach is a process of guiding, monitoring and coaching CHWs to promote compliance with practice standards, and ensure the delivery of quality of care services. The strategy allows supervisors and supervised CHWs to work together as a team to achieve shared goals and objectives. Typically, a formal health worker from a local health center or district health facility provides supervision on a monthly or quarterly basis.
- Implementation issues: Time consuming process, challenges in maintaining supervision coverage and motivation, providing intensive external support during initial supervision, organizing lengthy supervisory visits, and providing timely post-supervision visit feedback.
- Example models: Lady Health Worker Program (Pakistan), Integrated Management of Childhood Illness (Benin), and Health Extension Workers Program (Ethiopia).
Innovative approaches to CHW supervision
Group supervision is identified as the most time and resource efficient practice as it allows supervisors to cover a large geographic area at lower cost. It is at least as effective as standard supervision, and can even be more feasible in some settings.
- Description: This approach involves a formal health worker supervising a group of CHWs (at a facility or in a community). On a monthly or quarterly basis, multiple CHWs come together for a facilitated meeting with their supervisor. Meetings may include regular supervisory activities such as data collection, problem discussion, and continuing education.
- Implementation issues: As this requires strong leadership and management skills, it would become challenging if supervisors are really not “supervisors.”
- Example models: Vurhonga Child Survival Project (Mozambique), and Female Community Health Volunteer Program (Nepal).
Peer supervision shows the most potential as it takes advantage of peer-to-peer empathy to facilitate supervision of CHWs through on-the-job training and mentorship.
- Description: In this approach, peers take on supervisory roles through peer-to-peer learning, support and problem-solving. Specifically, it focuses on having CHWs help other CHWs learn new skills and assess the quality of work performed by peer CHWs. Peer supervision can be conducted quarterly and be a substitute for traditional supervision for cost-saving purposes. Some common forms of peer mentorship include observation and feedback, stronger peers supporting weaker peers, and group meetings for problem discussion and solving.
- Implementation issues: May not be a best practice in all settings as it could create tensions between CHWs; CHWs may not challenge each other or be able to recognize their peers’ weakness; possible high workloads due to staff turnover.
- Example models: Integrated Management of Childhood Illness (Rwanda).
Community supervision is based on the idea that a community can hold CHWs accountable if they have relevant information about the delivery of services and patient rights.
- Description: In this approach, community groups, members, or associations play a role in defining expectations, providing feedback, and tracking CHW activity through monthly meetings.
- Implementation issues: Challenges in measuring success or impact; requires community-based training, resources, materials as well as strong community-based organizations.
- Example models: Community-based monitoring public primary health care provider (Uganda), and Community-Directed Interventions Program (multiple African countries).
- Description: This approach allows CHWs to self-identify their own strengths and weaknesses in specific practice areas by completing a knowledge test or quality improvement checklist, in the absence of a supervisor. The assessment, which can be conducted weekly, monthly, quarterly or at will, is usually followed by guidance on how to improve performance. The test result may be recorded and shared with a supervisor later.
- Implementation issues: Feasibility issues for this strategy include arranging time and recalling session to complete forms, fatigue with filling the same forms repeatedly, and accuracy of the self-assessment result from low-performing CHWs.
Many strategies exist to ensure effective supervision of CHWs, yet care should be taken to match the best strategy to the setting. Lauren Crigler and colleagues stress the importance of achieving an agreement among key policymakers, stakeholders, and program managers on a supervision strategy before the supervision approach is designed. Some principles to consider are:
- Study and identify what has already existed in the system, and build upon it
- Use a bottom-up approach by involving CHWs and local communities in the design and implementation of supervision process
- Concentrate on planning of supervision, and make sure to monitor progress
- Hold all parties accountable, including senior managers, supervisors, CHWs, communities, and clients
- Develop skills at all levels, such as teamwork, data management, problem identification, prioritization, and resolution.
Clayton Velicer MPH
The ability to work in non-traditional medical settings gives peer supporters, promotoras, community health workers (CHWs) and other community-based caregivers a distinct advantage. Providing home-based visits for chronic disease care, for example, can benefit patients who otherwise may experience barriers to care because of culture, socioeconomic and/or health-related barriers. Previous research in this area has found home visits by CHWs to improve health outcomes for African American and Latino and Mexican American adults with type 2 diabetes.
Nelson and colleagues recently published a protocol paper highlighting the Peer-Support for Achieving Independence Diabetes (Peer-AID) intervention being conducted in King County, Washington, that aims to examine the effectiveness of CHWs in delivering diabetes self-management education in a home-based setting.
This blog highlights the Peer-AID protocol paper, explains its unique study design, and discusses implications for future care.
Background and Participants
The purpose of the Peer-AID study is to evaluate the clinical and cost-effectiveness of home-based CHW care to improve health outcomes among low-income patients with poorly controlled type 2 diabetes. Participants will receive health care at three different health systems. A total of 297 participants, between 30 and 70 years old, low-income and from diverse racial and ethnic backgrounds, have been recruited from a county hospital, a VA hospital and local community health center. As part of the study, they will receive either a home-based intervention over 12 months, or standard care.
The core component of the intervention is disseminating adoption of self-management behaviors that lead to improvements in type 2 diabetes control. Specifically, CHWs will work with their clients at their homes to set behavioral goals, identify feasible actions to achieve those goals, evaluate the progress of the actions toward the goals, and revise actions to make them more effective. Self-efficacy is prioritized, as increased self-efficacy is linked to improved quality of life, patient satisfaction, and glycemic control.
At the first visit, the CHW will help the patient evaluate personal diabetes self-management behaviors, health history, health care access, and health care utilization. The CHW and patient will then collaboratively develop an individualized diabetes self-management plan. Six mandatory education topics include general diabetes information, blood sugar information, blood glucose monitoring, treatment, diet, physical activity and medication. Other topics will be included based on the initial assessment. A complete set of education and training protocols is available online.
Training for CHWs
Training for CHWs is consistent with the American Diabetes Association and American Association of Diabetes Educators self-management education recommendations. The CHWs are trained to work with patients to set behavioral goals and improve self-efficacy based on a client-centered style and motivational interview techniques. Overall, the CHWs will complete 60 hours of training including didactic sessions, in-class exercises and field practices and they will receive training in health coaching and motivational interviewing by a professional health coach.
CHWs will be trained to provide social support for participants (e.g., joining group community-based activities that complemented home visits), and encourage family and other members of participants’ support networks to help participants by encouraging lifestyle changes and medication adherence, attending clinic visits, and providing emotional support.
Cultural and linguistic competency is also emphasized in the intervention, according to participants’ preference. Bi-lingual CHWs communicated in the patients’ primary language while educational materials are provided in both Spanish and English.
The Peer-AID study includes both primary and secondary outcomes, with the primary outcome being the participants’ HbA1c level. Secondary measurements include health-related quality of life, and diabetes self-management based on the Summary of Diabetes Self-Care Activities measurement (e.g., general and specific diet, exercise and physical activity, medication adherence, blood-glucose testing, foot care, and smoking).
The Peer-AID study plans to evaluate costs based on training, CHW utilization, and healthcare costs including self-reported clinic utilization, hospitalization and medication use.
As mentioned, one of the unique skills that peer support workers and CHWs can provide to chronic disease management is the ability to provide care outside the traditional medical center. CHWs and peer support workers may more easily gain access to a participant’s home because of shared cultural and community background, and in some cases, lived experience with the specific medical condition.
Neilson and colleagues highlight some of the mechanisms that may make peer supporters and community health workers particularly effective when providing home-based care:
“Basing the intervention in the home allows observation of home and social conditions affecting diabetes management, provides participants a more relaxed and comfortable setting, eliminates logistical barriers to attending diabetes education in classes or clinics, provides opportunities for CHWs to role-model and observe participants in practicing self-management behaviors and allows CHWs to meet household members and enlist their support in helping the participant self-manage.”
By evaluating a wide variety of health outcomes and behaviors over a 12 month period, the Peer-AID study will provide a unique opportunity to examine long term effectiveness of these home-based visits. Furthermore, by evaluating the costs associated with this program, Neilson and colleagues may be able to demonstrate to healthcare providers the financial benefit of providing home-based visits to those with diabetes. If effective in reducing hospitalizations, this model may be of particular interest to providers working with usage populations as a method of controlling costs. We encourage our readers to share their thoughts and experiences of home-based care from peer supporters, CHWs and promotoras and we look forward to the results of this promising study.
Sarah Kowitt, MPH
Two weeks ago marked my second trip to the annual American Diabetes Association conference. Held in San Francisco, the conference brought together experts from around the world to tackle the most pressing issues in diabetes care and research. As a PhD student in Health Behavior, here are my takeaways from the sessions.
Meeting People from Around the World
The ADA conference was attended by approximately 17,300 people from more than 121 countries. Anecdotally, I heard that 40% of the attendees came from outside the United States. With a “World Cup Lounge” set up on the second floor where participants could watch live football matches, this was not hard to believe.
While presenting my poster on emotional support for patients with type 2 diabetes, I struck up conversations with a researcher from Montreal, a health educator from Orlando, a doctor from Nigeria, a diabetologist from Denmark, and a nurse practitioner from China. I also participated in symposia featuring peer support programs in Cameroon, Argentina, Hong Kong, and along the US-Mexico border.
Clearly, diabetes is an issue of worldwide concern and people from all over the globe were united in their quest to find solutions. As one attendee stated, “health is the world’s greatest equalizer.”
I was impressed by the variety of health disciplines represented in the conference; physicians, researchers, behavioral health scientists, nurses, dieticians, pharmacists, and a whole range of other health care professionals that conduct diabetes research or deliver diabetes care.
Overall, I think this points to several issues. First, because diabetes affects so many millions of individuals and is associated with so many other health conditions, a diverse team of health care professionals is needed. Over the lifespan, support is necessary for prevention, management of disease, care for early complications, hospitalization, and end of life support.
Second, this diversity speaks to the need for concerted policies, programs, and strategies to tackle diabetes. We are not going to find a magic bullet to solve our diabetes problems; rather, we will need coordinated, multi-level strategies.
More than Diabetes
Not only did people come from a range of professions, but also they were also interested in issues beyond diabetes.
For instance, I attended a session on the role of gut bacteria in diabetes and obesity, in which the presenters spoke about how the types of bacteria in our body influence our immune system, metabolism, and development of obesity and insulin resistance. Admittedly, as a PhD student in behavioral (not clinical) sciences, I was lost in some of the clinical language, but the links that the authors presented between our genes, environment, and immune system were fascinating. For instance, our gut is home to over 100 trillion microorganisms and different species of bacteria have different effects on appetite and metabolism. Healthy gut bacteria are thus crucial for appetite regulation, weight, metabolism, and insulin resistance.
I also attended a session on the overlap between diabetes and depression, sat in on a symposium extolling the benefits of high intensity, short duration exercise, and listened to speakers discuss the implications of New York City’s food environment on diabetes and obesity.
Diabetes is associated with a number of other conditions, including obesity, mental health disorders, cardiovascular disease and hypertension, to name a few, which explains why the conference participants were interested in so many different diseases. Research is starting to show that peer support is a strategy that can target both diabetes and comorbid conditions.
Overall, I’m grateful that I had the opportunity to join the 74th ADA conference. With 96 symposia, 50 oral abstract sessions, 10 interest group discussions, 18 meet-the-expert sessions, 10 special lectures and addresses, and more than 2,000 poster presentations, I was only able to experience a small portion of the conference offerings. Looking forward to next year!