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Given shortages of health care providers and a rise in the number of people living with both communicable and non-communicable diseases, Community Health Workers (CHWs) are increasingly incorporated into health care programs. We sought to explore community perceptions of CHWs including perceptions of their roles in chronic disease management as part of the Academic Model Providing Access to Healthcare Program (AMPATH) in western Kenya. In depth interviews and focus group discussions were conducted between July 2012 and August 2013. Study participants were purposively sampled from three AMPATH sites: Chulaimbo, Teso and Turbo, and included patients within the AMPATH program receiving HIV, tuberculosis (TB), and hypertension (HTN) care, as well as caregivers of children with HIV, community leaders, and health care workers. Participants were asked to describe their perceptions of AMPATH CHWs, including identifying the various roles they play in engagement in care for chronic diseases including HIV, TB and HTN. Data was coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization and considering CHWs as a potential enabling resource. A total of 207 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 34 healthcare providers participated. Participants identified several roles for CHWs including promoting primary care, encouraging testing, providing education and facilitating engagement in care. While various facilitating aspects of CHWs were uncovered, several barriers of CHWcare were raised, including issues with training and confidentiality. Suggested resources to help CHWs improve their services were also described. Our findings suggest that CHWs can act as catalysts and role models by empowering members of their communities with increased knowledge and support.
The AMPATH Consortium, based in Eldoret, Kenya (about 350km north-west of Nairobi) was initiated in 2001 as a joint partnership between Moi University School of Medicine, Moi Teaching and Referral Hospital (MTRH) [35, 36], and a consortium of North American universities led by Indiana University School of Medicine. With financial support from United States Agency for International Development (USAID), the USAID-AMPATH Partnership was established in 2004. The history, organizational structure, and health programs of AMPATH have been described elsewhere [35, 37]. The AMPATH Consortium provides technical support, mentorship and training to Kenyan medical faculty and staff with the aim of developing healthcare services in Kenya. AMPATH delivers care, provides education, and performs research in networks of urban and rural Ministry of Health hospitals, health centers, and dispensaries in western Kenya. The initial goal of the program was to establish an HIV care system to serve the needs of both urban and rural patients as well as to assess the outcomes and barriers of antiretroviral therapy (ART). AMPATH has enrolled over 160,000 HIV-infected adults and children plus 21,000 HIV-exposed infants in >65 Ministry of Health facilities around western Kenya. Currently, >85,000 patients are actively followed, 83% of whom are on combination ART; 21% are aged ≤14 years. All HIV and tuberculosis (TB)-related care and treatment are free at the point of service for patients. Patients are managed according to National Kenyan protocols, which are consistent with WHO guidelines. While AMPATH initially focused on patients infected with HIV, it has since expanded to provide primary health care, maternal and child health services and chronic disease management (specifically diabetes and hypertension) to a catchment population of over 2 million persons [26]. This study was undertaken in three AMPATH sites, namely Chulaimbo, Teso and Turbo. CHWs are volunteers who are recruited from the community with input from Community Health Extension Workers (CHEWs) and members from the village, sub-location and district. They are often recruited through a baraza (i.e., a meeting with community elders) [34]. Ideally, CHWs should be literate and respected so that they can help to motivate others in their communities. In general, they receive approximately 6 weeks of initial training and quarterly refresher training [34]. In the current Kenyan government model, CHWs are supervised by a facility-based and government-employed CHEW. Each community unit, made up of approximately 5000 people is supported by 50 CHWs and 2 CHEWs. Each CHEW supervises approximately 25 CHWs [34]. CHEWs support CHW through supervision and coaching and meet with their CHWs ideally monthly [38]. CHWS perform numerous tasks both in households but also in the community at large. Essentially the role of CHW is to identify health needs, educate and manage some conditions at the household level and link/refer patients to health facilities. Their main tasks include disease prevention and control, family health services and hygiene and sanitation [39]. Specific tasks include taking vital signs, dispensing meds, providing individual and group education, community mobilization, and advising on proper diet/nutrition and sanitation/hygiene. Other tasks may include defaulter tracing, raising awareness of NCD control, caring for the chronically ill, and health promotion. CHWs are also trained on aspects related to community and household entry and data collection methods. Currently within AMPATH CHWs are considered volunteers, although at the time of the study were receiving 2000 Kenyan Shillings per month (~$20 USD) for overseeing 50 households. CHWs also received training certificates. At the time of this study, AMPATH worked with CHWs who were trained to do home-based HIV testing and some able to take blood pressure. Point of care testing has always been available at health facilities, however it has primarily been performed by facility-based providers (e.g., nurses and clinical officers) rather than CHWs. This study targeted patients within the AMPATH program including patients receiving HIV, TB, and HTN care, as well as caregivers of children with HIV, community leaders (religious leaders, traditional healers, village elders, assistant chiefs), and healthcare workers including the AMPATH safety net team (Nutritionist, Psychosocial, Outreach, Social Work teams) and providers (AMPATH clinical team, Ministry of Health staff). This was an exploratory qualitative study conducted between July 2012 and August 2013. The goal of the study was to understand the role of CHWs in linkage and retention, what they need to do their work and how communities perceive them. Study participants were purposively sampled from the three AMPATH sites: Chulaimbo, Teso and Turbo. Specifically, individuals were recruited if they could provide different perspectives on CHWs and their roles, could share their experiences, behaviours and perceptions, and have an understanding of the cultural and societal context. Individuals needed to be a resident of one of the three catchment areas. In-depth interviews and focus group discussions (FGDs) were used to collect data. We conducted a total of 16 in-depth interviews and 26 FGDs. Tables Tables11 and and22 shows the distribution of participants per site. FGD were utilized only for patient groups as they were considered a more homogenous group. In-depth interviews were held with community leaders and provider groups only as they were considered a more heterogeneous group that was purposely selected based on their unique and comprehensive knowledge on the topics relevant for the present study. PLWH = People Living with HIV; HTN = hypertensive patients; TB = TB Patients; Caregiver = for children living with HIV; Safety Nets = includes nutritionists, outreach workers, social workers, psychosocial works; HCW = Health Care Worker including clinical officers, nurses, pharmacists and lab technicians. Participants were asked to describe their perceptions of AMPATH CHWs including identifying the various roles they play in terms of chronic disease management including engagement in care for HIV, TB and HTN. A question guide was developed and individuals were asked: What is your perception of the AMPATH CHWs as linkage-to-care facilitators (Probes: confidentiality, what information do they give? Is there enough education?). As well, participants were asked: What linkage information do you think should be given by the CHWS at the community-level (Probes: What kinds of resources should they use? What information should resources contain?). Related to this was exploring positive and negative attributes of CHWs as well as identifying the resources CHWs need to be able to effectively link individuals to care. In addition, basic socio-demographic information including age, gender, educational level and occupation was collected. Trained research assistants identified the target groups at AMPATH health facilities and informed them about the study. Health facility in-charges assisted with contacting the participants. The interview sessions and FGDs took approximately 1 hour and were conducted in either, English, Swahili, Kalenjin, or Luo. All sessions were audio recorded and for the FGDs, scribes also recorded session proceedings. At the end of each session participants were provided with transport reimbursement of 200 Kenyan Shillings. This research was program driven and was situated within the broader AMPATH Care Program with the goal of improving linkage and retention of patients within existing clinics. It was considered a low-risk rapid appraisal. Consent was obtained prior to beginning data collection and again prior to commencing audio recording. While consent forms were not used, transcripts from the FGDs and in-depth interviews demonstrate agreement and consent to proceed with the data collection. Note that ethical approval for this study was obtained through an amendment of a larger AMPATH Program protocol that received ethical approval from the Institutional Research and Ethics Committee (IREC) of Moi University College of Health Sciences and Moi Teaching and Referral Hospital as well as the Indiana University Institutional Review Board (IRB). Recorded interviews were transcribed and translated to English. The data were then coded and themes related to general perceptions of CHWs, perceptions of CHW roles and resources used by CHWs to facilitate engagement in care were identified. Ideas from different interviews were pooled together and integrated into common themes. Concepts from these themes were generated and we used a conceptual model based on the Andersen-Newman Framework of Health Services Utilization to organize the presentation of the results. In the Andersen Newman Framework (Fig 1), an individual’s access to and use of healthcare is a function of three main factors: 1) Predisposing Characteristics (socio-cultural characteristics of individuals that exist prior to their illness); 2) Enabling Resources (the logistical aspects of obtaining care, which can include personal, family and community resources); and 3) Need Factors (the most immediate cause of healthcare use from problems that generate the need for care) [40]. In this analysis, CHWs are viewed as a potential enabling resource and we organized the findings based on positive and negative perceptions of CHWs as either enabling (i.e., facilitators) or inhibiting effective management of HIV, TB and HTN (i.e., barriers), respectively. For validation, independent coding and identification of themes were conducted by five investigators. We started with a codebook that had a priori codes that were derived from the original question guide. The 5 investigators worked independently to identify emerging inductive codes that were then added to the codebook as necessary although data was also interpreted based on pre-existing knowledge about the context, the study objectives and the identified themes. Training relating to qualitative data analysis including coding and thematic analysis was also provided. All had extensive experience collecting and analyzing qualitative data. Note that no software was used. The final write up consisted of summaries, interpretations and textual excerpts.
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