What do community health workers have to say about their work, and how can this inform improved programme design? A case study with CHWs within Kenya

Background: Community health workers (CHWs) are used increasingly in the world to address shortages of health workers and the lack of a pervasive national health system. However, while their role is often described at a policy level, it is not clear how these ideals are instantiated in practice, how best to support this work, or how the work is interpreted by local actors. CHWs are often spoken about or spoken for, but there is little evidence of CHWs’ own characterisation of their practice, which raises questions for global health advocates regarding power and participation in CHW programmes. This paper addresses this issue. Design: A case study approach was undertaken in a series of four steps. Firstly, groups of CHWs from two communities met and reported what their daily work consisted of. Secondly, individual CHWs were interviewed so that they could provide fuller, more detailed accounts of their work and experiences; in addition, community health extension workers and community health committee members were interviewed, to provide alternative perspectives. Thirdly, notes and observations were taken in community meetings and monthly meetings. The data were then analysed thematically, creating an account of how CHWs describe their own work, and the tensions and challenges that they face. Results: The thematic analysis of the interview data explored the structure of CHW’s work, in terms of the frequency and range of visits, activities undertaken during visits (monitoring, referral, etc.) and the wider context of their work (links to the community and health service, limited training, coordination and mutual support through action and discussion days, etc.), and provided an opportunity for CHWs to explain their motivations, concerns and how they understood their role. The importance of these findings as a contribution to the field is evidenced by the depth and detail of their descriptive power. One important aspect of this is that CHWs’ accounts of both successes and challenges involved material elements: leaky tins and dishracks evidenced successful health interventions, whilst bicycles, empty first aid kits and recruiting stretcher bearers evidenced the difficulties of resourcing and geography they are required to overcome. Conclusion: The way that these CHWs described their work was as healthcare generalists, working to serve their community and to integrate it with the official health system. Their work involves referrals, monitoring, reporting and educational interactions. Whilst they face problems with resources and training, their accounts show that they respond to this in creative ways, working within established systems of community power and formal authority to achieve their goals, rather than falling into a ‘deficit’ position that requires remedial external intervention. Their work is widely appreciated, although some households do resist their interventions, and figures of authority sometimes question their manner and expertise. The material challenges that they face have both practical and community aspects, since coping with scarcity brings community members together. The implication of this is that programmes co-designed with CHWswill be easier to implement because of their relevance to their practices and experiences, whereas those that assume a deficit model or seek to use CHWs as an instrument to implement external priorities are likely to disrupt their work.

The findings reported in this paper are based on a structured, in-depth qualitative case study of two communities in Kenya – one urban and one rural. The study was part of a project exploring the development, implementation and evaluation of a practice-based mobile learning intervention. The aim of the study reported here was to develop a thorough and systematic account of CHW’s practices, providing a baseline to inform the development and evaluation of subsequent interventions. Given the gaps identified in the literature above, particular concerns included the patterns of communal engagement and support, and the training and supervision of CHWs. A case study was chosen as the methodological approach because these are well suited to developing an in-depth understanding of contexts and issues, allowing for the ‘social construction of meaning in-situ’ (17, p. 33). The emphasis here is on the identification and description of issues as identified and understood by the CHWs and other CTC actors, as a precursor to theory development, claims about prevalence or other generalisations. Such cases can also contribute to theory refinement by generating interpretations, which can be useful in limiting other generalisations or identifying areas of complexity that warrant further study (18). Used in such ways, case studies support better informed understandings of factors influencing complex interventions (19), thus minimising the implementation variation (20) across sites when more generalisable methodologies (such as randomised control trials) need to be used. The kinds of analytical generalisations that case studies support also. The study therefore explored CHWs’ roles and practices, generating an explanation of the day-to-day practices of CHWs in their own words, and allowing an investigation of how CHWs understand their roles. Specifically, the study invited them to reflect on the challenges they face, and the forms of support that might help them with these. A case study approach was required to explore these open-ended, practitioner-focused questions. Both sites are located within Kenya. National statistics (21) show that the country is characterised by sharp contrasts between urban and rural households, for example in terms of access to improved water sources (90% urban, slightly over 50% rural) or electricity (around 65% urban, 8% rural), although access to mobile phones is comparatively high (86% of urban households, 53% of rural). Infant mortality nationally stands at 52 deaths per 1,000 live births, although mortality rates differ considerably by province. Home births are more common in rural than urban areas (63% compared to 25%) and only 44% of births are assisted by a doctor, nurse or midwife. Amref’s own internal statistics provide a more detailed picture, and are used here to help characterise the study sites. The first study site is a semi-arid rural county in Eastern Kenya which experiences long droughts, resulting in high poverty levels. The county has a low number of skilled health workers, low access for CHWs to continuing education to improve their capacity in service delivery, an estimated 86% shortage of CHWs and a doctor to population ratio of approximately 1:119,879. Health care services are delivered through an estimated 138 health facilities. Only 28% of women are recorded to deliver at health facilities (the national average is 46%), and only 42% seek four antenatal care visits, with 36% attending postnatal care services. The second site is an urban informal settlement in Nairobi. Health care provision is extremely limited, poorly resourced and difficult to access, making the extended reach of CHWs critically important. This site was important because over 34% of Kenyans live in urban areas; 71% of these live in informal settlements. The community is characterised by high levels of poverty, insecurity and inadequate access to basic social services. There is little or no access to water, electricity, basic services and adequate sanitation. Most structures are let on a room-by-room basis with many families (on average six people, compared to a national average household of 4.2) living in just one room. These factors have serious health repercussions, demonstrated by the child mortality rate: for every 1,000 children born in Nairobi’s informal settlements, 151 will die before the age of five (the average for Nairobi as a whole is 62). While these two study sites cannot be treated as statistically representative of all instances of CHWs’ working contexts, they provide compelling evidence from two contrasting situations from which lessons can be learned. Wide regional disparities in health services and shortages of human resources in the health sector make the availability and accessibility of health services in Kenya challenging. Prompted by these challenges in general and in response to deteriorating maternal and infant mortality rates specifically, in 2006, the Ministry of Health decided to decentralise the provision of health services and to devise a new health strategy, the Kenyan Community Health Strategy (22). A plan for the training and involvement of CTC providers on a regional level was designed and implemented in 2008. The administrative structure of this new community health strategy was divided into six levels: Level 6 – the national level; Level 5 – the provincial level; Level 4 – the district level; Levels 3 and 2 – the Health Facility Level; and Level 1 – the CHC level. This administrative and managerial decentralisation of the country’s health service provision allowed the communities to participate in health decision making on levels 1, 2 and 3, i.e. at a community and at a health facility level. According to these administrative levels, a district health management team now manages the committee of the health facilities, who in turn manages CHCs, and the CHCs manage their voluntary CHWs. (CHWs in Kenya have been re-titled as Community Health Volunteers, or CHVs; however, the more widely accepted term, CHW, will be used throughout this paper.) These voluntary CHWs are linked to primary health facilities through trained health workers employed in the facilities – called community health extension workers (CHEWs) (22). The CHEW’s role followed the supervisory model outlined by Mireku et al. (13). Currently, two government-employed CHEWs supervise 50 voluntary CHWs – although under revisions to the community health strategy it is proposed that in the future, five CHEWs will supervise 10 voluntary CHWs. The voluntary CHWs are managed by their CHCs. The purpose of the CHC is to represent issues affecting the provision of health services in the communities and direct resources and CHWs towards them. According to the community health strategy implementation guide (22), the CHC’s roles include: Members of the CHC are elected at the assistant chief’s baraza (a meeting with community elders) and generally are elders or of respectable social status. Together, these administrative and managerial structures constitute the community health strategy and shape the roles of CTC providers. The voluntary CHWs receive basic, 2-week long community health training from Amref Health Africa, Africa’s largest International Health NGO (23). Amref Health Africa is an African-based organisation that aims to strengthen the capacity and capability of health and health-related professionals and institutions in Africa through training, research, health care provision and advocacy. Its mission is to ‘improve the health of people in Africa by partnering with and empowering communities, and strengthening health systems’ (www.amref.org/about-us/who-we-are/#sthash.7xI5xIoB.dpuf, accessed 1 March 2015). Through a variety of different projects and partnerships, including e-learning initiatives and tailored community health courses, Amref Health Africa is training health workers in close to 35 African countries. It relies on an extended network of relations with governments, international donors and the private sector. In a 2010 report, Amref described itself as follows: From its decades of engagement with Africa’s most remote and impoverished populations, Amref has developed a specialised approach to its work in health. Much of its credibility with local communities and African governments stems from the relationship and trust that Amref has built over the past 54 years. Amref learns from, influences and partners with communities and community organisations; local and national governments and ministries of health; national and international NGOs and networks; global, regional institutions and donors to build long-term relationships and to ensure solutions are holistic and address the breadth of the communities’ health needs. (23, p. 4) The study reported here was conducted with CTC providers working directly under the community health strategy, i.e. the voluntary CHWs, the CHEWs and the CHCs, in two communities in Kenya – one a rural community, the other an informal settlement. To address the gap in understanding CHW’s practice identified above, a rich body of data was gathered through a series of four steps. Firstly, focus groups were held with groups of CHWs at which they were invited to talk through what they tended to do each day; these accounts were treated as data in their own right, but were also used to prompt mind-mapping activities that generated overviews of CHW practice. Following on from this, CHWs were given disposable cameras and asked to take images of their work, and the places in which this took place. This helped to ground the accounts of practice that CHWs gave. Thirdly, notes and observations of community meetings and monthly meetings contributed to a better understanding of the relationships between the CHWs as well as their supervisors, and the training needs and challenges identified by them. Finally, a series of interviews was undertaken with CHWs and representatives of the groups that were responsible for shaping their practice. The analysis presented in this paper focuses on the interview transcripts. The population for this study was the individuals identified as CHWs by Amref, drawn from two of the communities they support. In addition, individuals working with the CHWs were invited to participate, to provide a wider context for their accounts. The sampling was purposive, inviting participation to ensure a diversity in terms of region (rural community, informal settlement), gender, length of time in post and role (CHW, CHEW and CHCs). According to Mireku et al. (13, p. 22), ‘The CHC is the health governance structure adjoining the community; members are elected at the assistant chief’s baraza (administrative meeting with community elders) to allow for representation of all villages in the CU.’ Their inclusion provided a community-led account of CHW’s activities to be added to the analysis. In all, the sample consisted of eight CHWs, four CHEWs and two CHC members). The analysis in this paper draws on the interviews conducted with CHWs, CHEWs and CHC members (CHCs). A semi-structured approach was adopted, using themes identified through analysis of the preceding focus groups and visual mapping work. The interviews were conducted by two researchers, one from the UK partner and one from Amref; the UK researcher had spent time working with Amref in situ in order to develop sensitivity to the local culture and issues prior to beginning the interviews. Sections of the interview were dropped where these were not relevant to the interviewee. This provided consistency across participants whilst remaining flexible enough to respect the time and interests of those being interviewed. The interviews were transcribed by the research team. Each interview was analysed thematically. Transcripts were reviewed and exhaustively coded following a systematic process (24), and anonymised by replacing names with a tag, including reference to the field site (M – the rural site, or K – the informal settlement), interviewee’s role (CHW, CHEW, CHC) and when multiple individuals from a specific site and role, a numeral (1, 2, etc.) to distinguish them. For example, MCHW1 refers to the first CHW interviewed at field site M. Coding was crossed checked by two researchers, leading to refinement of the coding method. The coded extracts were then grouped and summarised. The relationship between code groups was considered, in some cases leading to the amalgamation of separate categories under superordinate groups. An important consideration was the relationship between routine and exceptional incidents: it would have been possible either to describe normal practice first, and then exceptions to it; or else to describe both normal and exceptional incidents of each kind of practice. The final decision was the latter, giving an overview of CHW’s practices, and within each, describing both normal and exceptional incidents. The resulting coding structure is reflected in the findings, below. In qualitative research, trustworthiness can be established by using well-established research methods, developing an early familiarity with the culture of participating organisations, triangulation, iterative questioning that provides depth and uncovers inconsistencies in accounts, frequent debriefing with the lead researchers and representatives of Amref through discussion of issues arising, peer scrutiny, ‘thick description’ of the case (25), and maintaining a detailed audit trail (26). The steps outlined above provided early familiarity with the communities and the CHWs; triangulation was achieved through comparing the accounts provided by CHWs, including contrasts across the two field sites, and through the interviews with CHEWs and CHCs, which provided independent (and sometimes challenging) perspectives on CHW’s work; the semi-structured interviews included sustained questioning about specific incidents in practice; the researchers engaged in regular debriefing during both data collection and analysis; and peer scrutiny and ‘thick description’ is provided in the reporting below. For the audit trail, field notes were taken during the empirical phase; coding notes were preserved; and coding decisions were recorded. For example, the quotes included below are all tagged, so that they can be traced back to specific interviews for context. Themes were identified independently, and consensus established through discussion, focusing on specific excerpts. The study followed the ethical guidelines of the British Educational Research Association and of Amref Health Africa, both of which required informed consent, guarantees of confidentiality and anonymity for participants, and the right of participants to withdraw and have their data removed. Care was taken to ensure that all participants understood that they were acting as volunteers, and were under no obligation to participate in the project. To avoid the influence of power relations on disclosure, the interviewers held no structural position in relation to interviewees, and in addition, the recordings and transcripts were kept confidential and anonymised, so that those with authority over participants had no access to the data set. The ethical protocol, including briefing sheets and informed consent forms, received approval from the lead institution’s ethical review board and from Amref.

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