The Word from ASTMH: Community Health Workers are the Eyes and Ears in Health Interventions

This post describes discussions held at the annual meeting of the American Society for Tropical Medicine and Hygiene (ASTMH), held November 13-17, 2016, in Atlanta, GA.

When someone gets sick in low and lower middle income countries, community health workers (CHWs) are the first to hear about it. Though these individuals have no clinical credentials and at most three years of paraprofessional training pertaining to a specific health intervention or treatment, they form a vital link in the chain of communication between community members, health professionals, researchers, and policymakers.

Because CHWs live or work in the areas they serve, they notice and report unusual symptoms that other health personnel may not get chances to see. Director of the Pan American Health Organization (PAHO) Dr. Carissa Etienne referred to one such example in the opening keynote address of the 2016 ASTMH Annual Meeting. “Astute front-line health care workers” reported a strange rash occurring among residents of Brazil in 2014. Specialists determined the rash was one of the first signs of the Zika virus.

“Community health providers serve as a bridge between communities and the formal health system,” affirms Theresa Hoke, FHI360’s Director of Health and Human Services, during a panel on Community Providers for Neglected Tropical Disease Control. Community members trust them. Their attention to common behaviors and any unexpected departures from the norm helps save lives and save money.

Hoke summarized a successful intervention developed by Daniel G. Datiko and Bernt Lindtjørn in Ethiopia regarding health extension workers who received additional training to identify and collect samples from persons suspected of having tuberculosis (TB), and to treat individuals who tested positive.[1] Hoke reported, “The cost of delivering these TB services in health facilities was 2.6 times higher compared to this community-level treatment.” Furthermore, the trained health workers identified and successfully treated significantly more cases than health workers who did not undergo the additional tuberculosis training, especially among female patients.

CHWs can be especially helpful when research teams propose health interventions for disease prevention among communities. They can relay feedback from community members to help researchers understand which interventions are likely to work. In the implementation phase, CHWs can relay to community members how the intervention will help prevent a particular disease. “That’s where quite a lot of health interventions fail, because communities don’t necessarily understand the need or the rationale behind the intervention, which then leads to poor uptake of the intervention,” summarized Christian Rassi, Project Coordinator for the Malaria Consortium, during a panel on Schistosomiasis Epidemiology and Control.

Stephen Luby, a medical epidemiologist at Stanford University, learned this lesson firsthand. During a panel on the Influence of Behavior and Culture within Water, Sanitation and Hygiene Interventions, he related that his team traveled to an area in Bangladesh where the people were accustomed to washing their hands with slivers of bar soap stuck to the walls of latrines.

When his team installed a chlorine tank for water purification, community members reported several problems: The chlorinated water smelled unappealing. The tanks were bulky and difficult to reach, and women had to spend even more time getting water for drinking and handwashing. Fewer than 10 percent of the people who had access to chlorine tanks added chlorine to their water over a twelve-month period.

So Luby and his team set out to determine whether promoting the use of soapy water in bottles placed near latrines could improve hand hygiene uptake. Their research – published in the American Journal of Tropical Medicine and Hygiene – leveraged CHWs to get the message out. The team trained local female community members to conduct household visits and give public demonstrations on preparing and using soapy water. In addition, the CHWs delivered soapy water to certain study sites, conferring with members of their community on the most opportune placement for the dispensers. While communities that received soapy water alongside promotion saw the greatest improvement, promotion alone made a big difference – with 18 percent more households having soapy water on hand upon a return visit.

These and other examples demonstrate how the voices of CHWs empower communities and spark healthy behavior change.  Simply put, these individuals – often volunteers – make disease control and elimination programs work, which makes them in turn the unsung heroes of global health.  

Photo: Community health workers in Honduras undergo training to conduct coverage surveys. (Katherine Gass, NTD-SC)

[1] Daniel G. Datiko and Bernt Lindtjørn (2009), “Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial,” PLOS ONE 4(5): e5543.