Community Health Workers: An
Essential but Challenging Component
of an Integrated Agriculture-Health
ProgramDr. Frederick K.E. Grant
International Potato Center-SSA
Integrated Nutrition Conference Sept 14-15 2015, Nairobi, Kenya.
Linking Agriculture & Nutrition to Health: the search for alternative effective delivery systems
• 5 year study in Western Kenya (2009-2013)
• Can linking OFSP access and nutritional training to existing health services provide:
• an incentive to pregnant women to increase health service utilization?
• increases in consumption of OFSP and other vitamin A rich foods by the women and their young infants in a cost-effective manner?
• Partners: CIP in collaboration with PATH (International Health NGO), Univ. of Toronto, Emory Univ., CREADIS & ARDAP ( 2 Local Agricultural NGOs), MoA & MoH
Mama SASHA Project : testing linking OFSP to health
services for pregnant women foriIncreased impact on
nutrition in Western Kenya
Roles and responsibilities of the CHW
• Recruitment of participants: home visits, community outreach with women’s groups, churches, village leaders
• Participate in initial and refresher training
• Intervention delivery
– Establish and operate pregnant women’s clubs
– Support Mama SASHA activities at the clinic –distribute vouchers, conduct group nutrition education
– Support women to pick up vines from vine multipliers, home visits
– Conduct demonstrations at the community & field day
Roles and responsibilities of the CHW
• Participate in monthly feedback meetings for implementing partners in health and agriculture
1. Cluster randomized at facility level – 4 intervention and 4 comparison facilities across Bungoma and Busia counties
2. Cross sectional baseline and endline surveys (n>2000 / round)– Objective: Assess population level impact on child nutrition
– Design: 2 stage cluster randomized surveys in catchment areas of intervention and control facilities; Mar-May 2011 and Mar-May2014
– Detailed costing data for cost-effectiveness analysis
3. Nested Cohort Study (COVA) – Assess individual level impacts on maternal and child nutrition
– Design: Longitudinal study of 505 women enrolled in pregnancy and followed to 9 months postpartum; Nov 2012-July 2014
4. Operational researchConducted twice (2010 & 2012) during the five year project period to inform project design and assess feasibility and acceptability of intervention
EVALUATION STRATEGY
Timeline for major implementation and research activities under Mama SASHA
FINDINGS
PROJECT REACH (Implementation from March 2011 to August 2013)
14 DVMs established
4 intervention sites
Over 4,600 women reached
7,159 voucher pairs issued
4,464 redeemed (63%)
3,281 women
CHWs established & run 215
PMCs/LMCs
2,764 members
18,730 attendances
784 mothers participated
monthly
254 newly recruited women
monthly
Activities and outputs per CHW
Activity Average output per CHW
Attend Chief Barazas (4x/y) 15 min/m
Home visits (recruitment) (1x/mo) 60 min/m
PWCs (1x/mo) 60 min/m
Follow-up with VMs, ANC, CHEW, etc. (1x/mo) 30 min/m
Other outreach: women’s group, clinic outreach, local dispensaries, etc. (1x/mo)
30 min/m
Feedback meetings (1x/mo) 300 min/m
Church meetings (4x/y) 15 min/w
Home visits (monitoring) (1x/w) 60 min/w
Health talks at facility (3x/w) 480 min/w
• Active CHWs per facility for Mama SASHA project• Naitiri (N=28); Sinoko (N=19); Mihuu (N=12); Ndalu (N=16)
Monthly average of 630 mins / 10.5 hours per CHW
CHW time allocation and annual cost per year
CHWactivities
%of
timeUSD/year
%of
time
Training 19% $148 14%
Awarenessraising 10% $78 8%
ImproveknowledgeandpracticesforOFSP15% $121 11%
ConductFielddays 6% $45 2%
ConductDemonstrations 2% $12 1%
Integration-coordinateandmonitor 30% $233 47%
Healthservicedelivery 19% $151 17%
Totalcostperfacilityperyear $789
Naitiri Sinoko
USD/year%of
timeUSD/year %oftime
95 23% 70 21%
53 11% 33 13%
75 20% 60 19%
16 6% 18 4%
7 4% 14 0%
320 32% 100 39%
118 4% 13 4%
$683 $309
Sinoko NdaluMihuu
USD/year
70
44
66
13
0
133
13
$340
Ndalu
CHW allowances & impact on output• April 2011 each CHW received 1000 KSh ($11.8 USD) /month
– Plus 500 KSh to cover transport to the monthly meetings
• May 2012, stipend was reduced in half by the Ministry
– Resulted in reduced output of the CHWs
– Decreased project intervention uptake by participants
• Incentivized through provision of badges and awards to CHWs
– Resulted in increased CHW output and hence increased uptake of project intervention
Finding 1: Knowledge of nutrition, child care & health seeking behaviors were significantly higher among women who fully participated than those who partially participated or resided in control areas.
Control Intervention Participation Level, Intervention Areas
Variable Areas Areas None Partial Full
Nutrition knowledge score 4.4 (0.08) 5.1 (0.08) 4.5 (0.11) 5.1 (0.13) 6.5 (0.20)
0.000 0.770 0.000 0.000Vitamin A knowledge score 2.8 (0.05) 3.4 (0.05) 3.1 (0.07) 3.3 (0.09) 4.4 (0.12)
0.000 0.004 0.000 0.000Knowledge about health service seeking score 5.8 (0.05) 6.0 (0.05) 5.6 (0.08) 6.1 (0.08) 6.6 (0.11)
0.002 0.082 0.001 0.000Knowledge about child care score 9.2 (0.08) 9.4 (0.08) 8.8 (0.11) 9.6 (0.13) 10.6 (0.15)
0.021 0.007 0.007 0.000OFSP knowledge score 3.1 (0.05) 4.1 (0.05) 3.5 (0.08) 4.3 (0.09) 4.9 (0.10)
0.000 0.000 0.000 0.000Attitude on child caregiving and feeding OFSP 5.4 (0.18) 6.1 (0.17) 5.1 (0.25) 6.0 (0.30) 8.3 (0.38)
0.005 0.449 0.082 0.000
Number of observations 1108 1163 536 386 235
Note: in this and subsequent tables, standard errors in parentheses are clustered at the sub-locality level; p values are in italics, comparing each participation group with the control group
Quantitative results 1
Finding 2: Intake of vitamin A rich foods & ANC visits higher
among women who fully participated than those who partially
participated or resided in control areas
Control Intervention Participation Level, Intervention Areas
Variable Areas Areas None Partial Full
Index of days consumed vitamin A rich foods6.1 (0.12) 6.4 (0.13) 6.1 (0.18) 6.0 (0.19) 7.7 (0.35)
0.093 0.849 0.748 0.000
Proportion with inadequate frequency (<6)0.6 (0.02) 0.6 (0.01) 0.7 (0.02) 0.6 (0.02) 0.5 (0.03)
0.856 0.189 0.803 0.003Proportion consuming any type of sweetpotato ≥1/wk 0.7 (0.01) 0.8 (0.01) 0.8 (0.02) 0.8 (0.02) 0.9 (0.02)
0.000 0.000 0.000 0.000
Proportion consuming OFSP at least once a week0.1 (0.01) 0.4 (0.01) 0.2 (0.02) 0.4 (0.03) 0.7 (0.03)
0.000 0.000 0.000 0.000
Number of times attended ANC 4.4 (0.05) 4.5 (0.05)4.3 (0.07) 4.6 (0.09)
4.8 (0.10)0.208 0.214 0.036 0.008
Number of Obs. 2271 1108 1163 536 390
Quantitative results 2
Conclusions • CHWs were essential for assuring the multi-sector
integration
– But few African health systems fund them
• Many projects use CHWs, recognizing the need to go-to-scale with community level interventions
– But how long is it realistic to expect a CHW to serve ‘gratis’ or for too low pay?
• Innovative approaches for financing CHWs and advocacy targeting policy makers based on evidence of their effectiveness is warranted
Thank you from the Mama SASHA Team
RESEARCH AND IMPLEMENTATION TEAM
Frederick Grant, PhD | International Potato Center
Jan Low, PhD| International Potato Center
Donald Cole, MD, MPH | University of Toronto
Carol Levin, PhD | PATH & University of Washington
Aimee Webb Girard, PhD | Emory University
Rose Wanjala, MPH | International Potato Center
Haile Selassie Okuku, MSc | International Potato Center
Ellah Kedera | PATH
Moses Wamalwa | International Potato Center
Thank you from the Mama SASHA Team
We gratefully acknowledge the contributions of
Participants, vine multipliers, community health workers and
health facility staff
Research assistants, enumerators and support staff
Cornelia Loechl, PhD | IAEA, Vienna, Austria
Hermann Ouedraogo, PhD | UNICEF, Chad, N’djamena
Yvonne Wangui Machira | Consultant Nairobi, Kenya
Rikka Transgrud, MPH | PATH, Nairobi, Kenya
Abdelrahman Lubowa, MSc | Consultant
Numerous MPH, MSc and PhD students