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