What makes community health worker models for tuberculosis active case finding work? A cross-sectional study of TB REACH projects to identify success factors for increasing case notifications

(2022) 20:25 Dam et al. Human Resources for Health https://doi.org/10.1186/s12960-022-00708-1 Open Access RESEARCH What makes community health worker models for tuberculosis active case finding work? A cross‑sectional study of TB REACH projects to identify success factors for increasing case notifications Thu A. Dam1, Rachel J. Forse1,2* , Phuong M. T. Tran1, Luan N. Q. Vo1,3, Andrew J. Codlin1, Lan P. Nguyen4 and Jacob Creswell5 Abstract Background: In the field of tuberculosis (TB), Community Healthcare Workers (CHWs) have been engaged for advocacy, case detection, and patient support in a wide range of settings. Estimates predict large-scale shortfalls of healthcare workers in low- and middle-income settings by 2030 and strategies are needed to optimize the health workforce to achieve universal availability and accessibility of healthcare. In 2018, the World Health Organization (WHO) published guidelines on best practices for CHW engagement, and identified remaining knowledge gaps. Stop TB Partnership’s TB REACH initiative has supported interventions using CHWs to deliver TB care in over 30 countries, and utilized the same primary indicator to measure project impact at the population-level for all TB active case finding projects, which makes the results comparable across multiple settings. This study compiled 10 years of implementation data from the initiative’s grantee network to begin to address key knowledge gaps in CHW networks. Methods: We conducted a cross-sectional study analyzing the TB REACH data repository (n = 123) and primary survey responses (n = 50) of project implementers. We designed a survey based on WHO guidelines to understand projects’ practices on CHW recruitment, training, activities, supervision, compensation, and sustainability. We segmented projects by TB notification impact and fitted linear random-effect regression models to identify practices associated with higher changes in notifications. Results: Most projects employed CHWs for advocacy alongside case finding and holding activities. Model characteristics associated with higher project impact included incorporating e-learning in training and having the prospect of CHWs continuing their responsibilities at the close of a project. Factors that trended towards being associated with higher impact were community-based training, differentiated contracts, and non-monetary incentives. Conclusion: In line with WHO guidelines, our findings emphasize that successful implementation approaches provide CHWs with comprehensive training, continuous supervision, fair compensation, and are integrated within the *Correspondence: 1 Friends for International TB Relief, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Hanoi, Vietnam Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Dam et al. Human Resources for Health (2022) 20:25 Page 2 of 12 existing primary healthcare system. However, we encountered a great degree of heterogeneity in CHW engagement models, resulting in few practices clearly associated with higher notifications. Keywords: Tuberculosis, Community healthcare workers, TB REACH, Impact evaluation, Active case finding Background Since the adoption of the Alma Ata Declaration in 1978 and most recently the Astana Declaration in 2018, primary care with community health workers (CHWs) has been considered a critical path to attain healthcare for all [1, 2]. The specific definition of CHWs can differ, with the term encompassing a diverse group of “lay and educated, formal and informal, paid and unpaid health workers”. These CHWs provide services such as health education and can refer or support individuals and families seeking preventative or curative care. In recognition of the importance of community networks in health, the Global Strategy on Human Resources for Health: Workforce 2030 in 2016 was adopted by the 69th World Health Assembly and subsequently the World Health Organization (WHO) issued guidelines on health policy and system support to optimize CHW programs [3, 4]. These guidelines specifically offered a set of recommendations on CHWs selection, training, management and supervision, career advancement, community embeddedness, and health system support. Despite substantial evidence on CHWs and their positive impact on communities [5, 6], there remain key knowledge gaps. In particular, the WHO guidelines cited knowledge gaps across six key themes: (1) intervention activities; (2) recruitment/selection; (3) training; (4) compensation/remuneration; (5) supervision; and (6) sustainable integration into the health system [4]. Moreover, studies have decried the lack of evidence on how to integrate and support CHWs within health systems and the “rights and needs of CHWs” [5]. Another review posited that efficacy assessments of CHW projects were carried out under ideal circumstances, leading to a need for more evidence under “real world” conditions [7]. Prior to the COVID-19 pandemic, tuberculosis (TB) was registered as the deadliest infectious disease caused by a single pathogen, resulting in 10 million cases and 1.4 million deaths in 2019 [8]. Meanwhile, the United Nations has made the elimination of TB one of its Sustainable Development Goals [9] and the WHO End TB Strategy aims for a 90% reduction in TB incidence rate by 2035 [10]. These global ambitions acknowledge the importance of community involvement in the fight to end TB, particularly through strengthening the community health workforce. The contribution of CHWs to TB care and prevention have been well documented [11, 12]. Specifically, CHWs have enabled the task-shifting of a variety of TB program responsibilities to optimize capacity utilization of the public health system. These decentralized tasks include active case finding [13]; sputum collection and transport, slide fixing and other laboratory support [14]; and treatme (...truncated)