"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
VISIONS OF THE FUTURE: Building Tomorrow's Community Health Workforce
As part of the ‘Symposium on CHWs and Their Contribution Towards the Sustainable Development Goals’ Makerere University (Uganda), CHW Central, Nottingham Trent University (UK), and World Vision are supporting a series of interviews with academic leaders and experts in international health development and delivery fields to provide their vision of the future of CHWs in a new light.
We will explore: How can CHWs create lasting impacts in the era of the Sustainable Development Goals? What steps need to be taken to scale up, empower, and create changes within in our global workforce?
The interviews will be posted on CHW Central over the next weeks as part of the preparation for the Symposium taking place from February 21st-23rd in Uganda. Past interviews will be posted on the CHW Hub.
Read our fifth interview with Dr. Aisha Yousafzai below.
Dr. Yousafzai is an Associate Professor of Global Health, Department of Global Health and Population at the Harvard T.H. Chan School of Public Health. She was most recently an Associate Professor in Early Childhood Development and Disability in the Department of Paediatrics and Child Health at the Aga Khan University in Karachi, Pakistan. She has extensive experience in evaluating early childhood interventions in south Asia, east Africa, and in central and east Europe. One of Dr. Yousafzai’s most significant studies is the Pakistan Early Child Development Scale-Up (PEDS) trial, a cluster randomized controlled trial evaluating responsive stimulation and nutrition interventions to strengthen early child development and growth outcomes. Dr. Yousafzai has written extensively about early childhood interventions in low- and middle-income countries including recent articles in Annals of the New York Academy of Science, Annual Review of Psychology, Lancet, Lancet Global Health, and Pediatrics. She also service on a number of Advisory Groups on early child development for international organizations including co-Chair for the Intervention Taskforce of the Early Childhood Development Action Network-ECDAN.
Learn more about Dr Yousafzai’s work here: https://www.hsph.harvard.edu/aisha-yousafzai/
What is your vision of how ‘tomorrow’s CHWs’ will contribute to early child development?
Ideally, I would like to see nurturing care and family empowerment at the heart of CHWs work. This will enable the CHWs to focus on behaviour changes that lead to improvements in children’s development, strengthen care for children in safer, happier and healthier families, and support healthy life choices to reduce risk of infectious illnesses and non-communicable diseases. I would also like to see CHWs serve all children in an inclusive manner. At the moment, we think of ECD and childhood disability as two separate agendas rather than a spectrum of development. As we see greater integration of ECD in community services, it will be great to plan how the needs of children with disabilities are addressed- what the CHW can do and what other resources need to be developed or strengthened to address more complex issues. Early stimulation through play, however, can and should be promoted for every child!
Why is ECD important, and why specifically should CHWs be involved?
Early Child Development can be defined as the progressive attainment of sensory, motor, social-emotional, cognitive and language capacities and sense of self that are driven by both biology and environment. These capacities are the building blocks for future human development enabling us to think, solve problems, communicate, express our emotions, form relationships, and create and develop new ideas. When children develop these skills, they benefit from being able to take better advantage of educational and economic opportunities, and are less vulnerable to poor mental and physical health. Importantly, their communities also benefit from citizens who are able to contribute more to the development of the community through economic growth, creative innovations that help communities, safer communities, and more engaged citizens. Investing in children is investing in all our futures!
Around the world, CHWs have served their communities well and contributed to the improved survival rates of young children and women. In taking on this role, the CHWs have established long-term trusting relationships with the families they serve, and are respected and knowledgeable members of their communities. It is because of this special position of trust and familiarity with her community that a CHW is ideally placed to deliver interventions that promote children’s development which involves strengthening parenting knowledge and skills, and supporting family relationships. At the heart of this strategy is providing parents with the knowledge and skills to provide their children with nurturing care- this includes care for children’s health and hygiene, nutrition and feeding, learning, and protection in a stable, safe and emotionally healthy family environment.
A CHW can deliver for three key reasons. Firstly, she is able to support the mother and family from the beginning and stay with the child throughout the early years. For example, she can advise the family about healthy pregnancy and safe delivery, parent readiness, stress management, and family planning. Secondly, the CHW is able to integrate advice on health and nutrition with advice on learning and protection because these messages all support healthy development and share common synergies. For example, when advising a mother about breastfeeding, the CHW can also provide practical advice about building a secure early attachment with her infant and introduce infant play idea like singing to your child. Thirdly, the CHW is a ‘community connector’ – she can identify and refer children to other health services when needed, encourage families to make sure their child is enrolled for preschool on time, and connect families to other essential local resources or social support. The more we learn about how to effectively deliver interventions that require behaviour change in caregiving, the CHWs of tomorrow will be trained in core essential skills for good counselling and problem solving that are critical for all aspects of nurturing care and essential as health systems transition from a survival only focus to one of survival and thriving children and strong families.
What different ways can CHWs promote play and communication in community and household approaches?
Play and communication can be promoted in a number of different ways by CHWs, depending on what is acceptable and feasible in the local setting. Home visiting and parent groups have both been used effectively. In both strategies, demonstrating how to introduce a variety of play materials is important; for example, making-toys, toy and book libraries, using every day materials and objects in the home for play. Also, it is important to help the parent and family engage with the child during play; for example, encouraging parents to talk to their children, tell stories, sing songs, explore playthings together, encourage their child to explore and praise their child when she or he figures something out!
I am not suggesting we have separate visits for ECD, but rather what do we do that embraces the needs of the child at the 1 month, 3 months, 6 months visit. We need to create an environment where the CHW has a little bit of autonomy to be responsive so if the mother is breastfeeding and there’s no problem, then great and move on and focus on what she does need support for. But we don’t trained health workers in that way, we are being very prescriptive without being responsive- that’s more complicated, yes but they can be more effective if we invest in that training. Even the most basic of CHWs can promote simple messages about play. In Pakistan, lady health workers in reality have very low literacy level, so we phased our expectations: in the very basic training just including a play message in visits, before worrying about other issues. Once you introduce those messages the CHW will then begin to look at play practices, interact with the child more, and is then learning through her observations and experience, so with time her competencies will increase. Over time and through the supervision and refresher training, as ECD becomes more embedded in practice you can gradually introduce more complex skills.
What does the evidence say about CHWs and ECD?
Many studies from low- and middle-income countries demonstrate CHWs can effectively deliver interventions that promote early child development including interventions implemented in Bangladesh, India, Jamaica, Pakistan, Uganda to name a few. We do need more studies to report what it costs to deliver these interventions, how we better create demand for these services from local policy makers to health services, and how we can better support CHWs so she is motivated, incentivised and receives the support from the health system to develop her competencies. This would create the environment required for CHWs to deliver on ECD not only in the short-term but also in the long-term.
There is less evidence for the simpler model of integration of ECD messages within a larger MNCH program, and there is a need to examine this within the larger structure and a large scale program. If I really strictly say let’s look at the evidence, that is probably less, as most of the trials have been a community person delivering just the ECD curriculum on its own. What we did in Pakistan was a Lady Health worker, having to do all her other tasks, and the play piece was included, with up to 10 minutes spent on ECD. So that was a strong trial which showed that this could be done. We need more of these types of trials. In Pakistan LHWs are paid, not a great salary. We need to know how this works in CHW programs where they are incentivised and or paid. I think that the capacity potential is there.
How feasible is it to include ECD in this way, and would this overload CHWs?
With the example of Pakistan, they were already doing monthly home visit. Our intention was not to increase the frequency of visits, or duration of that visit, or make workload unmanageable. Our intention was to see within that visit, how is her time broken up? Actually what we saw is that it’s very feasible because if you are training the CHW appropriately, you are helping them identify the opportunities to talk about play, communication, responsive feeding. I think that parents welcome the advice too, if you are introducing messages that say “whilst you are cooking, bathing etc.. there are play opportunities” this is a much better accepted message than saying “take out 20 minutes of your day to do just this”. So, finding those teachable moments and play opportunities is important for the CHW and for the parents too.
I think it comes back to how we integrate this. We need to stop seeing ECD as a whole separate activity. I think we need to hold programs to a greater level of accountability so there is a lot of wastage on the ground. Visits not made due to supplies, many assumptions about the hours worked which when you shadow a CHW this might not be the case. So I think that sometimes our research doesn’t reflect all of that learning. We haven’t reported enough on how you go about introducing a new intervention, into an existing platform. There is definitely not money for a new ECD sector, so it must be embedded in current programs.
How could CHW approaches bridge health and social care interventions for children?
We need to make sure no individual community based agent is responsible for delivering everything! The wellbeing of children requires a range of interventions. The CHW is ideally placed to deliver on key components of nurturing care including health, hygiene, nutrition, and early learning. She can help to connect families to other resources; for example, food assistance.
What child protection interventions should be considered and in what contexts?
Given CHWs are intimately familiar with the environments children grow up in, they will likely be aware of risks such as violence in the home. They can play a vital role in connecting families to the interventions they need. However, in many parts of the world, additional resources and services and not always available and a focus on prevention is necessary. In addition to play and communication to promote early learning, CHWs may also be trained in interventions designed to support positive parenting to prevent harm. The key is designing a programme to promote nurturing care that is manageable, where messages are organized by developmental stage of the child and responsive to family needs.
When it comes to preventing violence against children, firstly, it’s about building a strong responsive more sensitive caregiving relationship, promoting positive parenting, teaching them how to manage a toddlers behaviour. But there are some strategies which are better for attitudinal change. There was a parenting review with UNICEF where groups were considered as more successful as a way of challenging social norms. Then there are also the issues where there are homes that have family stressors like violence in the home, alcohol and other stressors. So the root isn’t always thinking about what the parent does for the child, but how you support the parent to manage their stressors. It isn’t all the responsibility of the CHW but more how she can connect to other resources where they exist.
You speak a lot about the mother, but where do the fathers fit in your vision?
I think there are two issue: one the one hand, I do use the word mother as I think the mother do have a special role. I don’t want mothers to be seen as just there to breastfeed the child – she should have the opportunity to have a more enjoyable time with the child, not just the dad coming in and doing the play. We need the support system to ensure the mother is able to do that. But, I completely agree that I am also wanting to see the family environment but about co-parenting together and taking all of those opportunities.
What are the critical success factors for integrating ECD in MNCH programs by CHWs?
There are a number of ingredients for success.
- Firstly, it is important to have a clear objective for the programme. For example, is the programme designed to improve parenting knowledge? Is the programme designed to improve children’s behaviour management? Is the programme designed to improve children’s development? The components of the intervention must align with the programme objective.
- Secondly, for early stimulation interventions (promoting play and communication), key features for effectiveness include giving the parent/caregiver an opportunity to try the play activity with their child and receive feedback on how they might strengthen their responsiveness to their child during play, making sure families have access to a variety of stimulation materials and ideas of activities, problem solving with families about challenges they face in making time to be involved in play, and providing families with small media (pamphlets, SMS, posters in the village) to serve as reminders of activities.
- Thirdly, plan how a programme can optimize the duration, frequency and intensity of the programme. A programme may not be able to deliver weekly home visits over 12 months, but a shorter programme may benefit from boosters or refreshers at key time points in the child’s development.
- Fourthly, create a strategy of support for the CHW. Ensure CHWs are supervised and supported. We demand a greater deal from the CHWs but invest far less in their support compared with other health workers. If we want to see lasting impacts in promotive interventions around nurturing care we need to better support our front line workers.
In the SDG era, what will be the biggest challenges to CHW implementing this work?
The biggest thing will be the work force development. I really believe we just don’t invest enough in CHWs but we expect a lot. We put so much in professional development for nurses, doctors, everyone except CHW. We need to think about how we support the CHWs, build their skills and place greater value within a health system so they aren’t just there as a ‘plaster on the wounds in the community’ but are recognised as a key part of the health team.
Can we achieve the SDGS without ECD?
I think if we want to see better outcomes for children we have to start from the earliest time frame. We want to put in place an early foundation we can build upon. Unless you start there then everything else you do is just a little bit less effective.
All CHW Visions interviews have been conducted and compiled by Polly Walker.