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Assessment of Community Health Volunteers contribution and factors affecting their health care service delivery in selected urban wards of Puducherry – A mixed-methods operational research study

Open AccessPublished:October 01, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101135

      Abstract

      Introduction

      Community participation gained its importance from the Alma Ata declaration in 1978. Improving coverage of these services depends on factors like availability, accessibility, and quality of service delivery. Involving Community Health Volunteers to deliver health services would help in decentralizing health care delivery.

      Methods

      A mixed-method approach (Sequential experimental design) was employed to evaluate the contributions of CHVs. The data collection methods included Key Informant Interviews (KII) and a pre-tested semi-structured self-introspection questionnaire to capture both volunteer's and health system side perspectives of the intervention. The study was conducted from October 2017 to May 2018.

      Results

      At the end of the intervention, only 33 volunteers (51%) had contributed to health care delivery in their respective anganwadis. We compiled the contributions made by the CHV during the intervention period. We explored the facilitating, hindering factors that influenced the outcome and gathered suggestions for the same. The CHVs felt that they have contributed adequately to the delivery of health care.

      Discussion and conclusion

      The study explores the contributions of CHVs and their evaluation using a mixed-methods design capturing the perspectives of various stakeholders. Our study results highlight the spectrum of contributions that can be rendered through CHV's if adequately trained, who can be utilized as an effective workforce in resource-poor settings.

      Keywords

      1. Introduction

      Community participation gained its importance from the Alma Ata declaration in 1978. The declaration emphasized the community's involvement in the planning, organizing, and implementing primary health care.
      • Haldane V.
      • Chuah F.L.
      • Srivastava A.
      • et al.
      Community participation in health services development, implementation, and evaluation: a systematic review of empowerment, health, community, and process outcomes.
      Since the establishment of Sustainable Development Goals (SDG), community participation has regained its global health importance. Universal health coverage (UHC) also warrants that all individuals and communities must receive the entire spectrum of essential and quality health services without facing financial hardships. Improving coverage of these services depends on factors like availability, accessibility, and quality of service delivery.
      With the rapid expansion of chronic disease patterns across countries, it is essential to take the necessary steps to decrease the enormous burden. Many studies have identified community participation as a key strategy in implementing UHC, thereby preventing and controlling chronic diseases.
      • Narain J.P.
      Integrating services for noncommunicable diseases prevention and control: use of primary health care approach.
      Investing in primary care interventions has evolved as the most cost-effective way of ensuring UHC.
      The umbrella term "community health worker" (CHW) encompasses a wide variety of individuals who are selected, trained to work in their communities. Generalizations about their profile may be tricky. They can be of any gender, young or old, literate or illiterate, who volunteer to deliver health services in liaison with the health system. This process of involving the community in implementing health programs positively impacts social capital and social cohesion, thereby neutralizing health inequalities.,
      • Sangwan M.J.
      • Puoane T.
      Knowledge, beliefs and attitudes of community health workers about Hypertension in the Cape Peninsula, South Africa.
      Despite their effective contribution, much of the literature holds good only in developing countries, particularly in those lacking adequate healthcare access. From the available literature, it is proven that adequate training and sensitization are necessary for making the CHVs more effective and efficient.
      • Huang W.
      • Long H.
      • Li J.
      • et al.
      Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996–2016).
      This service delivery framework through CHVs was in place in India since the 1970s as Village health guides, Multipurpose Health Workers. Etc., who ASHA workers now replace. Studies have shown the effectiveness of CHVs in various fields.
      • Sangwan M.J.
      • Puoane T.
      Knowledge, beliefs and attitudes of community health workers about Hypertension in the Cape Peninsula, South Africa.
      • Huang W.
      • Long H.
      • Li J.
      • et al.
      Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996–2016).
      To establish such a decentralized health system in urban India, Urban Health Mission (UHM) recommended U-PHCs and U-CHCs as the peripheral health services units.
      National Rural Health Mission
      National health mission [Internet].
      The UHM also emphasized the involvement of private-public partnerships for ensuring community participation. It has recommended recruiting USHA workers in place of ASHA workers as grass root level workers in urban areas. But in most urban areas, involvement of the community is still a query.
      Furthermore, CHW performance is context-specific and is linked with several internal and external factors. It is necessary to understand the importance of their internal characteristics and external social and political influences before implementing them in the community. This study was our attempt to develop systems of identifying appropriate community volunteers and empower them to take the services closer to the community. This strategy might help in facilitating better access to available health services by empowering the CHVs. The CHVs might bridge the community's ethnic, cultural, or geographic differences and promote health through outreach activities and social support. It is always necessary to look into both sides of the coin (volunteer side and the health system side) when evaluating such volunteer-led programs.
      • Woldie M.
      • Feyissa G.T.
      • Admasu B.
      • et al.
      Community health volunteers could help improve access to and use of essential health services by communities in LMICs: an umbrella review.
      The present study attempts to assess such Community Health Volunteers' contribution by hearing both volunteer side and health system perspectives.

      2. Methodology

      For assessing the contribution of CHVs, we adopted a mixed-method approach taking up a Sequential exploratory design (Qual → Quan).
      • Doyle L.
      • Brady A.-M.
      • Byrne G.
      An overview of mixed methods research.
      The data collection methods included Key Informant Interviews (KII) and a pre-tested semi-structured questionnaire. A self-introspection questionnaire was administered among the volunteers and Key Informant Interviews (KII) among the health staff to capture both sides' perspectives of the intervention. The study was conducted from October 2017 to May 2018. The study setting constituted the urban field practice area of a tertiary care center in Pondicherry comprising four wards, namely Kurusukuppam, Chinnayapuram, Vazhaikulam, and Vaithikuppam, with a total population of around 8500. The center provides comprehensive primary care services to all four wards and has approximately 13 Anganwadis functioning under it. Anganwadi is a government-sponsored child and maternal care center which covers a population of 400–800 population.

      2.1 Existing system

      Until the commencement of this study, the peripheral most health workers working under the center were Auxiliary Nursing Midwives (ANM) and Anganwadi Workers (AWW). There are no Accredited Social Health Activist (ASHA) workers in our service center. We were unable to reach the population (working population and adolescents) who were not accessible during the regular working hours. Our vision was to reach the unreached population through CHVs.
      In consultation with the community, we had planned to involve 5–6 volunteers from each Anganwadi area (which constitutes a population of around 400–800). Of the 13 anganwadis, 65 volunteers were selected from the selected primary health center's service area.
      The health center provided health services to 4 wards comprising of 13 anganwadis functioning under it. The four wards of the service area, catering to 13 anganwadis, were distributed among two staff nurses and two field workers. One pair of staff nurse and field worker took care of 6 anganwadi areas whereas the other pair of staff nurse and field worker took care of 7 anganwadi areas.
      This article is part of a more extensive study that encompassed Community health volunteers' contribution in facilitating health care delivery in selected areas like mobilization of the eligible population for diabetes and hypertension screening, adolescent health, blood donation camps, and reduction of mosquito breeding sites. The volunteer's contribution in these areas was evaluated based on the logic model and is explained (Supplementary Tables 1 and 2).

      2.2 Sample size and sampling procedures

      Phase I: (Qualitative) Around 5 Key Informant Interviews (KII) were conducted among the health care personnel working in the center, namely the medical officer, ANMs, Staff nurses, and the medico-social worker.
      Phase II: (Quantitative) All the volunteers selected for imparting services were interviewed to self-introspect their contribution during the intervention.

      2.3 Study procedure

      We choose to interview the health staff of the center, who worked closely with the volunteers. Around 5 Key Informant Interviews (KII) were conducted among the medical officer, ANMs, 2 Staff nurses, and the medico-social worker posted in the center. The central theme of the KIIs was to capture the various contributions made by the volunteers, the facilitating and hindering factors influencing the contribution, and suggestions to improve their contribution/framework. Intimation regarding the necessity of the interview and the importance of their perception in assessing the intervention was explained prior. Five KIIs were conducted separately in the center at their convenient time. The interviews were carried out in the participant's regional language (Tamil) and English. Each discussion lasted for 45–50 min. We utilized a descriptive approach for qualitative data collection. The interview guide for conducting the interview was prepared following an elaborate discussion with all the investigators. The principal investigator, trained in qualitative research, conducted the interview and a note-taker using the same interview guide. Other than the participants and investigators, none were allowed during the KIIs. Necessary probes that were prepared and reviewed by the investigators were used to gather more detailed information. The KIIs were audio-recorded after obtaining the participant's consent. At the end of each session, a discussion summary was presented to the participants for participant validation. A verbatim transcript was first prepared in Tamil, which was translated to English and then back-translated to Tamil on the same day to reduce information loss.
      Phase II: (Quantitative) The Quantitative survey was conducted over one month (December). The Principal Investigator did face-to-face interviews, interviewing all the identified CHV individually to assess their contribution. This was done using a pre-tested semi-structured questionnaire consisting of three domains, namely: i) sociodemographic details ii) duration of time spent for imparting health iii) adequacy and satisfaction on time spent (Scale of 1–10) and iv) the difficulties faced during the intervention. The questionnaire was subjected to face validation and was reviewed by experts in the field before finalizing the content. The same opportunity was used to cross-check their contribution areas with the list we got from the qualitative interviews.

      2.4 Data entry and analysis

      Qualitative Data: Collected data was transcribed in verbatim format. The unit of Analysis was participant's statements. Descriptive manual content analysis was conducted to draw the categories and themes. The analyzed data was again double reviewed by other investigators to cut down subjective interpretation, after which final consensus was obtained. Recurring themes that emerged were utilized in preparing a schematic diagram. The study was reported following the consolidated criteria for reporting qualitative research (COREQ).
      Quantitative Data: Entered into Epidata v 3.01 software
      • Choi Y.
      • Oketch S.Y.
      • Adewumi K.
      • Bukusi E.
      • Huchko M.J.
      A qualitative exploration of women's experiences with a community health volunteer-led cervical cancer educational module in Migori county, Kenya.
      and analyzed using STATA 20.
      Stata Corp
      Intercooled Stata. 12.0 ed. [Internet].
      Continuous variables were summarized as mean (SD), and Categorical variables were summarized as proportions.

      2.4 Ethical statement

      The study was reviewed and approved by the institutional review board and ethics committee (JIP/IEC/2017/0264).

      3. Results

      Totally around 5 KIIs and sixty-five personal interviews were conducted in our study. Significant themes that unfolded during the KIIs were grouped into contribution, facilitating, and hindering factors influencing the volunteer's contribution.
      At the end of the intervention, we found that only 33 volunteers had contributed to health care delivery in their respective anganwadis. We found that all the 33 volunteers belonged to 6 Anganwadi areas. In the rest seven Anganwadi regions, where we observed few volunteers discontinued in the initial stage of intervention, other volunteers also did not participate. The common reasons for failing to contribute were lack of their family support, lack of remuneration and for moved out of the area. We have thus analyzed the community volunteers contribution in the six anganwadis where they had contributed.

      3.1 Qualitative

      Fig. 1 explains the thematic qualitative analysis diagram describing the various contributions of the Community Health Volunteers as perceived by the health staff
      • i)
        Contributions: Our study aimed at assessing the contribution of selected CHVs in imparting health care services. We consulted the health staff (who worked with the volunteers) to assess the health workers' perspectives regarding the contribution of CHVs in various areas. It was elicited from the health workers that the CHVs had contributed to various activities depending on their area/areas of interest like taking up activities like mobilizing people for health camps, diabetes and hypertension screening at the health centre and motivating adolescents for attending adolescent clinics and source reduction of mosquito breeding sites. One training session was conducted for each batch of CHVs; each batch constituted 15–20 volunteers. A total of 4 training sessions were conducted for training the identified 65 CHVs. The training sessions were conducted by the investigators and the health staff of the health center. The contribution of the CHVs towards adolescent, Diabetes, and hypertension screening was evaluated using a logic model (Supplementary Tables 1 and 2). We noticed that the volunteers also involved themselves in various other areas during the intervention period. They reported about 6 cases of mild/severe adverse events following immunization (out of 10 total cases reported – 60%), and they reported around ten fever cases and four scabies cases from the field. They also reported seven presumptive Tuberculosis cases (out of 21 tested during the three months – 33%). CHVs also reported certain vital events like deaths and marriages from their allotted area. Concerning other aspects of NCDs, they helped the health staff in educating the population regarding the various services rendered from the health centre and the schedule/timing of various special clinics and accompanied the team during their house visits. The volunteers also facilitated formation of 3 walking groups for promoting physical activity among patients with diabetes and hypertension. They also mobilized around 20 patients with hypertension and/or diabetes for yoga clinics and three patients for de-addiction services. The other miscellaneous contribution included mobilizing about 67 out of 85 (78.8%) volunteers for a blood donation campaign and taking care of 19 potential mosquito breeding sites. Approximately five volunteers took up the responsibility of cleaning three drainages in their areas. The volunteers also played a vital role in increasing the daily OPD attendance of the health center. They played a significant part in improving the NCD patients' treatment-seeking behavior by mobilizing the defaulters to start treatment again.
      Fig. 1
      Fig. 1Schematic diagram depicting the thematic Analysis of the various contributions of Community Health Care Volunteers during the intervention period.
      Table .2 represents the thematic Analysis of the facilitating factors, hindering factors, and suggestions as perceived by the health staff regarding the program. The facilitating, hindering factors were grouped into "Intrinsic (volunteer related)" and "Extrinsic (health system-related)."
      Table 1Sociodemographic characteristics of the Community Health Care Volunteers among the selected wards of Urban Puducherry, (n = 65).
      VariableCategoryFrequency (%)
      Age18–30 years20 (30.7)
      31–45 years24 (37)
      46–50 years16 (24.6)
      51–65 years5 (7.7)
      GenderMale22 (33.8)
      Female43 (66.2)
      EducationNo Formal Education5 (7.6)
      Primary10 (15.4)
      Higher Secondary41 (63)
      Graduate9 (13.8)
      Employment statusUnemployed40 (61.6)
      Employed25 (38.4)
      Marital StatusMarried56 (86.2)
      Unmarried9 (13.8)
      Socio economic statusLower class3 (4.6)
      Lower middle class19 (29.2)
      Middle class25 (38.5)
      Upper middle class12 (18.4)
      Upper class6 (9.3)
      Prior involvement in social service activitiesYes11
      • Mdege N.D.
      • Chindove S.
      • Ali S.
      The effectiveness and cost implications of task-shifting in the delivery of antiretroviral therapy to HIV-infected patients: a systematic review.
      No54 (83)
      Women Self Help Group memberYes11
      • Mdege N.D.
      • Chindove S.
      • Ali S.
      The effectiveness and cost implications of task-shifting in the delivery of antiretroviral therapy to HIV-infected patients: a systematic review.
      No54 (83)
      Table 2Thematic analysis of the facilitating factors, hindering factors and suggestions as perceived by the health staff during the intervention period.
      Facilitating factorsHindering factorsSuggestions
      INTRINSIC Volunteers related
      • 1.
        CHCVs being local residents
      • 2.
        Female gender
      • 3.
        The selection process
      • As informed by the CHCVs
      • 1.
        Inadequate family support
      • 2.
        Lack of time and stress
      • 3.
        Overburdened by house works
      • 4.
        Expectations by the volunteers
      • 1.
        Reduce the number of meetings
      • 2.
        Define clear responsibilities
      • 3.
        Link with SHGs
      • 4.
        Appreciation and rewards
      • 5.
        Utilize them more in adolescent health and communicable diseases
      • 6.
        Engage during field visits
      EXTRINSIC

      Health system related
      • 1.
        Training sessions
      • 2.
        Sensitization sessions
      • As perceived by the staff
      • 1.
        Difficulty in tracking
      • 2.
        Non response by half of the volunteers
      • 3.
        No remuneration provided
      • 4.
        Lack of initiatives from the volunteer side1.
      Facilitating factors: The staff felt that ‘female gender’ and ‘CHV being a local resident’ were crucial facilitating factors.
      Staff nurse: "Most volunteers were women, it was easy for us to approach, they were patient, mostly available at home when we approached them"
      They mentioned that the robust selection process of choosing CHVs in consultation with the community also proved to be a facilitating factor.
      Medical officer: "The CHVs were initially selected by the community themselves, which was a big positive thing, especially selecting volunteers from each Anganwadi ensured equal service delivery."
      ANM: "All were belonging to the same service area, so service delivery and accessibility to us was easier."
      With respect to health system-related factors, they felt that the sensitization and training sessions were beneficial.
      Staff nurse: "I feel that the initial sensitization meetings were a major plus. It helped us to build a good rapport. It also helped us a lot to know about each other"
      ANM: "The training which the volunteers received initially allowed us to brief them about their job responsibilities. It also served as a doubt clearing session."
      Hindering factors: To know the supply-side perspective, we enquired the staff regarding the difficulties faced by the CHVs during the program. Regarding the hindering aspects, the staff expressed the feedback they obtained from the volunteer during the intervention. They also said that the volunteers often discussed the difficulties with them. The health workers informed us that the CHVs felt overburdened due to field activities. They said many volunteers were housewives, so it was difficult for them to find time in between their household chores. Furthermore, they added that there could be other personal problems with them, which they haven't discussed with the workers.
      Medico social worker: "They are interested only, but their working timing was a problem to contribute. I think that's why only 20 to 30 were able to contribute. I feel giving them continuous activity is not good. Giving one activity at a time for ten people will be good."
      Staff nurse: "They were mostly married; they expressed their difficulty of finding time in contributing to health care activities in addition to taking care of their children and household works."
      The staff also had issues in tracking/contacting the CHVs. They also expressed their difficulty in convincing the CHVs to attend the follow-up group meetings.
      Staff Nurse: "Not all the selected volunteers participated, I would say around 50% participated"
      ANM: "Many times when we call, they don't attend the calls, and some do not respond well, and it was challenging initially."
      They said that many CHVs did not have proper family support. The staff mentioned that a few volunteers expected recognition like volunteer identity cards and remuneration for their work.
      Staff nurse: "Many volunteers told me that their family members were not happy about them doing these activities as they were not paid or given any honorarium."
      "Some volunteers felt that they were not paid for their work, so they need not contribute, but I feel more than money at least giving them some recognition like volunteer identity cards will be useful."
      They felt that there was a lack of initiatives from the volunteer's side. They mentioned that provision of rewards for gratifying their contribution would be helpful in future programs. Despite these pitfalls, the staff was satisfied with the assistance of the volunteers.
      ANM: "Any new idea, it is always from our side; very rarely we find an initiative coming from the CHCVs side."
      Medico social worker: "I feel more than money at least giving them some recognition of volunteer identity cards will be useful."
      Staff Nurse: "What I would say is. Though there was no proper response from half of the volunteers, the volunteers who contributed did a good job. I am thrilled with what they have done."

      3.2 Suggestions

      We encouraged suggestions to form the health staff for the future betterment of the framework. They expressed their views: reducing the number of group meetings (one meeting every three months), linking the CHVs with existing Self Help Groups, and defining clear responsibilities. They said they are willing to utilize the CHVs more towards adolescent health services as it has inferior coverage compared to other services provided by the center. They also explained the importance of involving the CHVs during the field visits.
      Medico social worker "We covered only one aspect of adolescent health, i.e., Nutrition. They have done a good job, and now I think we can concentrate on other health aspects of adolescents."
      Staff nurse: "Some volunteers told us that conducting meetings frequently is tiresome as most are housewives and they have other household chores, I; Iel… having group meetings once in three months is okay…"
      ANM: "As the volunteers are predominantly women, I feel linking them with available SHG will be beneficial for them (financially and supportive) and also the community."
      Medico social worker "Whenever I go for field visits, I used to take my area volunteers with me, which enabled building rapport with them. By this, they also get to know about the issues in the area."
      The information collected during the qualitative part was used to devise the quantitative questionnaire, which captured the areas of contribution, level of satisfaction, and the difficulties faced by the CHVs. We observed that the volunteers' areas of contribution and challenges were triangulating with the information obtained from the health staff during KIIs.

      3.3 Quantitative

      Table .1 depicts the sociodemographic characteristics of CHVs. Among the 65 who volunteered, the majority (67.7%) belonged to the 18–45 year group with the mean age of 35.3 ± 6.8 years, and about 22 (33.8%) were males. Nearly 50 (76.8%) had primary schooling as minimum education, and about 40 (61.6%) were not actively involved in employment. According to the modified BG Prasad scale, around 56 (86.2%) were married, and 43 (66.2%) belonged to the middle class or above socioeconomic level.
      Out of the 65 who volunteered, we observed 8 (12.3%) dropouts (moved out of the field service area) who were excluded from the study. About 24 (39.6%) discontinued the study during the intervention due to various reasons. Thus, the retention rate was found to be 50.8% at the end of the intervention.
      We observed that the remaining 33 volunteers had devoted 6.2 h (0.5)/week/person to delivering health services. Table 3 depicts the duration of time spent by the volunteers for various health promotion activities, its adequacy, and level of satisfaction on time spent. We noted that the volunteers had devoted maximum time to facilitating mobilization for camps, Diabetes and Hypertension screening, and adolescent health. We had asked the CHVs to rate their adequacy of time spent for delivering health care services and their level of satisfaction (using a 10 point rating scale). The scoring pattern ranged from 0 to 10 (not satisfactory to very satisfactory). The volunteers have devoted less time to reporting important events and sanitation. We noted that the CHVs were happy and satisfied with the time they spent on each activity.
      Table 3Frequency, duration spent, time adequacy and satisfaction level for various health promotional activities performed by the volunteers (N = 33).
      ActivitiesFrequency (%)Duration of time spent (Mean hrs±SD)/weekTime adequacy grade
      • Haldane V.
      • Chuah F.L.
      • Srivastava A.
      • et al.
      Community participation in health services development, implementation, and evaluation: a systematic review of empowerment, health, community, and process outcomes.
      • Narain J.P.
      Integrating services for noncommunicable diseases prevention and control: use of primary health care approach.
      • Sangwan M.J.
      • Puoane T.
      Knowledge, beliefs and attitudes of community health workers about Hypertension in the Cape Peninsula, South Africa.
      • Huang W.
      • Long H.
      • Li J.
      • et al.
      Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996–2016).
      National Rural Health Mission
      National health mission [Internet].
      • Woldie M.
      • Feyissa G.T.
      • Admasu B.
      • et al.
      Community health volunteers could help improve access to and use of essential health services by communities in LMICs: an umbrella review.
      • Doyle L.
      • Brady A.-M.
      • Byrne G.
      An overview of mixed methods research.
      • Choi Y.
      • Oketch S.Y.
      • Adewumi K.
      • Bukusi E.
      • Huchko M.J.
      A qualitative exploration of women's experiences with a community health volunteer-led cervical cancer educational module in Migori county, Kenya.
      Stata Corp
      Intercooled Stata. 12.0 ed. [Internet].
      (Mean ± SD)
      Satisfaction level
      • Haldane V.
      • Chuah F.L.
      • Srivastava A.
      • et al.
      Community participation in health services development, implementation, and evaluation: a systematic review of empowerment, health, community, and process outcomes.
      • Narain J.P.
      Integrating services for noncommunicable diseases prevention and control: use of primary health care approach.
      • Sangwan M.J.
      • Puoane T.
      Knowledge, beliefs and attitudes of community health workers about Hypertension in the Cape Peninsula, South Africa.
      • Huang W.
      • Long H.
      • Li J.
      • et al.
      Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996–2016).
      National Rural Health Mission
      National health mission [Internet].
      • Woldie M.
      • Feyissa G.T.
      • Admasu B.
      • et al.
      Community health volunteers could help improve access to and use of essential health services by communities in LMICs: an umbrella review.
      • Doyle L.
      • Brady A.-M.
      • Byrne G.
      An overview of mixed methods research.
      • Choi Y.
      • Oketch S.Y.
      • Adewumi K.
      • Bukusi E.
      • Huchko M.J.
      A qualitative exploration of women's experiences with a community health volunteer-led cervical cancer educational module in Migori county, Kenya.
      Stata Corp
      Intercooled Stata. 12.0 ed. [Internet].
      (Mean ± SD)
      Mobilization for camps19 (57)1.4 (0.4)7.2 (1.2)8.4 (1.1)
      Mobilization for NCD screening22 (66)1.9 (0.9)8.4 (1.5)8.8 (0.7)
      Mobilization of Adolescents17 (51)1.7 (0.8)7.9 (0.9)8.3 (1.2)
      Source reduction15 (45)0.8 (0.3)8 (1.3)9 (0.5)
      Vital event reporting12 (36)0.5 (0.2)6.9 (1.5)7.9 (1.3)
      Cleaning drainage5
      • Balagopal P.
      • Kamalamma N.
      • Patel T.G.
      • Misra R.
      A community-based participatory diabetes prevention and management intervention in rural India using community health workers.
      0.4 (0.2)7.8 (1.3)8.9 (0.7)
      Table 4 represents the perception of CHVs regarding the program. It was elicited on a five-point Likert scale (1-strongly disagree and 5- strongly agree). The majority (60.6%) of the participants strongly agreed that the health staff adequately guided them. About one-third of the participants, 12 (36.4%), felt that they faced disturbances in their day-to-day activities during their involvement in health care activities. Regarding the perception of ease in carrying out the activities, about 25 (75.9%) felt it was easy for them to carry out the assigned activities.
      Table 4Likert scale of the perception of CHVs regarding various aspects during their involvement in the program in urban Puducherry, N = 33.
      Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
      Adequate guidance by the health care personnel20 (60.6)7 (21.2)4 (12.1)2 (6.1)0
      Disturbance in day to day routine activities10 (30.3)2 (6.1)5 (10.59)10 (30.3)6 (15.2)
      Ease in carrying out the activities assigned15 (45.6)10 (30.3)4 (12.1)2 (6.1)2 (6.1)
      Fig. 2 explains the difficulties faced by the volunteers during the program. To capture various reasons for the high attrition rate, we interviewed all the 65 volunteers to capture their challenges. We also did subgroup analysis to know the differences between difficulties faced by the participants and non-participants. We observed that the common difficulty (63.1%) faced by them was family pressure; it was more common among non-participants than participants. Though there were high levels of willingness at the initial phase, volunteers explained the inadequate support received from their families that influenced withdrawal from the study. The other difficulties faced by the volunteers were work pressure from the office (55.4%), difficulty in managing time due to household chores (21.5%), and inability to attend too many meetings (13.9%); it was again more common among non-participants.
      Fig. 2
      Fig. 2Difficulties faced by the volunteers during their involvement in the program.

      4. Discussion

      This study explores the contributions of CHVs and their evaluation using a mixed-methods design capturing the perspectives of various stakeholders. The data collection methods included Key Informant Interviews (KII) among the health staff to evaluate the contribution of CHVs and a questionnaire-based quantitative survey among the CHVs to self-introspect themselves regarding their contribution to health care.
      Many studies have emphasized that CHVs can act as catalysts bridging the community and the health sector.
      • Sreedharan J.
      • Muttapppallymyalil J.
      • Divakaran B.
      Scope and extent of participation of female volunteers in tobacco control activities in Kerala, India.
      • Vir S.C.
      • Kalita A.
      • Mondal S.
      • Malik R.
      Impact of community-based mitanin programme on undernutrition in rural Chhattisgarh State, India.
      • Medhanyie A.
      • Spigt M.
      • Kifle Y.
      • et al.
      The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study.
      The importance of engaging community volunteers for improving health-seeking behavior is emphasized across multiple settings.
      • Karim A.M.
      • Admassu K.
      • Schellenberg J.
      • et al.
      Effect of Ethiopia's health extension program on maternal and newborn health care practices in 101 rural districts: a dose–response study.
      ,
      • Balagopal P.
      • Kamalamma N.
      • Patel T.G.
      • Misra R.
      A community-based participatory diabetes prevention and management intervention in rural India using community health workers.
      Studies from other low-income countries have also elaborated on the importance of interlinking CHVs with the health staff for better health outcomes.
      • Bateganya M.
      • Abdulwadud O.A.
      • Kiene S.M.
      Home‐based HIV voluntary counselling and testing (VCT) for improving uptake of HIV testing.
      • Mdege N.D.
      • Chindove S.
      • Ali S.
      The effectiveness and cost implications of task-shifting in the delivery of antiretroviral therapy to HIV-infected patients: a systematic review.
      • Schneider H.
      • Okello D.
      • Lehmann U.
      The global pendulum swing towards community health workers in low-and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014.
      Our study focused mainly on the contribution of CHVs in adolescent health, infectious diseases, mobilization for: camps, Diabetes and Hypertension screening, and reporting of vital events. Our study adds to the existing literature supporting the contribution of CHVs for the services mentioned above. Several systematic reviews also support the involvement of CHVs in improving access and community utilization of services.
      • Huang W.
      • Long H.
      • Li J.
      • et al.
      Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996–2016).
      ,
      • Petersen I.
      • Fairall L.
      • Egbe C.O.
      • Bhana A.
      Optimizing lay counsellor services for chronic care in South Africa: a qualitative systematic review.
      Community-based initiatives in delivering health can address the social determinants of health, thereby improving social capital, social cohesion, and capacity building.
      • Huang W.
      • Long H.
      • Li J.
      • et al.
      Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996–2016).
      A systematic review from Australia explains how community participation influences access, acceptability, availability of services.
      • Gomersall J.S.
      • Gibson O.
      • Dwyer J.
      • et al.
      What Indigenous Australian clients value about primary health care: a systematic review of qualitative evidence.
      Our study showed that involving the community in selecting CHVs from their locality is a facilitating factor for the program's success. Studies done in various parts of the world have also produced similar findings.
      • du Toit R.
      • Courtright P.
      • Lewallen S.
      The use of key informant method for identifying children with blindness and severe visual impairment in developing countries.
      • de Vries D.H.
      • Pool R.
      The influence of community health resources on effectiveness and sustainability of community and lay health worker programs in lower-income countries: a systematic review.
      • Rajaa S.
      • Sahu S.K.
      • Thulasingam M.
      Contribution of community health care volunteers in facilitating mobilization for diabetes and hypertension screening among the general population residing in urban puducherry - an operational research study.
      • Rajaa S.
      • Sahu S.K.
      • Thulasingam M.
      Contribution of community health volunteers in facilitating mobilization for nutritional screening among adolescents (10-19 years) residing in urban Puducherry, India – an operational research study.
      In our study, we found that one important hindering factor for CHVs contribution was inadequate family support. A study was done by Shipron et al. also emphasized the importance of family support in the successful implementation of such CHV programs.
      • Shipton L.
      • Zahidie A.
      • Rabbani F.
      Motivating and demotivating factors for community health workers engaged in maternal, newborn and child health programs in low and middle-income countries: a systematic review.
      Sufficient literature has shown the importance of health system-related factors like adequacy of training sessions and sensitization sessions in influencing volunteer's actions. Literature also supports the fact that lack of clear responsibilities, lack of time due to work pressure, and lack of remuneration as significant health system barriers that influence CHV programs.
      • Kok M.C.
      • Kane S.S.
      • Tulloch O.
      • et al.
      How does context influence performance of community health workers in low-and middle-income countries? Evidence from the literature.
      ,
      • Charanthimath U.
      • Katageri G.
      • Kinshella M.W.
      • et al.
      Community health worker evaluation of implementing an mHealth application to support maternal health care in rural India.
      Our study highlights the importance of capturing both volunteer and health system perspectives in assessing community-based interventions. Previous studies have quoted the importance of examining the "process" as an essential factor in evaluating such community-based interventions.
      • Haldane V.
      • Chuah F.L.
      • Srivastava A.
      • et al.
      Community participation in health services development, implementation, and evaluation: a systematic review of empowerment, health, community, and process outcomes.
      Thus, it is necessary to adopt a rigorous methodology in selecting the volunteers, focusing more on training, thereby establishing a strong linkage with the health systems. Shifts could influence Community-based interventions in social, economic, and political contexts over time. It is thus essential to address these challenges affecting program sustainability.
      Our study's major strength is that we adopted a mixed-methods design for capturing both the volunteer perspective and the health system perspective in scaling the yield of this framework. We observed sufficient triangulation of data between the qualitative and quantitative components, thus ensuring credibility. Our study also adds to the limited literature involving CHV for health promotion activities in South India. This model of strengthening community participation for health service delivery could be further expanded based on the community's other needs. Usually, studies involving program evaluation are primarily descriptive. It is vital to undertake randomized controlled trials or quasi-experimental studies with a comparison group to establish stronger causal linkages between intervention components and outcomes. Notably, there are minimal studies reporting outcomes taking into account the costs incurred. Further evaluations to examine the cost-effectiveness of the program to conclude is necessary.
      However, our study had certain limitations. This paper only discusses the evaluation of the CHVs for pre-specified priority areas. The intervention duration was limited to only three months; a longer duration and follow-up are necessary to scale our study's more considerable impact. The priority areas of contribution reflect local issues and problems about south India; thus, generalizability may be an issue. Qualitative interviews involving the CHVs would have given a deeper understanding of their problems. Encouraging more robust studies in evaluating community participation through qualitative perspectives to report long-term outcomes is necessary.

      5. Conclusion

      About half of the CHVs, who volunteered to impart health care services, remained with us till the end of the intervention. The main reasons for dropouts were inadequate family support and work pressure from their workplaces. The volunteers contributed maximum towards screening for non-communicable diseases and mobilization for camps. The majority of the volunteers who contributed were happy and satisfied with their contribution in imparting health services. The health staff also acknowledged the involvement of the volunteers. Though they had difficulty managing the time, they felt that health staff guided them adequately during the intervention. This study adds to the evidence, supporting the importance of community participation in yielding positive outcomes at the individual, community, and organizational levels.

      Funding

      The author(s) received no financial support for the research, authorship, and/or publication of this article.

      Declaration of competing interest

      None.

      Acknowledgement

      We would like to acknowledge the staff of the urban health center and the Community Health Care Volunteers for their immense contribution & continuous technical support for completing the study.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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