Impact of community health workers on improving identification and primary care of hypertension among the urban poor - findings from Chhattisgarh state of India.

BACKGROUND: Hypertension is a major health problem globally and in India. Around 60% of people with hypertension in India are not aware that they have the condition. Less than 30% of individuals with hypertension are on treatment. Existing studies have indicated that community health workers (CHWs) can play a useful role in expanding the care for hypertension. Evaluations are needed to study the impact when an intervention is implemented by the government in its existing large-scale CHW programme to improve the identification, regular follow-up and medication adherence for hypertension. METHODS: Chhattisgarh state implemented a pilot intervention to improve screening and follow-up for hypertension by equipping Mitanin-CHWs to measure blood pressure (BP). The study design involved an intervention-group and a comparison-group of urban slum population. The survey covered 5974 individuals (30-79 years age) in intervention-group and 5131 in comparison-group. Multivariate analysis was conducted to find out the effect of intervention on the desired outcomes. RESULTS: In intervention-group, 80.2% of the individuals (30-79 years age) had been screened for hypertension whereas the proportion was 37.9% in comparison-group. For 47.0% of individuals in intervention-group, Mitanin CHW was the provider who measured BP for the first time. Around 16.3% of individuals in intervention-group and 9.5% in comparison-group had been diagnosed with hypertension. Around 85.9% of hypertension cases in intervention-group and 77.0% in comparison-group were on treatment. BP had been measured in preceding 30 days for 81.8% of hypertension-cases in intervention-group and 64.3% in comparison-group. Around 70.3% of hypertension-cases in intervention-group and 55.1% in comparison-group had taken their complete medication for last seven days. Multivariate analysis showed that CHW intervention was associated significantly with improvements in all the desired outcomes. CONCLUSION: Equipping the CHWs to measure BP was effective in increasing the screening and identification of hypertension, regular measurement of BP of individuals with hypertension and the adherence to medication. This shows the potential if the one-million strong work-force of Accredited-Social-Health-Activists (ASHA) CHWs in India gets equipped for this role. Governments need to provide a stronger policy push to get this materialised.

Assessing the time use and payments of multipurpose community health workers for the various roles they play-a quantitative study of the Mitanin programme in India.

BACKGROUND: Community health workers (CHWs) are crucial human resources for health. While specialist CHWs focus on a single disease vertically, the generalist or multipurpose CHWs perform wider functions. The current study was aimed at examining the time multipurpose CHWs spend on performing their different roles. This can help in understanding the importance they attach to each role. Since CHWs in many developing countries are classified as part-time volunteers, this study also aimed to assess the adequacy of CHW payments in relation to their time use. METHODS: The study covered a well-established CHW programme in India's Chhattisgarh state. It had 71,000 multipurpose part-time CHWs known as Mitanins. Data collection involved interviews with a representative sample of 660 rural and 406 urban Mitanins. A semi-structured tool was designed and field tested. It included 26 pre-coded activities of CHWs placed under their six purposes or roles. Prompting and triangulation were used during interviews to mitigate the possibility of over-reporting of work by CHWs. The recall period was of one week. Descriptive analysis included comparison of key indicators for rural and urban Mitanins. A multi-variate linear model was used to find the determinants of CHW time-use. RESULTS: The rural and urban Mitanins respectively spent 25.3 and 34.8 h per week on their CHW work. Apart from location (urban), the total time spent was associated with size of population covered. The time-use was well balanced between roles of service-linkage, providing health education and curative care directly, COVID-19 related work and action on social determinants of health. More than half of their time-use was for unpaid tasks. Most of the cash-incentives were concentrated on service linkage role. The average payment earned by Mitanins was less than 60% of legal minimum wage. CONCLUSION: The time-use pattern of Mitanins was not dictated by cash-incentives and their solidarity with community seemed be a key motivator. To allow wide ranging CHW action like Mitanins, the population per CHW should be decided appropriately. The considerable time multipurpose CHWs spend on their work necessitates that developing countries develop policies to comply with World Health Organisation's recommendation to pay them fairly.