Factors Impacting the Effectiveness of Community Health Worker Behavior Change: A Literature Review

" Social and behavior change communication (SBCC), which uses communication to positively influence the social dimensions of health and well-being, is an important strategy for improving health services at the provider level. "

This 24-page literature review was produced to inform how social and behaviour change communication (SBCC) programmes can contribute to improving services provided by community health workers (CHWs) and strengthen their ability to effectively deliver quality health care to community members. Produced as part of the Health Communication Capacity Collaborative (HC3) project, the literature review examines barriers and facilitating factors for CHWs in three areas: knowledge and competency, structural and contextual barriers (systemic and environmental factors), and motivational barriers (such as social norms and attitudes that effect CHWs willingness to provide services). Findings revealed that "CHWs face significant barriers, ranging from lack of materials and high workloads to ingrained attitudes and insufficient training." The report shares results and recommendations that can be used to anticipate and respond to potential barriers and promote facilitators to service provision through SBCC programmes for CHWs.

Based on a literature review, which included both peer-reviewed journals and grey literature on the topic of CHWs (with a particular focus on CHWs abilities, performance and attitudes), limited to resources published in the last 10 years focussing on middle- and lower-income countries, the report outlines a number of key findings, summarised briefly below:

Knowledge and Competency Barriers
As discussed in the report, knowledge is an important factor in determining the success of a CHW programme, yet health workers often lack the knowledge necessary to safely and effectively perform their responsibilities. Research also shows that many programmes continue to provide training that is insufficient or of poor quality, resulting in knowledge gaps among health workers. These knowledge barriers comprise both technical topics, such as around contraceptive methods, as well as non-technical knowledge such as problem-solving or time management. It was also found that the role of CHWs is continually expanding, with community demands of and expectations for CHWs often extending beyond the scope of CHWs knowledge and competencies. This requires continual monitoring and responsive training, possibly integrating peer learning. Below are a few selected recommendations outlined in the report.

• "CHW programs should have provisions for providing additional trainings that are responsive to CHW and community needs."
• "Communication programs should work to clearly establish the role of CHWs within the community to manage community-level expectations."
• "Programs should supply on-site mentorship or access to experts to supplement training."

Structural and Contextual Barriers
This section discusses how institutionalised and structural deficiencies can pose significant barriers to CHWs. CHWs' informal position within the health sector itself can lead to difficult relationships between CHWs and professional health workers, which can be avoided by effectively engaging both throughout the planning process. Other structural challenges include limited resources and capacity at the facilities that CHWs may refer their clients, heavy workloads, and lack of necessary supplies and resources. Other contextual barriers result from the community's attitude toward and support for CHW activities. This can include lack of clarity on the CHWs role, as well as stigma and tradition around controversial health topics, such as family planning. CHW programmes benefit significantly from interventions that encourage community ownership and community support for the CHWs and their activities. Below are a just a few selected recommendations outlined in the report:

• "Community members should be engaged with CHW program development early in the process to secure support and buy-in."
• "When designing CHW programs, care should be taken to ensure that appropriate systems and policies are in place to facilitate CHW service delivery objectives."
• "Programs should look beyond impacting CHWs to influencing the wider community, finding ways to engage the community around issues of stigma and discrimination."

Attitudinal Barriers
The third section outlines how CHWs' attitudes toward their work, controversial health topics, or certain individuals or groups within their community can prevent them from providing health services. "However, these attitudinal barriers also present opportunities in which SBCC programs can be particularly effective in influencing CHWs and thereby improving service delivery." This largely focuses on improving motivation and countering stigma and negative attitudes among CHWs themselves. These could be negative attitudes toward certain health topics - such as HIV/AIDS or family planning - but can also be a result of stigmatising attitudes toward individuals based on socio-economic status, ethnic profile, or perceived affiliations. The following are a few selected recommendations:

• "Recognition for CHWs' contributions, both within the health system and in the community, and when possible, opportunities for advancement, should be included as part of a CHW program."
• "CHW training should include components to help CHWs recognize and overcome their own preconceptions and stigma."
• "If appropriate, selection of CHWs should include screening for stigmatizing beliefs held by CHWs that might impact their ability to provide equal and quality care for all community members."

The report concludes that "while identifying and understanding barriers can assist in the design and implementation of SBCC programs, additional research is needed to evaluate the actual impact of SBCC programs in overcoming these barriers. Some knowledge and attitudinal barriers may be easily addressed through communication strategies, however, more serious systemic barriers may prove more challenging to resolve."