Lay Health Workers in Community-based Care and Management of Dementia: a ‘Pre’ and ‘Post’ Pilot Intervention Study in Southwestern Uganda

Background: The global need for efficient and cost-effective use of healthcare resources in low-income countries has led to the introduction of lay health workers (LHWs) as a link of the community to the formal health care services, especially in remote areas. As such, the LHWs perform a variety of tasks such as patient care, education, support for care delivery, and social support across all disease types. However, little is known about their ability to support dementia care and management in the community. Purpose: The goal of the pilot intervention study was to evaluate the ability of LHWs in rural southwestern Uganda to support community-based care and management for people with dementia. Methods: This was a ‘pre’ and ‘post’ pilot intervention study which involved a qualitative assessment of LHWs’ knowledge on community-based management and care for people with dementia. The pilot intervention focused on four core competency domains in the WHO dementia toolkit. It began with a five-day training of the LHWs, followed by eight weeks of implementation of knowledge and skills gained during the training, and an evaluation of their experiences. Analysis focused on apriori themes i.e., needs assessment, early detection and management, community engagement, and support for people with dementia; as well as evaluation of the eight-weeks implementation. Results: Before the training, the LHWs did not know much about dementia and provided no dementia-specific support in the community. Activities were limited to general support, including sanitation, nutrition, and health education. After the training, LHWs had a basic understanding of dementia and began sensitizing their communities. They provided dementia-specific support, although they had challenges in differentiating the signs of early dementia from superstitious beliefs. They felt more comfortable in handling people with dementia and reported a notable change in the attitude of family members towards people with symptoms of dementia. Conclusion: Results from the pilot intervention study showed that, with enhanced capacity, LHWs may be able to support community-based management for people with dementia. A larger study is needed to confirm these findings and further assess effectiveness of the LHWs’ skills.

“Like a doctor, like a brother”: Achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia

Background There are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries. Methods We conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data. Results There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed. Conclusion It is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision.

Roles and Responsibilities of Expert Clients in Adolescent HIV Service Delivery in Eswatini: A Conventional Content Analysis

BackgroundLike in other countries throughout sub-Saharan Africa, Eswatini employs a cadre of HIV-positive lay health workers known as expert clients (ECs) for the purpose of mitigating human resource gaps in HIV care. However, there are no insights in the literature describing the scope of their contribution to adolescent-specific HIV service delivery. Therefore, we aimed to elucidate the specific roles and responsibilities of ECs with regard to service delivery among adolescents living with HIV in Eswatini, and to provide recommendations for enhancing adolescent service provision among ECs and similar lay health workers throughout low- and middle-income countries. MethodsAn exploratory qualitative descriptive methodology using conventional content analysis was employed to meet our study aims. We recruited 20 expert clients and 12 key informants (i.e., program managers, program coordinators, and nurses) to participate in semi-structured interviews, and we arranged four focus group discussions among adolescents living with HIV with 7 to 10 participants per focus group. ResultsAdherence counseling in clinical and community settings was considered paramount to the roles and responsibilities of ECs with regard to adolescent-specific HIV service delivery. The following recommendations were made to enhance EC service delivery practices among adolescents: a) training in adolescent developmental, sexual, and reproductive needs, b) training to enhance clinical knowledge and skills, c) additional work equipment and compensation, and d) more parent and guardian engagement in their work. ConclusionsWhile expert clients meet the needs of HIV-positive adolescents in several capacities, ECs require additional resources, skills, and training to improve their work, especially within the realm of sexual and reproductive health. Future research is needed to evaluate the impact of EC service delivery on adolescent health outcomes.

Lay Health Workers’ Perspectives on Delivery of Advance Care Planning and Symptom Screening Among Adults With Cancer: A Qualitative Study

Introduction: Advance care planning and symptom screening among patients with cancer require team-based approaches to ensure that these services are equitably and appropriately delivered. In several organizations across the United States, we trained and employed lay health workers (LHWs) to assist with delivering these services for patients with cancer. The aim of this study was to understand LHWs’ views on delivering these services. Methods: We conducted semi-structured interviews with 22 LHWs in 6 US-based clinical cancer care settings in 4 large cities. We recorded, transcribed, and analyzed interviews using the constant comparative method of qualitative analysis. Results: Participants noted the importance of their role in assisting with the delivery of advance care planning (ACP) and symptom screening services. Participants noted the importance of developing relationships with patients to engage openly in ACP and symptom screening discussions. Participants reported that ongoing training provided skills and empowered them to discuss sensitive issues with patients and their caregivers. Participants described challenges in their roles including communication with oncology providers and their own emotional well-being. Participants identified solutions to these challenges including formal opportunities for introduction with oncology clinicians and staff and grievance sessions with LHWs and other team members. Discussion: LHWs from several organizations endorsed the importance of their roles in ensuring the delivery of ACP and proactive symptom screening. LHWs noted challenges and specific solutions to improve their effectiveness in delivering these important services to patients after their diagnosis of cancer.