Performance Evaluation of Community Health Workers: Case Study in the Amazon of Peru

Abstract

A shortage in human resources for health is a growing crisis that has led to an inability to provide adequate health services to impoverished populations. By “task-shifting”, health systems can delegate certain activities, such as health promotion and referral, to trained community members to help fill the human resource gap. An effective community health agent program can improve maternal and child health and overall effectiveness of rural health systems. Such a program is most effective when the community health agents receive supervision and evaluation of their performance. There is a shortage of literature that provides instruction and example on how to conduct a performance evaluation in the developing world to improve maternal and child health outcomes. The current study provides a case study of a performance evaluation in the Amazon region of Peru and how the findings can be used to make program adjustments. A set of instruments to measure the performance of CHWs was adapted from the literature and then implemented in the field. The instruments were used to measure the quality of home visits by the CHWs, their knowledge of the health topics, and structural activities. Three communities with an active CHW program in Loreto, Peru were chosen to receive the evaluation. All CHWs in the communities were evaluated. The scores from the evaluation were compared internally to identify strengths and weaknesses of the program and within the population of CHWs. The evaluation was completed on 52 home visits and 27 CHWs in three communities. The CHWs were found to be most effective at creating good relationships with caregivers and delivering health messages, and least effective at interacting with the child during the home visit and using material to deliver health messages. The evaluation instruments were well suited for the CHW program that utilizes home visits to teach about child health and development.

Appendices

Appendix 1: Home Visit Checklist

Home visit checklist
1. Time visit started			1.1 Time visit ended
2. Name of child
3. Child’s age
4. Primary caregiver	Mother □ Father □ Grandparent □ Sibling □ Aunt/Uncle □ Other relative □ Non-relative □
Description of the visit
5. Did the child participate in the visit?	Yes					No
	5.1 If no, why not?					Away □ Sick □ Sleeping □ Other □ ________________________
6. Who was the visit conducted with?	Mother □ Father □ Grandparent □ Sibling □ Aunt/Uncle □ Other relative □ Non-relative □
7. Was anyone else present throughout (most of) the visit?	Yes					No
	7.1 If yes, who?					Mother □ Father □ Grandparent □ Child < 5y □ Child > 5y □ Aunt/uncle □ Other relative □ Non- relative □
Review of previous visit
8. Home visitor checked with caregiver about play sessions between visits (content, frequency, enjoyment)		Well		Adequately		A little		Did not check		N/A
9. Home visitor asked the caregiver to demonstrate with the child what had been done since the last visit		Demonstrated or explained most of activities		Demonstrated or explained some of activities		Demonstrated or explained little of the activities		Home visitor did not ask		N/A
10. Home visitor asked about health topics discussed during the last visit		Asked WHICH health activities were practiced			Asked IF the health activities were practiced		Home Visitor did not ask		N/A
Home visit activities and methods
11. Home visitor reviewed the child’s growth monitoring check-up card		The card was reviewed and the contents were discussed			The card was reviewed, but not discussed		The card was not reviewed		N/A
12. Home visitor used the agenda/curriculum for guiding the visit		Used the agenda to guide the visit and explain the information		Used the agenda to guide the visit		Limited use of the agenda		Did not use the agenda		N/A
13. Home visitor brought toys to the visit		Used several toys for various activities		Used a toy sufficiently		Used a toy for very little time		Brought a toy but didn’t use		Did not bring
14. Home visitor used age-appropriate materials and activates		Always		Most of the time		Some of the time		Few times		Never
15. Home visitor puts special emphasis on language development		Always		Most of the time		Some of the time		Few times		Never
16. Home visitor explained activities and objectives (what the child should achieve) to the caregiver		Explained everything		Explained most		Explained some		Explained few		Never explained
17. Home visitor demonstrated the activities to the caregiver		Demonstrated all		Demonstrated most		Demonstrated some		Demonstrated few		Never demonstrated
18. Home visitor demonstrated the activities to the child		Demonstrated all		Demonstrated most		Demonstrated some		Demonstrated few		Never demonstrated
Home visitor explained activities to the child		Explained everything		Explained most		Explained some		Explained few		Never explained
19. Home visitor asked the caregiver to do the activities alone with the child		Asked for all of the activities		Asked for most of the activities		Asked for some of the activities		Asked for few of the activities		Never asked
20. Home visitor wrote down information and results of the visit		Wrote information and commitment for next visit		Wrote information about the child of the visit		Only Obtained caregiver’s signature		Did not		Unsure
Relationship between the home visitor and caregiver
21. Home visitor listen to the caregiver		All the time		Most of the time		Some of the time		Little of the time		Never
22. Home visitor was responsive to the caregiver		All the time		Most of the time		Some of the time		Little of the time		Never
23. Home visitor asked the caregiver’s opinion		All the time		Most of the time		Some of the time		Little of the time		Never
24. Home visitor encouraged and positively reinforced the caregiver		All the time		Most of the time		Some of the time		Little of the time		Never
25. Overall, the relationship between the visitor and caregiver was warm, understanding and cooperative		All the time		Most of the time		Some of the time		Little of the time		Never
Relationship between the home visitor and child
26. Home visitor listened to the child and responded to his/her vocalizations and gestures		All the time		Most of the time		Some of the time		Little of the time		Never
27. Home visitor praised the child when he/she attempted/completed activities		All the time		Most of the time		Some of the time		Little of the time		Never
28. Home visitor talked about activities that the child was doing		All the time		Most of the time		Some of the time		Little of the time		Never
29. Home visitor gave the child enough time to explore the materials and to complete the activities		All the time		Most of the time		Some of the time		Little of the time		Never
30. Overall, the relationship between the home visitor and the child was warm, understanding, and cooperative		All the time		Most of the time		Some of the time		Little of the time		Never
Overall home visit
31. Child actively participated in the visit		All the time		Most of the time		Some of the time		Little of the time		Never
32. Caregiver actively participated in the visit		All the time		Most of the time		Some of the time		Little of the time		Never
33. The home visitor actively encouraged participation		All the time		Most of the time		Some of the time		Little of the time		Never
34. The home visitor showed overall good knowledge of the material presented		Shared excellent knowledge of health topics		Shared sufficient amount of information		Shared little information or did not explain well		Shared incorrect information		N/A
35. The overall atmosphere of the visit was		Very happy		Happy		Neutral		Unhappy		Hostile
Home visit duration
36. Amount of time of the visit (in minutes)
37. Amount of time dedicated to language development (in minutes)
38. Amount of time dedicated to motor development (in minutes)
39. Amount of time dedicated to health messages (in minutes)

Appendix 2: Demographics Questionnaire

1. Date
2. Community
3. District
Demographic Questionnaire
4. Name
5. Sex	Male	Female
6. Age
7. Number of children
8. Occupation
9. Number of years working as a CHW
10. Number of families in catchment
11. Number of home visits completed per month
12. Received incentive as a CHW		Yes	No
13. If yes, value of incentive (in soles)
14. Education level (age withdrawn from school)

Appendix 3: Knowledge Test

Knowledge test
1. When should you wash your hands? Choose all that apply	□ Before handling food □ After caring for someone who is sick □ After using the bathroom □ After coming in contact with animals □ Other correct response □ Unsure □ Incorrect response
2. What are some ways to treat water? Choose all that apply	□ Boiling water □ Chlorine (Bleach) □ Solar disinfection □ Filtration □ Other correct response □ Unsure □ Incorrect response
3. What are sanitary practices for food preparation? Choose all that apply	□ Cooking food well (with heat) □ Washing hands before and after food preparation □ Washing the food when needed (e.g. fruits and vegetables) □ Washing dishes and environment □ Use clean water □ Keep the raw meat separate □ Other correct response □ Unsure □ Incorrect response
4. How should you serve the micronutrient powder? Choose all that apply	□ Serve with solid foods □ Serve with lukewarm food □ Serve with a little portion of food □ Other correct response □ Unsure □ Incorrect response
5. How do you prevent diarrhea? Choose all that apply	□ Washing your hands thoroughly with soap □ Using only clean water for drinking, cooking, etc. □ Prepare foods properly using sanitary practices □ Using latrines □ Having a clear environment □ Other correct response □ Unsure □ Incorrect response
6. How can you treat diarrhea? Choose all that apply	□ Go to the health post if experiencing diarrhea □ Drink lots of liquids □ Oral rehydration salts □ Zinc □ Home treatment (salt water solution) □ Other correct response □ Unsure □ Incorrect response
7. What are the symptoms of anemia? Choose all that apply	□ Fatigue □ Lack of an appetite □ Headaches □ Difficulty breathing □ Skin paleness □ Other correct response □ Unsure □ Incorrect response
8. How can you prevent malaria? Choose all that apply	□ Sleeping in a mosquito net □ Eliminate stagnant water from the environment □ Wearing long sleeves and pants □ Fumigation □ Other correct response □ Unsure □ Incorrect response
9. What are some indicators of malnutrition? Choose all that apply	□ Stunting (short for age) □ Under weight for age □ Other correct response □ Unsure □ Incorrect response
10. What are the benefits of breastfeeding? Choose all that apply	□ Nutritious for the child □ Builds child’s immune system □ Greater bond between mother and child □ Other correct response □ Unsure □ Incorrect response
11. What are some signs of danger in pregnant women? Choose all that apply	□ Convulsions □ Fever □ Burning when urinating □ Abdominal pain □ Bleeding □ Loss of consciousness □ Headache □ High blood pressure □ Other correct response □ Unsure □ Incorrect response
12. What recommendations would you give to a pregnant woman? Choose all that apply	□ Attend all prenatal checkups □ Avoid alcohol □ Take vitamin supplements □ Eat well □ Do not engage in strenuous activities □ Other correct response □ Unsure □ Incorrect response
13. What are some benefits of child stimulation? Choose all that apply	□ Physical development □ Language development □ Emotional Development □ Social development □ Development of intelligence □ Bonds mother and child □ Other correct response □ Unsure □ Incorrect response

Appendix 4: Results of Demographic Questionnaire

Demographic Questionnaire (N = 27)	Range	Average (%)	Mean
Sex: female	–	19	–
Age	21–63	–	42.2
Number of Children	1–8	–	4.6
Occupation	–	–	–
CHW only	–	63	–
Agriculture	–	19	–
Store	–	7	–
Other	–	11	–
Years as a CHW	1–5	–	3.4
Number of families to visit	4–29	–	12.3
Number of home visits per month	5–50	–	19.9
Age when finished school	10–24	–	16

Appendix 5: Results of CHW Performance Evaluation

Indicators	Range	Average of all CHW	Community averages
			Indiana	Mazán	Santa Clotilde
Child Health Score (%)	0–1	0.4	0.4	0.4	0.3
Knowledge Score	19–35	28.2	26.5	31.3	30.3
Total Check List Score	0–4	2.4	2.4	2.6	2.4
Demographic
Years as CHW	1–5	3.4	3.3	3.2	3.8
Number of children	1–8	4.6	5.3	3.8	3.4
Age at end of education (years)	10–24	16.0	16.2	16.3	15.4
Number of families in CHW’s Catchment	4–25	12.3	8.4	25.8	13.6
Dosage
Duration of home visit (min)	5–45	18.9	19.0	20.5	17.9
Time dedicated to cognitive development (min)	0–30	2.4	2.7	5.0	0.4
Time dedicated to health messages (min)	0–28	13.4	12.7	13.4	15
Number of home visits per month	1–50	16.3	7.3	37.8	24.6
Content
Delivery of Health Messages (#15, 16, 17, 18, 19, 35)	1–5	2.6	2.5	2.9	2.5
Structure of home visit (#8, 9, 10, 11, 21)	1–5	2.4	2.2	2.0	3.0
Use of material (#12, 13, 14)	1–5	1.5	1.5	2.2	1.2
Relationship
Relation with caregiver (#22–26, 33)	1–5	2.6	2.6	2.8	2.3
Relation with child (#27–32)	1–5	0.9	0.9	1.7	0.2
Promote caregiver—child interaction (#20)	1–5	1.3	1.4	1.4	1.0
Overall atmosphere of home visit (#34, 36)	1–5	2.8	2.8	3.0	2.7