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Knowledge, attitudes, and practices of community health workers regarding noncommunicable diseases in São Paulo, Brazil: a cross-sectional study

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Catherine Ji at University of Toronto
Catherine Ji
Tibor Schuster
Tibor Schuster
Tibor Schuster
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Julie Silvia Martins
Julie Silvia Martins
Julie Silvia Martins
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Samuel Soares Filho at McGill University
Samuel Soares Filho
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Abstract and Figures

This study aims to determine the knowledge, attitudes, and practices (KAP) of community health workers (CHWs) working in the eastern region of São Paulo, Brazil, regarding noncommunicable diseases (NCDs) and their risk factors, as a preliminary step toward training optimization. We conducted an online cross-sectional survey study with KAP questions on NCD risk factors, cardiovascular diseases (CVD), diabetes, chronic obstructive pulmonary disease (COPD), and cancer. CHWs working full-time in family health teams were invited to participate in the months of January and February 2019. Descriptive analyses were performed for all survey questions, and knowledge scores were calculated from the sum of correct answers to the knowledge questions. The survey was completed by 1071 CHWs (85% response rate). Most respondents were women and had less than five years of work experience. The mean overall knowledge score was 62%. The highest score was obtained for the CVD category (80.2%), and the lowest scores in the COPD (28%) and cervical cancer (32.9%) categories. The majority of CHWs considered diabetes as the most important NCD in their communities. At the practice level, CHWs reported being the most confident about their counseling on cervical and breast cancer screening, and the least confident about colon cancer screening. Several knowledge and practice gaps across different NCDs have been identified, which can inform the optimization of CHWs’ training and clinical activities in order to improve their effectiveness in preventing and managing NCDs in the Brazilian context.
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Vol.:(0123456789)
1 3
Journal of Public Health
https://doi.org/10.1007/s10389-023-02079-w
ORIGINAL ARTICLE
Knowledge, attitudes, andpractices ofcommunity health workers
regardingnoncommunicable diseases inSão Paulo, Brazil:
across‑sectional study
CatherineJi1,2,3 · TiborSchuster1· JulieSilviaMartins4· SamuelSoaresFilho1,4,5· WagnerNicola1,4,5·
YvesBergevin1
Received: 1 June 2023 / Accepted: 22 August 2023
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023
Abstract
Aim This study aims to determine the knowledge, attitudes, and practices (KAP) of community health workers (CHWs)
working in the eastern region of São Paulo, Brazil, regarding noncommunicable diseases (NCDs) and their risk factors, as
a preliminary step toward training optimization.
Subject and methods We conducted an online cross-sectional survey study with KAP questions on NCD risk factors, car-
diovascular diseases (CVD), diabetes, chronic obstructive pulmonary disease (COPD), and cancer. CHWs working full-time
in family health teams were invited to participate in the months of January and February 2019. Descriptive analyses were
performed for all survey questions, and knowledge scores were calculated from the sum of correct answers to the knowledge
questions.
Results The survey was completed by 1071 CHWs (85% response rate). Most respondents were women and had less than
five years of work experience. The mean overall knowledge score was 62%. The highest score was obtained for the CVD
category (80.2%), and the lowest scores in the COPD (28%) and cervical cancer (32.9%) categories. The majority of CHWs
considered diabetes as the most important NCD in their communities. At the practice level, CHWs reported being the most
confident about their counseling on cervical and breast cancer screening, and the least confident about colon cancer screening.
Conclusion Several knowledge and practice gaps across different NCDs have been identified, which can inform the optimi-
zation of CHWs’ training and clinical activities in order to improve their effectiveness in preventing and managing NCDs
in the Brazilian context.
Keywords Knowledge, attitudes and practice· Community health workers· Noncommunicable diseases· Cross-sectional
studies· Surveys and questionnaires· Attitude to health
Background
Noncommunicable diseases (NCDs) include four main
groups: cardiovascular diseases (CVDs), cancer, chronic res-
piratory diseases and diabetes (World Health Organization
2017). These diseases share known modifiable behavioral
risk factors (tobacco use, physical inactivity, unhealthy diet,
and harmful use of alcohol), which can lead to metabolic
changes (hypertension, overweight/obesity, hyperglycemia
and hyperlipidemia) that increase the overall risk of develop-
ing NCDs (World Health Organization 2017). NCDs have
become the leading causes of adult mortality and morbidity
worldwide, and they disproportionately affect people in low-
and middle-income countries (LMICs) (Murray etal. 2012;
World Health Organization 2017). In Brazil, the estimated
* Catherine Ji
catherine.ji@uhn.ca
1 Department ofFamily Medicine, McGill University,
Montreal, Quebec, Canada
2 Present Address: Department ofFamily andCommunity
Medicine, University ofToronto, Toronto, Ontario, Canada
3 Present Address: Toronto Western Family Health Team,
University Health Network, Toronto, Ontario, Canada
4 Santa Marcelina Health, SãoPaulo, SãoPaulo, Brazil
5 Faculty ofMedicine, Faculdade Santa Marcelina, SãoPaulo,
SãoPaulo, Brazil
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... The interviewer-administered questionnaire covers socio-demographic information, knowledge and health system related questions. The assessment of variables was made according to suggestions by different scholars or standard guidelines such as measurement of sociodemographic variables [29], wealth index [25,26] and variables for evaluating physical activity [30], and fruits and vegetables consumption [31]. ...
Factors associated with fruit and vegetable intake and physical activity among reproductive age women in Gofa and Basketo Zones, Southern Ethiopia: a community based cross-sectional study
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  • Nov 2024
Background The escalation in burdens of non-communicable diseases coupled with unmet needs of sexual and reproductive health services progressively impacting women, and posing significant threats to forthcoming generations. Low fruits and vegetables intake, and insufficient physical activity are known risk factors of NCDs. This research endeavors to assess the level and factors associated with fruit and/or vegetable intake and physical activity among women of reproductive age in Gofa and Basketo Zones, Southern Ethiopia. Methods A community based cross-sectional study was employed among reproductive age women from September 9/2022 to December 6/2022. A multistage cluster sampling was used to select participants from the designated zones. A total of 1404 study participants were included in the analysis. Statistical analysis was conducted using Statistical Package for the Social Sciences software encompassing descriptive statistics, bivariate analysis, and multivariate logistic regression. Associations were deemed statistically significant if the p-value was < 0.05. Result Prevalence of adequate fruit and/or vegetable (FV) intake and physical activity were 48.4% and 78.3% respectively. Women who were from younger age groups, getting advice from health professionals, having primary school education, having > 4 family size, women from households with the lower wealth status, widowed/separated and Gofa zone residents were more likely to have adequate FV intake. Being married, single and Basketo zone residence were positively associated with physical activity. However, women from older age groups and having lesser educational status were less likely to be physically active. Women who were rural residents and having no family history of NCD were more likely to have both adequate FV intake and physical activity. Conclusion A substantial gap exists between the recommended level and actual FV consumption and physical activity. They are associated with different socio-economic, knowledge and health system factors. However, these preventive factors are more influenced by rural residence, having no family history of NCD, women’s occupation. Therefore, NCD prevention would be more effective if they account specific determinants in their design. Policy and socio-political factors influencing the rise of NCD risk factors should also be addressed.
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An Evaluation of Community Health Workers' Knowledge, A itude and Personal Lifestyle Behaviour in Non-Communicable Disease Health Promotion and Their Association with Self-Efficacy and NCD-Risk Perception
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Non-communicable disease care and management in two sites of the Cape Town Metro during the first wave of COVID-19: A rapid appraisal
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Background: Non-communicable diseases (NCDs), including type-2 diabetes and hypertension, have been associated with increased morbidity and mortality rates because of coronavirus disease 2019 (COVID-19). Maintaining quality care for these conditions is important but data on the impact of COVID-19 on NCD care in South Africa are sparse. Aim: This study aimed to assess the impact of COVID-19 on facility and community-based NCD care and management during the first COVID-19 wave. Setting: Two public health sector primary care sites in the Cape Town Metro, including a Community Orientated Primary Care (COPC) learning site. Methods: A rapid appraisal with convergent mixed-methods design, including semi-structured interviews with facility and community health workers (CHWs) (n = 20) and patients living with NCDs (n = 8), was used. Interviews were conducted in English and Afrikaans by qualified interviewers. Transcripts were analysed by thematic content analysis. Quantitative data of health facility attendance, chronic dispensing unit (CDU) prescriptions and routine diabetes control were sourced from the Provincial Health Data Centre and analysed descriptively. Results: Qualitative analysis revealed three themes: disruption (cancellation of services, fear of infection, stress and anxiety), service reorganisation (communication, home delivery of medication, CHW scope of work, risk stratification and change management) and outcomes (workload and morale, stigma, appreciation and impact on NCD control). There was a drop in primary care attendance and an increase in CDU prescriptions and uncontrolled diabetes. Conclusion: This study described the service disruption together with rapid reorganisation and change management at primary care level during the first COVID-19 wave. The changes were strengthened by the COPC foundation in one of the study sites. The impact of COVID-19 on primary-level NCD care and management requires more investigation.
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Roles for community health workers in diabetes prevention and management in low- and middle-income countries
Article
Full-text available
  • Nov 2021
Diabetes prevalence is increasing worldwide, especially in low- and middle-income countries (LMIC), posing the need for improved detection and management strategies. Chronic disease models and lifestyle medicine provide structures for action. Community health workers (CHWs) can significantly contribute to chronic disease care if they are trained and integrated into low-resource health systems. Although most current CHWs worldwide are performing maternal/child health and infectious disease-related tasks, other programs involving CHWs for noncommunicable disease prevention and management are increasing. In this article, we discuss the advantages, challenges, and questions regarding possible roles assigned to CHWs in the prevention and management of diabetes. These roles include performing simple screening tests, implementing lifestyle/behavioral interventions, and connecting patients with alternatives to biomedicine. Specifically, CHWs can aid diabetes epidemiological surveillance by conducting risk score-based screening or capillary glucose testing, and they can facilitate diabetes self-management by delivering interventions described in the transcultural diabetes nutrition algorithm. Furthermore, while this role has not formally been assigned, CHWs can leverage their intimate knowledge of local practices to provide decision-making support to patients in environments with pluralistic health systems. Ethnocultural differences in CHW functions and transcultural adaptations of their roles in diabetes care should also be considered. In summary, CHWs can improve diabetes care by screening high-risk individuals and implementing lifestyle interventions, especially in LMIC.
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Diagnostic Accuracy of a Two-Stage Sequential Screening Strategy Implemented by Community Health Workers (CHWs) to Identify Individuals with COPD in Rural India
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Purpose Undiagnosed Chronic Obstructive Pulmonary Disease (COPD) results in high morbidity, disability and mortality in India. Effective strategies for active COPD screening in community settings are needed to increase early identification, risk reduction and timely management. The objective of this study was to test the diagnostic accuracy of a sequential two-step screening strategy to detect COPD, implemented by community health workers (CHWs), among adults aged ≥40 years in a rural area of North India. Patients and Methods Trained CHWs screened all consenting (n=3256) eligible adults in two villages using the Lung Function Questionnaire (LFQ) to assess their COPD risk and conducted pocket spirometry on 268 randomly selected (132 with high risk ie LFQ score ≤18 and 136 with low risk ie LFQ score >18) individuals. Subsequently, trained researchers conducted post-bronchodilator spirometry on these randomly selected individuals using a diagnostic quality spirometer and confirmed the COPD diagnosis according to the Global Initiative for Obstructive Lung Disease (GOLD) criteria (FEV1/FVC ratio <0.7). Results This strategy of using LFQ followed by pocket spirometry was sensitive (78.6%) and specific (78.8%), with a positive predictive value of 66% and negative predictive value of 88%. It could accurately detect 67% of GOLD Stage 1, 78% of GOLD Stage 2, 82% of GOLD Stage 3 and 100% of GOLD Stage 4 individuals with airflow limitation. Conclusion COPD can be accurately detected by trained CHWs using a simple sequential screening strategy. This can potentially contribute to accurate assessment of COPD and thus its effective management in low-resource settings.
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The global role, impact, and limitations of Community Health Workers (CHWs) in breast cancer screening: a scoping review and recommendations to promote health equity for all
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Introduction: Innovative interventions are needed to address the growing burden of breast cancer globally, especially among vulnerable patient populations. Given the success of Community Health Workers (CHWs) in addressing communicable diseases and non-communicable diseases, this scoping review will investigate the roles and impacts of CHWs in breast cancer screening programs. This paper also seeks to determine the effectiveness and feasibility of these programs, with particular attention paid to differences between CHW-led interventions in low- and middle-income countries (LMICs) and high-income countries (HICs).Methods: A scoping review was performed using six databases with dates ranging from 1978 to 2019. Comprehensive definitions and search terms were established for 'Community Health Workers' and 'breast cancer screening', and studies were extracted using the World Bank definition of LMIC. Screening and data extraction were protocolized using multiple independent reviewers. Chi-square test of independence was used for statistical analysis of the incidence of themes in HICs and LMICs.Results: Of the 1,551 papers screened, 33 were included based on inclusion and exclusion criteria. Study locations included the United States (n=27), Bangladesh (n=1), Peru (n=1), Malawi (n=2), Rwanda (n=1), and South Africa (n=1). Three primary roles for CHWs in breast cancer screening were identified: education (n=30), direct assistance or performance of breast cancer screening (n=7), and navigational services (n=6). In these roles, CHWs improved rates of breast cancer screening (n=23) and overall community member knowledge (n=21). Two studies performed cost-analyses of CHW-led interventions.Conclusion: This review extends our understanding of CHW effectiveness to breast cancer screening. It illustrates how CHW involvement in screening programs can have a significant impact in LMICs and HICs, and highlights the three CHW roles of education, direct performance of screening, and navigational services that emerge as useful pillars around which governments and NGOs can design effective programs in this area.
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Effectiveness of a community health worker (CHW) training in monitoring and care of patients with chronic obstructive pulmonary disease (COPD) in rural Gujarat, India
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  • Apr 2020
Context: Chronic obstructive pulmonary disease (COPD) is the second leading contributor to the disease burden of India. The current COPD burden cannot be managed effectively just through a physician-based approach. In a primary care setting, community health workers (CHWs) can play an effective role in making COPD care accessible and effective. Aim: Findings of an assessment of a training program for CHWs on COPD have been reported here. Methods: 90 CHWs working as a part of a noncommunicable disease prevention and care program in a rural primary care setting were exposed to a series of five training sessions. The sessions were designed and administered jointly by a team of public health experts and physiotherapists in the year 2017-18. Topics covered were basic clinical aspects of COPD, monitoring a patient with COPD, and basic aspects of pulmonary rehabilitation. The assessment comprised 12 MCQs and short questions, 7 video exercises, 2 case vignettes, and 5 skill assessments through objectively structured clinical examination (OSCE). Statistical analysis: Mean percentage scores were calculated for each domain of assessment to make it comparable. Results: 70 CHWs with a mean age of 42.2 years completed all the training and underwent the assessment. Mean percentage score (SD) for knowledge was 62% (16.3). In OSCE assessment, scores were best in sputum clearance technique demonstration (92.1%) and the least in dyspnea relieving positions (59.2%). The CHWs had difficulties in identifying signs of respiratory distress (score - 55.1%). No statistically significant association was observed between performance scores and their sociodemographic profile. Conclusion: The results were encouraging and the program may be pilot tested in a government setting particularly using the health and wellness centers (HWC) platform.
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Expanding the use of community health workers in urban settings: A potential strategy for progress towards universal health coverage
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  • Feb 2020
  • HEALTH POLICY PLANN
Community health worker (CHW) programmes have been used for decades to improve access to health services in rural settings in low- and middle-income countries. With more than half of the world's population currently living in urban areas and this population expected to grow, equitable access to health services in urban areas is critically important. To understand the extent to which CHW programmes have been successfully deployed in low-income urban settings, we conducted a review of the literature between 2000 and 2018 to identify studies evaluating and describing CHW programmes implemented fully or partially in urban or peri-urban settings. We identified 32 peer-reviewed articles that met our inclusion criteria. Benefits have been documented in several urban settings in low- and middle-income countries including those to address TB/HIV, child health, maternal health and non-communicable diseases through a variety of study designs.
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The role of community health workers in cervical cancer screening in low-income and middle-income countries: a systematic scoping review of the literature
Article
Full-text available
  • May 2019
Introduction Community-based screening for cervical cancer and task sharing to community health workers (CHWs) have been suggested as a potential way to increase screening coverage in low- and middle-income countries (LMICs). The aims of the scoping review were to understand the following: (i) where and how CHWs are currently deployed in screening in LMIC settings; (ii) the methods used to train and support CHWs in screening, and (iii) The evidence on the cost-effectiveness of using CHWs to assist in screening. Methods A scoping literature search of 11 major databases and the grey literature was performed between 1978 and 2018. We included comprehensive search terms for ‘CHWs’ and ‘Cervical Cancer’, and used the World Bank criteria to define LMICs. Results Of the 420 articles screened, 15 met the inclusion criteria for review. Studies were located in Africa (n=5), Asia (n=5), and South and Central America (n=5). CHWs played a role in community education and raising awareness (n=14), conducting or assisting in cervical screening (n=5), or follow-up (n=1). 11 studies described CHW training activities. Only one study provided a formal cost analysis. Conclusion The roles of CHWs in cervical cancer screening in LMICs have largely to date focused on education, outreach, and awareness programmes. Community-based approaches to cervical cancer screening are feasible, although the sociocultural context plays an important role in the acceptability of these interventions. Further in-depth contextually grounded studies exploring the acceptability of such interventions are required, as well as studies exploring the cost-effectiveness of involving CHWs in cervical cancer screening activities.
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