Introduction

To achieve universal health coverage, Sustainable Development Goal (SDG) 3 emphasizes the importance of quality essential services such as reproductive, maternal, and newborn care [1]. Community health workers (CHWs) are considered the cornerstone for promoting primary health care and are recognized as key players in achieving these SDGs. They play an important role in community-based care for maternal, newborn, and child health (MNCH) interventions, and creating liaison with facility-based care, thus saving the lives of mothers and children [2]. CHWs are mainly responsible to provide preventive and promotive health messages, distributing basic health supplies (iron and folic acid supplements, contraceptives, etc.), and acting as a linkage between far-flung communities and health centers [3]. A recent systematic review of the scope of work of CHWs highlights this cadre’s role as change agents in the communities they serve by connecting communities to care facilities, providing case-based management of common illnesses, and empowering communities to address the social determinants of health [4]. With a dire shortage of trained healthcare providers in Pakistan, the minimally trained CHW serves as a catalyst between the community and skilled care providers to improve outcomes [3,5].

CHWs in MNCH programs play a vital role in demographic surveillance activities at several research field sites in low-middle income countries (LMICs). One successful example of this is the ’MATLAB’ site in Bangladesh. ’MATLAB’ was initiated in 1966 which aimed to develop a registration system for married women of reproductive age (MWRAs) and under 5 children to provide MNCH interventions [6]. MATLAB program reported a decrease in maternal and under 5 years mortality from 412 to 131 per 100,000 pregnancies and 59.1 to 43.5 per 1000 live births respectively [7]. The Kilifi Health and Demographic Surveillance System (KHDSS) was established in 2000 by the KEMRI-Wellcome Trust Research Program (KWTRP) which reported a reduction in under-5 mortality from 13.1 to 7.4 deaths per 1000 person-years of observation (PYO) from 2013 to 2015, with a further decline of 5.4 deaths per 1000 PYO from 2015 to 2018 [8]. These programs not only showed improvement in health outcomes but also yielded critical insights for guidelines and best practices for community-based MNCH programs [8,9].

Although, the indicators for success of CHWs in LMICs are well established (7, 8), the perceptions of the communities towards them is relatively understudied. According to a study conducted in Kenya, CHWs were perceived by the community as facilitators for care seeking and health education in the community [10]. The communities also felt that CHWs had good communication skills and ensured confidentiality. However, participants indicated that due to the incentives offered by CHWs, communities were temporarily driven to obtain compensation rather than improve their health [10]. Participants also stated that CHWs were not always equipped with adequate health information (due to lack of formal training) and that they were unable to favorably influence care seeking behaviors [10]. Grant et al. identified that lack of trust and the possibility of breach in their health information was the primary barrier towards the acceptability of CHWs [11].

It is equally important to understand the perceptions of CHWs regarding their work. A study from Pakistan reported that CHWs felt respected and social prestige in the community as a result of their role as care providers [12]. On the other hand, lack of career advancement and a sense of being undervalued in the health care system were cited as major barriers by CHWs [10,13]. Grossmann-Kahn et al. reported that CHWs described a lack of knowledge about preventive treatments among community members, misunderstandings or failure to provide timely information to CHWs as significant barriers to their performance [14].

Although these community-based research surveillance sites provide valuable data on burden of maternal and child morbidity and mortality they require a relatively high amount of data collection from the community as compared to standard CHW programs. The successful functioning of these sites necessitates motivated CHWs as well as receptive, tolerant communities. However, there is paucity of literature on the perception of surveillance activities by the population as well as on the CHWs involved in these activities, both of which are critical for the long-term sustainability and functioning of these sites.

The purpose of this study was (1) to explore perceptions of MWRAs regarding role of CHWs involved in maternal and child surveillance in their area and (2) explore facilitators and barriers for CHWs involved in surveillance activities.

Materials and methods

Results

We conducted a total of 40 interviews, 25 with MWRAs and 15 with CHWs (i.e. 5 and 3 per site respectively). The mean age of MWRAs was 30 ± 6 years. Seventy-two percent of MWRAs (n = 18) had some level of education, with only 16% (n = 4) involved in gainful employment such as embroidery and stitching. The mean age of CHWs was 31± 8 years with 40% (n = 6) having graduate-level education or higher. The mean work experience of these CHWs in surveillance activities was 5.6 ± 2.5years. The demographic details of the study participants are reported in Table 1.

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Table 1. Baseline characteristics of study participants.

https://doi.org/10.1371/journal.pgph.0000295.t001

The thematic analysis centered around three major a priori themes for each set of participants (i.e. MWRAs and CHWs): (i) Perceptions (ii) Facilitators (iii) Barriers. For MWRAs, facilitators were factors that motivated them to share health information with the surveillance CHWs while the barriers were reasons which prevented them from doing so. For CHWs, facilitators and barriers were factors that affected their work performance.

Discussion

The current study reports the perceptions of MWRAs and the CHWs regarding MNCH surveillance activities in peri-urban marginalized communities in a low-resource setting. Both MWRAs and CHWs themselves reported this cadre as the main source for maternal and child health information and linking them to health facility services.

The key perceptions of MWRAs regarding CHWs were as basic care providers for themselves and their young children at the household level. Our findings were supported by other studies where MWRAs showed gratitude towards CHWs attitude and routine activities in contributing towards primary health care. This was also confirmed when MWRA’s acknowledged that during CHWs routine visits, they provided services in the form of dispensing of iron and folic acid tablets to pregnant women, monitoring newborn growth, and standard counselling for pregnant women [20,21]. Apart from this, surveillance CHWs connect community women to health care facilities for their antenatal and postnatal visits, however, MWRAs did not emphasize this aspect of CHWs work during the interviews. Studies conducted in LMICs have reported that CHWs encourage the community to avail services which in turn improved health outcomes such as skilled deliveries, improved immunization, and timely referral of sick children. This approach has led to improving lives and reduction in child mortality at certain study sites [22,23].

In the current study, MWRAs felt that routine surveillance visits enabled them to trust and build relations with CHWs for communication of health issues. These findings were similar to a study conducted in South Africa where CHWs were able to rebuild the broken trust of the community by developing personal relationships and spending time with the community [24]. In addition, the present study also demonstrated the MWRAs trust in surveillance CHWs due to their association with a well-established organization.

It was also commonly observed that MWRAs thought the provision of incentives (such as medicines, transportation to health facilities) should be part of the CHWs regular household visits as they should be compensated for providing data. However, such demands are beyond the scope of surveillance activities which include capturing pregnancies, births, and deaths in the community. A similar perception was also reported by Glenton et al where the community showed dissatisfaction from CHWs and considered their work insufficient when they provided only promotional health services [21].

At the community level, CHWs perceived themselves as important pillars of primary health care at community level as they act as a bridge between individuals and the health facility. Their work provided them an opportunity to help underprivileged communities, where access to basic health care services is limited. Mlotshwa et al. reported that being from the same community strongly enhances CHWs sense of belonging [25].

At a personal level, CHWs believed that routine surveillance provided a platform for improving their own knowledge and skills which was a key motivating factor for their work.

CHWs reported supportive supervision, respect, and appreciation from the community, knowledge and communication skills sessions, and the digitalization of data collection as facilitators for their current work. These facilitators have been reported by other studies where the work of CHWs, may be improved through defined catchment areas, clear job descriptions, support and ownership of the community, regular training, supervision, and monitoring system [20,26].

The barriers reported by CHWs in this study were similar to the findings of other authors including the community’s low health literacy, disrespectful attitude, safety and security concerns, lack of provision of tangible benefits by the CHWs to the community, and limited resources that influence routine surveillance activities [14]. The quality and number of services provided at health care facilities also played a pivotal role, as the experiences of MWRAs at the facility shaped their relationship with the CHWs during the home visit [14].

Similar work on CHWs performance in LMICs has suggested that ongoing trainings to improve knowledge and skills, supportive supervision, strong coordination between healthcare facilities and CHWs, and community in terms of stakeholder engagement and managing realistic community expectations could lead to improved CHW performance [27,28]. The current study has further strengthened these insights that a secure and conducive work environment, training opportunities for CHWs and fostering trust between MWRAs and CHWs would empower them to ensure that the overarching goals of MNCH surveillance activities in LMICs are met.

Due to the nature of the interactions with the community through regular home visits, it is important to understand the perspectives of MWRAs and CHWs involved in surveillance activities. The strength of this study was to provide detailed insights of both MWRAs and CHWs about these activities in low-resource settings. However, this study was conducted in peri-urban communities which are research sites for the Aga Khan University therefore the results of the study may not be generalizable to other parts of Pakistan or other countries. Another limitation was that the perception of non-married women was not included as part of the study.

Conclusion

Surveillance initiatives in Asia and Africa have strongly demonstrated that MNCH surveillance can help improve mother and child health indicators. However, to do so, it is essential to understand the perception of stakeholders (i.e. MWRAs and CHWs) involved in household surveillance in order to create an enabling environment for preventive home-based counseling and high-quality accurate data that can eventually translate into meaningful and impactful results in terms of lives saved.

Supporting information