To our knowledge, only one study has reported on CHWs' time utilization using direct time-motion observation in Malawi, focusing on cervical cancer and family planning [36]. However, our study focused on household visits and time taken for specific tasks among diverse multiple health areas. We found that CHWs in the Neno district spend significantly less time on monthly household visits than expected through program design, with a median time of 34 minutes. Despite our study showing that CHWs spend less time on monthly household visits than the expected 60 minutes from program design, prior studies done in Neno have shown that CHWs provide high-quality, patient-centred care with improved health outcomes in the community associated with CHWs work [15, 40–44].
We found that CHWs were spending > 50% of their time on disease screening and providing health education and promotion within the monthly household visit – a core design of the CHW program in Neno District [15]. Similar findings have been reported in India and South Africa where on average, CHWs spend 30 minutes on similar health education activities, nutrition screening, family planning, and immunizations [45, 46] as their core activities. However, a study done in Burkina Faso, Nigeria and Uganda found that CHWs spend longer visit times between 56–77 minutes on activities of testing and treatment components [47], which makes sense for the type of activities.
In our study, four out of six catchment areas have greater than 33 households assigned to each CHW despite this being within the expected number of households in the Neno district. Even though not all the catchment areas with higher numbers of households spent less median time spent on monthly visits in this study, CHWs with higher numbers of households assigned may have increased workload with less time available to spend at a household [26, 48]. Further studies of our CHW program and others are required to further understand the ideal amount of time for high-quality care depending on visit type and expected tasks.
During monthly household visits, however, we found few CHW touches for STIs with significantly higher median times than all other health areas. This finding may be partly due to this study's small number of observations. Still, it could also be partly due to the stigma and discomfort present with sexual-related health conditions in many communities with potentially a lack of health knowledge in the community [49]. Following STIs, the median time spent on NCDs was statistically higher than the remainder of all other health areas. With a correspondingly high proportion of touches, this finding is likely due to the growing burden of NCDs encompassing a complex, diverse set of health conditions in Malawi [50]. There is extensive literature on how CHWs have contributed to improved outcomes for NCD patients from the follow-up for missed facility visits to treatment outcomes and [15, 51–53] suggesting that more time is required.
Following STIs and NCDs, TB and COVID-19/respiratory disease had frequent touches by CHWs. This finding is likely due to the COVID-19 pandemic during the study period. In Neno, at the onset of COVID-19, CHWs were trained on preventive measures and COVID-19 education provision to their communities. Similar approaches have been reported by other LMICs as part of the response [54, 55].
Another critical function of CHWs is to provide psychosocial support and more needed especially in light of the COVID-19 pandemic-induced stress and anxiety [56–60]. However, we found that CHWs were only spending a median of 2 minutes in each household, which is considered less than necessary to support individuals. In addition to eight health condition focus areas and COVID-19, CHW also focused on Malaria and other conditions including water sanitation and hygiene. This is not surprising as the Neno district has an estimated malaria prevalence of 34% per year [61], with frequent episodes of typhoid and diarrheal disease outbreaks [62, 63]. This finding supports that these health areas are of concern within the community and should be given consideration for additions to the program through training and education tools.
On child health and malnutrition, we found that CHWs were spent only a median of 3 and 2 minutes respectively, with few touches for both health areas. This finding could be explained in part due to a “no-touch” policy introduced for COVID-19 infection control with a lack of personal protective equipment (PPE) for CHWs in Malawi. Similar “no-touch” policies were implemented for CHW programs during the Ebola outbreak in Guinea, Liberia and Sierra Leone, indicating adopting a syndromic surveillance approach [64, 65]. Thus, mid-upper arm circumference (MUAC) for malnutrition screening was replaced with the visual screening of the child’s weight, wasting, hair colour and texture [66]. These findings suggest that through community and health workforce engagement with active participation in shaping CHW tasks and focus areas, additional screening processes for all health areas with special attention to childhood malnutrition and child health should be adapted within the CHW program with the ongoing pandemic and future outbreaks of infectious disease.
While CHWs appropriately only spend a short time (median of 1 minute) on logistics such as appointment reminders, these reminders have been shown to be crucial to the patients and improve health outcomes [67]. A systematic review of 25 studies found that informative appointment reminders through phone calls or text messages or actual household visits improve facility attendance two-fold [39]. In Neno District, we have observed the same with programmatic retentions of patients in care at 85% for HIV, and 72% for NCDs driven largely by CHW follow-up and appointment reminders [42, 43]. Further investigation of CHW patient support functions is needed to ensure that CHWs properly provide psychosocial care, education, and reminders to their households for facility follow-up. This study did not measure an association between the amount of time and service done with further studies to compare time spent on tasks to service quality, such as individual patient follow-up required.
Limitations
Our study has several limitations including limited generalizability with data from one rural district population in Malawi. However, we have cited numerous CHW programs in similar contexts and program designs worldwide in this study [2, 12, 30, 31, 34–36, 46, 53, 68] who could benefit from these findings on CHW time, health focus areas and time for specific tasks. Additionally, with study observations during the onset of the COVID-19 pandemic, the CHW time spent in the household may have been affected due to fears of transmission and programmatic changes without the necessary PPE with adjustments in screening and time spent on specific health areas. However, these findings also provide valuable information on how CHW programs should adjust for incorporating COVID-19 and emerging outbreaks into essential health care.