CHWs in all three settings were predominantly male, over 30 years old and relied on farming for income. In Benin most had been to secondary school, but not in Burkina Faso or The Gambia. In Benin, most were in post between 5 and 10 years, in Burkina Faso and The Gambia the majority had been CHWs for over 10 years. The most notable differences between settings were in terms of their incentives and time commitments to CHW duties. In Burkina Faso, CHWs were observed spending the most time on their activities both in terms of weekly and daily commitments. They also received the highest financial incentives paid to CHWs delivering the COSMIC intervention. Their incentive was aligned on that paid officially by the government to CHWs of approximately 40 US$ per month. The level of incentives for The Gambia were discussed with community leaders to ensure they were in line with incentives given for previous similar works in other MRC projects and also in line with salaries in The Gambia in general.
No clear pattern emerged of whether CHWs were substituting their time between COSMIC and non-COSMIC activities. Indeed, it appears that while the time to undertake CSST remained similar during and outside of the malaria season, it was time spent on other activities that showed the most variation. When given an opportunity to report challenges, the time taken to do COSMIC related activities was not mentioned. Our findings echo other studies that found CHWs increasingly involved in CSST programmes face significant challenges [24, 38]. The results vary depending on the setting. In The Gambia and Benin for instance, the CHWs mentioned challenges related to their low remuneration. This corroborates several studies regarding remuneration as a source of CHWs’ dissatisfaction [24, 39, 40]. All CHWs in the three countries emphasized transport difficulties, including movements between villages, especially during the rainy season; a barrier also noted in Senegal [41]. These frustrations may be mitigated both by better transportation and the use of mobile phones to remind pregnant women about their IPTp-SP visits [42, 43]. However, CHWs stayed motivated by the social recognition that they received while doing their work in the community.
While acknowledging the small sample size, our findings offer a multi-country look at the CHW characteristics and time commitment related to malaria screening and treating activities. These findings add to the growing evidence on the impact new interventions place on CHWs workload, both positive and negative [44–48]. We highlight the importance of taking into account the local health system realities when planning and sustaining new CHW led interventions, as suggested in several studies [18, 24, 27].
This study has its limitations. Although the time and motion approach is considered the gold standard for measuring health workers’ time use, it is labor-intensive and can only be done with a small number of participants [49–51]. As with all studies of this type, there was a risk of the Hawthorne effect, as while being observed, it is possible that the CHWs changed their behaviors [52, 53]. For example, CHWs may have wanted to demonstrate their challenging working conditions and therefore chosen, on the observation days, to visit pregnant women who lived very far from the health facility. In addition, contrary to other studies [24, 41], the CHWs in this study did not mention the lack of training or lack of supplies as challenges of their work. This is likely due to the trial context and because the intervention provided high levels of training, supervision and ensured drug supplies over the trial period.
The COSMIC trial results showed that adding community-based scheduled screening and treatment by CHWs to the standard IPTp-SP at ANC did not reduce the risk of placental malaria or peripheral malaria infection at delivery. The COSMIC trial did, however, support previous evidence that CHWs can both correctly use RDTs and adhere to test results and treatment guidelines [54, 55], increase ANC attendance, particularly in early pregnancy (in Burkina Faso), identify and treat infections between scheduled ANC visits, and encourage women to adhere to a full treatment course. All these aspects point to the potential of CHWs in curbing malaria.