Strengthening the role of community health workers in supporting the recovery of ill, undernourished children post hospital discharge: qualitative insights from key stakeholders in Bangladesh and Kenya

Background: Even when undernourished children in low- and middle-income countries are treated using World Health Organisation recommended guidelines, they remain at elevated risk of death following hospital discharge. The role of community health workers (CHWs) in supporting post-discharge recovery to improve outcomes has not been adequately explored.

Methods: Qualitative research was conducted as part of the Childhood Acute Illnesses and Nutrition (CHAIN) Network in rural and urban Bangladesh and Kenya. Interviews were conducted with family members of a total of 64 acutely ill children admitted in four hospitals (two rural and two urban- across both contexts). Children included those with undernutrition, and interviews were repeated in family members’ homes over several months. Data collected from families were supplemented by observations in facilities and homes, key informant interviews with CHWs and policy makers in Bangladesh, and a review of relevant guidelines.

Findings: Guidelines suggest that CHWs could play a role not only in initially referring undernourished children to hospital, but also in supporting recovery post-discharge. However, the specific mechanisms to link CHWs into hospital discharge and post-discharge support processes are not specified. Data suggest a range of access and communication challenges that community health workers (CHWs) could potentially contribute towards overcoming. However, few families we interviewed reported any therapeutic interactions with CHWs post-discharge, especially in Kenya. Although CHWs are generally available in communities, they face significant challenges in conducting their roles, including unmanageable workloads, few incentives, lack of equipment and supplies and inadequate support from supervisors and some community members.

Conclusion/recommendations: There is need for context sensitive policy and guidance documents that include specific recommendations on post-discharge linkage or down-referral to support for vulnerable children. Consideration should be given to introducing and supporting a dedicated staff member (whether defined as a CHW or patient advocate) whose tasks and responsibilities include playing a linking role between family members and community-based post-discharge support services. These additional tasks should take into consideration the broader responsibilities of CHWs, and consider recognised challenges such as appropriate recognition, training and remuneration. Potential interventions need to be evaluated in carefully designed and conducted studies.