5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting

Daniel Palazuelos, Kyla Ellis, Dana DaEun Im, Matthew Peckarsky, Dan Schwarz, Didi Bertrand Farmer, Ranu Dhillon, Ari Johnson, Claudia Orihuela, Jill Hackett, Junior Bazile, Leslie Berman, Madeleine Ballard, Raj Panjabi, Ralph Ternier, Sam Slavin, Scott Lee, Steve Selinsky, Carole Diane Mitnick, Daniel Palazuelos, Kyla Ellis, Dana DaEun Im, Matthew Peckarsky, Dan Schwarz, Didi Bertrand Farmer, Ranu Dhillon, Ari Johnson, Claudia Orihuela, Jill Hackett, Junior Bazile, Leslie Berman, Madeleine Ballard, Raj Panjabi, Ralph Ternier, Sam Slavin, Scott Lee, Steve Selinsky, Carole Diane Mitnick

Abstract

Introduction: Despite decades of experience with community health workers (CHWs) in a wide variety of global health projects, there is no established conceptual framework that structures how implementers and researchers can understand, study and improve their respective programs based on lessons learned by other CHW programs.

Objective: To apply an original, non-linear framework and case study method, 5-SPICE, to multiple sister projects of a large, international non-governmental organization (NGO), and other CHW projects.

Design: Engaging a large group of implementers, researchers and the best available literature, the 5-SPICE framework was refined and then applied to a selection of CHW programs. Insights gleaned from the case study method were summarized in a tabular format named the '5×5-SPICE charts'. This format graphically lists the ways in which essential CHW program elements interact, both positively and negatively, in the implementation field.

Results: The 5×5-SPICE charts reveal a variety of insights that come from a more complex understanding of how essential CHW projects interact and influence each other in their unique context. Some have been well described in the literature previously, while others are exclusive to this article. An analysis of how best to compensate CHWs is also offered as an example of the type of insights that this method may yield.

Conclusions: The 5-SPICE framework is a novel instrument that can be used to guide discussions about CHW projects. Insights from this process can help guide quality improvement efforts, or be used as hypothesis that will form the basis of a program's research agenda. Recent experience with research protocols embedded into successfully implemented projects demonstrates how such hypothesis can be rigorously tested.

Keywords: case study; community health workers; conceptual framework; quality improvement; research.

Figures

Fig. 1
Fig. 1
The 5-SPICE framework graphically represented.
Fig.2
Fig.2
Partners In Health (PIH) CHW Project characteristics (from the ‘Rich grids’). (a) Number of CHWs vs. Years in operation for various PIH CHW projects. (b) Distribution of CHW package of service across PIH programs. (c) CHW selection and recruitment at PIH programs. (d) Patient load per CHW by PIH program. Note: Data for PIH-Mexico are not yet available due to ongoing changes in this new program's implementation.
Fig.2
Fig.2
Partners In Health (PIH) CHW Project characteristics (from the ‘Rich grids’). (a) Number of CHWs vs. Years in operation for various PIH CHW projects. (b) Distribution of CHW package of service across PIH programs. (c) CHW selection and recruitment at PIH programs. (d) Patient load per CHW by PIH program. Note: Data for PIH-Mexico are not yet available due to ongoing changes in this new program's implementation.
Chart 1
Chart 1
5×5 SPICE chart-positive interactions.
Chart 2
Chart 2
5×5 SPICE chart-negative interactions.

References

    1. Bhutta Z, Lassi Z, Pariyo G, Huicho L. Geneva: World Health Organization; 2010. Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems.
    1. Lehmann U, Sanders D. Geneva: World Health Organization; 2007. Community health workers: what do we know about them?
    1. Prasad B, Muraleedharan V. Community health workers: a review of concepts, practice and policy concerns. 2008. pp. 1–32. Available from: [cited 31 August 2012]
    1. Crigler L, Hill K, Furth R, Bjerregaard D. Bethesda, MD: USAID; 2011. Community Health Worker Assessment and Improvement Matrix (CHW AIM): a toolkit for improving CHW programs and services.
    1. Meister JS, Moya EM, Rosenthal EL, Careaga K, Robinson JG. University of Arizona: Phoenix; 1998. Community health worker evaluation tool kit: increasing the quality of community health worker program evaluations. Available from: [cited7 March 2013]
    1. Palazuelos D. 5-SPICE: the structure and origins of an original community health worker conceptual framework. Unpublished manuscript.
    1. Mitnick CD, Shin SS, Seung KJ, Rich ML, Atwood SS, Furin JJ, et al. Comprehensive treatment of extensively drug-resistant tuberculosis. N Engl J Med. 2008;359:563–74.
    1. Rich ML, Miller AC, Niyigena P, Franke MF, Niyonzima JB, Socci A, et al. Excellent clinical outcomes and high retention in care among adults in a community-based HIV treatment program in rural Rwanda. J Acquir Immune Defic Syndr. 2012;59:35–42.
    1. Rigodon J, Joseph K, Keshavjee S, Cancedda C, Haidar M, Lesia N, et al. Training community health workers to scale-up HIV care in rural Lesotho: implementation lessons from the field. World J AIDS. 2012;2:135–42.
    1. Franke MF, Kaigamba F, Socci AR, Hakizamungu M, Patel A, Bagiruwigize E, et al. Improved retention associated with community-based accompaniment for antiretroviral therapy delivery in rural Rwanda. Infect Dis Soc Am. 2012. Available from: [cited 7 March 2013]
    1. Partners In Health. Program Management Guide. Boston: Partners In Health, 2011. Available from: [cited 7 March 2013]
    1. US Agency for International Development. Washington, DC: Government Printing Office; 2012. Community and formal health system support for enhanced community health worker performance: a U.S. Government Evidence Summit.
    1. Ahmed S. Taking healthcare where the community is: story of the Shasthya Sebikas of BRAC in Bangladesh. BRAC Univ J. 2008;5:39.
    1. BRAC. 2013. Available from: [cited 3 March 2013]
    1. BRAC. Dhaka: BRAC; 2007. BRAC health programme annual reports.
    1. BRAC. Dhaka: BRAC; 2006. Breaking new grounds in public health: annual report.
    1. Khan SH, Chowdhury AM, Karim F, Barua MK. Training and retraining Shasthyo Shebika: reasons for turnover of community health workers in Bangladesh. Health Care Superv. 1998;17:37–47.
    1. Lovell CA. Scaling-up in health: two decades of learning in Bangladesh. In: Rhode J, Chatterjee M, editors. Reaching health for all. Delhi: Oxford University Press; 1993. pp. 212–32.
    1. Mahbub A. A documentation on BRAC's Shastho Shebika: exploring the possibilities of institutionalization. Dhaka: BRAC Research and Evaluation Divisions; 2000.
    1. Rahman MS. Getting to know Shasthyo Shebikas: a case study of Tangail. Dhaka: BRAC Research and Evaluation Division; 2007.
    1. Reichenbach LS. Sustaining health: the role of BRAC's community health volunteers in Bangladesh, Afghanistan and Uganda. Dhaka: BRAC Research and Evaluation Division; 2011.
    1. Salam S. A study on the status of interpersonal health communication under essential health care program of BRAC. Dhaka: BRAC; 2006.
    1. UNICEF. Kathmandu: UNICEF; 2004. What works for children in South Asia: community health workers.
    1. Wyon JR, Rhode J. Community-based health care: lessons from Bangladesh to Boston. Boston: Management Sciences for Health; 2002.
    1. Teklehaimanot A, Kitaw Y, Yohannes AG, Girma S, Seyoum A, Desta H, et al. Study of the working conditions of health extension workers in Ethiopia. Ethiop J Health Dev. 2008. pp. 246–59. Available from: [cited 7 March 2013]
    1. Center for National Health Development in Ethiopia. Assessment of working conditions for the first batch of health extension workers. Addis Ababa. 2006. Available from: [cited 7 March 2013]
    1. Bilal NK, Herbst CH, Zhao F, Soucat A. Health extension workers in Ethiopia: improved access and coverage for the rural poor. In: Chuhan-Pole P, Angwafo M, editors. Yes Africa Can: success stories from a dynamic continent. Washington, DC: The International Bank for Reconstruction and Development/The World Bank; 2005. pp. 433–44.
    1. Center for National Health Development in Ethiopia. New York: Earth Institute; 2005. Training of health extension workers: first intake assessment.
    1. Independent Review Team. Addis Ababa: Ethiopia Health Sector Development Programme; 2010. Mid-term review. Available from: [cited 7 March 2013]
    1. United Nations Children's Fund. New York: UNICEF; 2012. Review of systematic challenges to the scale-up of integrated community case management: lessons & Recommendations from the Catalytic Initiative (CI/IHSS) Available from: [cited 7 March 2013]
    1. USAID. Ethiopia: USAID; 2012. All eyes on Ethiopia's national health extension program. Available from: [cited 14 July 2012]
    1. Glenton C, Scheel IB, Pradhan S, Lewin S, Hodgins S, Shrestha V. The female community health volunteer programme in Nepal: decision makers’ perceptions of volunteerism, payment and other incentives. Soc Sci Med. 2010;70:1920–7.
    1. Maes KC, Kohrt BA, Closser S. Culture, status and context in community health worker pay: pitfalls and opportunities for policy research. A commentary on Glenton et al. (2010) Soc Sci Med. 2010;71:1375–8.
    1. Glenton C, Scheel IB, Pradhan S, Lewin S, Hodgins S. Should we care what policy makers think? A response to Maes, Kohrt and Closser. Soc Sci Med. 2010;71:1379–80.
    1. Cherrington A, Ayala GX, Elder JP, Arredondo EM, Fouad M, Scarinci I. Recognizing the diverse roles of community health workers in the eliminiation of health disparities: from paid staff to volunteers. Ethn Dis. 2010;20:189–94.
    1. Nohria N, Groysberg B, Lee LE. Harvard Business Review. 2008. Jul-Aug. Employee motivation: a powerful new model; pp. 78–84.
    1. Bhattacharyya K, Winch P, LeBan K, Tien M. Community health worker incentives and disincentives: how they affect motivation, retention and sustainability. Arlington: USAID; 2001.
    1. Bhandari N, Mazumder S, Taneja S, Sommerfelt H, Strand TA. Effect of implementation of Integrated Management of Neonatal and Childhood Illness (IMNCI) programme on neonatal and infant mortality: cluster randomised controlled trial. BMJ. 2012;344:e1634. Available from: [cited 26 August 2012]
    1. Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR, et al. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet. 2008;371:1936–44. Available from: .
    1. Hussey MA, Hughes JP. Design and analysis of stepped wedge cluster randomized trials. Contemp Clin Trials. 2007;28:182–91.
    1. Palazuelos D, Lee S. Partners In Health Cross-Site CHW Summit. Boston: 2012. May, Panel discussion.
    1. Ashraf N, Bandiera O, Lee S. “Community Health Workers.” Policy Brief, Innovations for Poverty Action. 2012. Apr, Available from: [cited 20 March 2013]
    1. Ashraf N, Bandiera O, Kelsey J. “No Margin, No Mission? A Field Experiment on Incentives for Pro-Social Task.” Working Paper, Harvard Business School. 2012. Available from: [cited 7 March 2013]
    1. Freire P. Pedagogy of the oppressed. New York: Continuum; 1968.
    1. Werner D. Where there is no doctor. Berkeley, CA: Hesperian Foundation; 1977.

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