Maya J. Stephens ,Leah A. Schrumpf, Nathaniel E. Nsarko, Joy Noel Baumgartner, Seth Ohemeng-Dapaah, Eric Akosah & Melissa H. Watt s
Published online: 12 May 2020
In rural settings with shortages in trained health care workers, community health workers (CHWs) play an important role in the delivery of health care services. The Ghana Health Service initiated a national CHW programme in 2016 to expand health services to rural populations. This study explored the perceived role and value of CHWs in addressing family planning issues in the Amansie West district of Ghana. The study included in-depth interviews (IDIs) with 28 women in the community, ages 18–49, and 30 CHWs. Using inductive thematic analysis, IDIs were coded to explore opinions on the CHWs’ role and perceived value in the delivery of family planning. Participants explained that CHWs provided family planning as part of a healthcare package through household visits and referrals to government services. The value of CHWs in delivering family planning was seen in confidentiality, accessibility, and comfort. Participants recommended an enlarged CHW workforce with a range of commodities and programmatic support. The findings suggest CHWs play an important role in promoting family planning, by serving as a bridge between the community and clinics. In rural communities where resources are scarce, CHWs are an invaluable part of the broader healthcare system.
In an effort to address health provider shortages in low-resource rural settings, task shifting from higher-level health providers to community health workers (CHWs) has become increasingly common (McPake & Mensah, 2008). Economic analysis suggests that CHWs can be complementary as a low-cost health care service in settings where there is a human resource crisis (McCord et al., 2012). CHW programmes have been successfully implemented to address community-level access to a range of primary health care services including immunizations, maternal and child health, HIV/AIDS, and mental health (Keller et al., 2017; Liu et al., 2011; Perry et al., 2014). CHWs have the potential to play a substantial role in facilitating access to family planning services in rural areas, especially where there are high levels of unmet need for contraception (Janowitz & Stanback, 2009).
Globally, 214 million women of reproductive age who want to avoid pregnancy are not currently using a modern contraceptive method, which contributes to unintended pregnancies, maternal mortality, and unsafe abortions (Amo-Adjei et al., 2017; World Health Organization, 2018). Given their relationships within the community, CHWs can address gaps in family planning uptake and continuation. The provision of family planning services by CHWs generally include dispelling myths, counselling on the range of contraceptive methods, provision of certain methods, and referrals for other methods. Task shifting family planning education to CHWs is beneficial because it frees up time for higher-level professionals, increases access to information in rural areas, and reduces the costs of health service provision by targeting people in their home (Agarwal et al., 2016; Janowitz & Stanback, 2009).
Other settings have seen success in using CHWs to promote the uptake of family planning. In Ethiopia, the National Extension Worker Program increased contraceptive use by 25% (Weidert et al., 2017), and Madagascar saw a 26% greater uptake of contraceptives after a family planning programme was delivered by CHWs (Comfort et al., 2016). Additional studies in Tanzania and Kenya have shown that when the CHWs have trained adequately the provision of certain methods was feasible and acceptable in the communities (Agarwal et al., 2016; Olawo et al., 2013). CHW programmes vary considerably, and interventions must be tailored specifically to the sociocultural demographics of the setting.
Although fertility has declined precipitously in Ghana over the last few decades, there remains a burden of unmet need for family planning in rural areas (Ghana Statistical Service et al., 2015). Addressing the unmet need for family planning in rural populations is challenging. For example, a study in Ghana that integrated family planning into antenatal and child wellness clinics was only shown to increase prevalence in the urban setting not the rural. Barriers to use in the rural setting included previous contraceptive experiences and spousal communication (Wuni et al., 2017). Finding ways to identify and address the barriers to access are major goals of the Ghana Health Service (GHS), especially considering the large rural population in Ghana.
The 2000 implementation of the Community-based Health Planning and Services (CHPS) programme was a coordinated effort by the Ghana Health Service to strengthen health sector presence in the community. Geographic areas were divided into CHPS zones, which each had a CHPS clinic that was led by a Community Health Officer (CHO). The CHO was tasked with meeting the primary health care needs of the community, including both prevention and treatment. However, limited resources and volunteer fatigue slowed the community-based health efforts leaving a deficit in healthcare delivery.
To fill the gap, the Community Health Workers (CHW) programme was established to support the CHO in community-level health care delivery. The 2007 Millennium Villages Project examined the use of dedicated and incentivised CHWs to support CHOs in 30 communities within the Amansie West District, Ghana (Pronyk et al., 2012). In 2013, the 1 Million Community Health Workers Campaign was integrated into the CHPS strategy to improve healthcare access through the introduction of CHWs and the Ashanti region was selected as the baseline demonstration site. In 2016, the Ghana Health Services (GHS) partnered with the Youth Employment Agency to recruit, train, and deploy 20,000 CHWs and 1000 eHealth technical assistants (eTA) across the 216 districts in Ghana.
Ghana’s National Community Health Worker programme started in 2016 with a goal of providing universal health coverage to its citizens, strengthening the overall health system, and achieving the Sustainable Development Goals. Through the national programme, the CHWs are integrated into the CHPS programme to assist the CHOs with their work for health promotion, disease surveillance, and treatment of minor ailments. CHWs are uniquely situated to address these rural challenges with the provision of information about reproductive health and family planning being a key function of the CHWs’ efforts of health promotion.
Each CHW covers a catchment area of about 500 people and is supervised by a CHO, who is responsible for the CHPS zone. CHWs are between the ages of 18–35 and two-thirds are women. Other requirements include that CHWs must have secondary education or the ability to read and write, be nominated to serve, be well-known within their respected areas, and spend at least 80% of their time in their communities. CHWs receive a monthly stipend through the Youth Employment Agency; anecdotally, however, that payment is inconsistent. Although Ghana has a relatively strong national healthcare programme, statistics suggest that uptake of family planning is significantly lagging, despite broad knowledge in the population of contraceptive methods (Ghana Demographic and Health Survey, 2014) and infrastructures in place to provide services. The CHW programme was established in part to bridge that gap.
With the relatively recent investment in Ghana’s CHW programme, it is important to understand the impact of the CHW programme on family planning thus far. The goal of this study was to explore the perceived role and value of CHWs in supporting family planning services and addressing associated barriers to family planning use in Amansie West, a rural district in Ghana.
This qualitative study took place between May and July 2018 in the Amansie West district of the Ashanti Region of Ghana. Data included in-depth interviews (IDIs) with 33 women who were potential beneficiaries of the CHW programme and 30 active CHWs. Ethical approval for the study was received from the Duke University Institutional Review Board and the Ghana Health Service Ethical Review Committee.
The study was conducted in the predominantly rural Amansie West district of the Ashanti Region of Ghana, which was the pilot site of the initial programme. The 2010 Population and Housing Census reported that over 95% of the 134,331 residents of Amansie West were rural (Ghana Statistical Service et al., 2015). The six sub-districts were selected for this study due to penetration by the national CHW programme and accessibility to the research team. Between 2007 and 2015, two of the six sub-districts received donor-driven support via the Millennium Villages Project. The remainder were incorporated into the national CHW programme.
The sample included two groups: 33 women who were potential beneficiaries of the CHW programme and 30 active CHWs. The 33 women were selected from 280 women who participated in a cross-sectional survey about family planning use. Women were eligible for the survey if they were of fertility age (18–49) and had been registered by a CHW since the inception of the expanded Ghana National CHW programme in 2016. At the completion of the survey, research assistants asked participants about their interest in participating in an IDI and assessed their fit as a qualitative respondent (e.g. willing to speak freely about their experiences). Using this information and the survey data, 33 women were purposively selected based on contraceptive use history for an in-depth interview, in order to have representation for both unmet and met need for modern family planning.
The 30 CHWs (25 females and 5 males) were conveniently sampled from a list of 48 active CHWs within the Ghana Health Service database for the Amansie West District. All CHWs were English speaking and able to travel to the interview site.
Interviews with the beneficiary population were conducted by three female community health nurses from the surrounding communities. The interviewers received a five-day training that included research ethics, interview procedures, and practice interviews. Interviews with the CHWs were conducted by graduate student researchers completing a Master of Science degree in Global Health at a North American university (MS and LS) with training in research ethics and qualitative methods. Debriefing forms were completed by the interviewer after each contact and comments were discussed daily to ensure fidelity and clarity.
Interviews were conducted using semi-structured interview guides that included questions and probes about perspectives on family planning and the CHW programme. Interviews with women were conducted in their households or place of work (e.g. market or a small shop). Interviews with CHWs took place in the research office in the community or at a community health post. The women interviews were conducted exclusively in Twi, and the CHW interviews were conducted in a mix of English and Twi, with a translator available as needed.
Audio recordings and field notes were uploaded daily to a secure file sharing programme. The audio recordings of the women’s interviews and the CHW interviews conducted in the local language were sent for translation and transcription into English. The CHW interviews conducted in English were transcribed by the interviewers (MS and LS). Five of the women who were interviewed were excluded from analysis due to lack of interactions with CHWs, making the total sample for analysis 28 women.
Data were analysed using an inductive thematic analysis approach (Guest et al., 2014), which involved multiple analytic techniques that allowed for a nuanced synthesis of the data. As a first step, interviews were read thoroughly and document memos were written to highlight key points and arising themes related to the research question. Using the memos, three themes were identified as parent codes (perceived roles of CHWs, perceived value of CHWs, recommendations for CHW provision of family planning). Child codes were then identified under each parent code to identify emerging sub-themes. A codebook was created and reviewed by the research team that included descriptions of the codes, examples of coded text, and exclusion criteria. All transcripts and memos were uploaded onto NVivo 12 for organisation and coding. After coding, analyses included queries and code memos to synthesise data and identify representative quotes. Reflection memos were written throughout to reflect, describe, and document the data analysis process.
The 28 women ranged in age from 18 to 46. Thirteen of the women were currently using a modern family planning method, ten were not currently using a modern family planning method, and five were not currently using but had used in the past two years.
The 30 CHWs ranged in age from 20 to 35. The sample included 25 women and 5 men who had been working as CHWs between two and seven years. All of the CHWs were currently living in the communities where they worked; a majority were originally from the community. The motivations for becoming a CHW ranged, but most stated that they decided to become a CHW for financial reasons or because they wanted to help their community. Financial reasons included unemployment, financial instability, and wanting to save money for future education. The CHWs consistently stated that they were motivated to do their job in order to help their communities to progress toward social and health goals.
Participants described the role of CHWs was to provide health education through household visits to promote improvements in overall health outcomes. Information and referrals related to family planning were seen as an essential part of the overall health package that CHWs provided to households. CHWs reported that their household conversations about family planning led to an increase in uptake of family planning services at the clinic.
CHW interactions and exposure varied throughout the communities. CHWs were provided a geographic area and charged with enrolling households that contained pregnant women and children under the age of five. Each CHW typically reported having 150 or more households registered, whom they were supposed to visit at least once a month. During the household visits, CHWs said they were expected to discuss one or more topics from a larger healthcare package, including sanitation, hygiene, nutrition, water purification, malaria prevention and treatment, family planning and other health issues.
When I go there, I know this morning I’m going to teach family planning or I’m going to teach sanitation, or I’m going to teach breastfeeding. When I go there, I greet and ask everybody how they are feeling, or I start to ask what is sanitation. … Before I go talk with them, I already have a list of topics I’m going to teach, and I have that ahead of time. – CHW, Female, 26 years old
Although family planning was part of the larger package of CHW activities, all participants mentioned this as a key topic of discussion for household visits. CHWs discussed prioritising family planning discussions in households where the children were closely spaced, where there were many children in the household, and for young mothers or adolescents. Family planning was described as a method to space births, provide more economic opportunity, decrease abortions, and improve the health of women and children.
Discussions of family planning included general advice on birth delay or spacing, the various family planning methods, and the benefits of family planning use. Although CHWs were unable to directly deliver family planning services, participants said that discussions with CHWs about family planning were determining factors for their uptake or continued use of family planning methods. By having the conversation frequently, they felt more knowledgeable and informed about their family planning method.
She told me that if I want to do the family planning, I could go to the clinic where the midwife will do it for you. Also, she gave me information regarding family planning, about the methods for me to decide which one I want. I told her I want the injectable method and when I visited the clinic, the nurse explained to me exactly as the CHW told me and checked my weight and vitals and did the family planning for me. – Beneficiary, 23 years old, currently using
Household visits sometimes also increased men’s knowledge and willingness to allow their wives to use family planning. Permission from husbands was noted as a cultural norm for some households. Although few, some women discussed times when their husbands also participated in family planning conversations with CHWs. CHWs also highlighted the few times they were able to have successful conversations with male partners about family planning. However, these conversations are difficult and while perhaps well-intentioned, the CHWs themselves may have also enforced cultural patriarchal norms if they did not support at least joint decision-making as noted below.
Some lady’s husband came and informed me that he wants his wife to do family planning, but because of the religion that his wife is in, [the religion] doesn’t give [permission]. But the husband wants his wife to do it … . So, I advise the wife to accept what the husband is saying [about the benefits of use]. Maybe he is not having money, so he wants to care for those [children] that she has given birth to. – CHW, Female, 23 years old
In discussing family planning with households, CHWs must often dispel the myths and rumours that serve as barriers to women’s use of family planning. The beliefs and perceptions of traditional medicine sellers on negative side effects of family planning were common discussion points. The types of side effects that were described as concerns were infertility, hypertension and other heart problems, changes in menstruation, dizziness, fluctuations in weight, and fibroids which represent a mix of known side effects, particular for hormonal methods, and non-evidence-based side effects. During home visits, the CHWs aimed to answer questions, resolve doubts, and encourage uptake of family planning for the long-term benefits such as financial stability, increased educational opportunity, and better health outcomes.
When a woman is not menstruating, they think she’s sick and she can get fibroids. That is why they fear to do the family planning. But as it now, they don’t fear anything if I talk to her, (saying): “Oh Madame, you have to do this. It will prevent you, it will help you to get chance to look after the one you first give birth to so and it will help you to distance your births so that you will get money to do what you want to do.” So now they take my advice, and I assure you [claps], 70% of my women in my community they did family planning. – CHW, Female CHW, 26 years old
Some participants reported that a CHW convinced them of the benefits of family planning in a single visit. However, most participants reported that having the conversation repeatedly with CHWs increased their confidence and helped them decide to start or continue to use family planning methods during times when they felt ambivalent.
CHWs were often seen as the only verified source of health education in a community and therefore served as the gateway to the broader health system. The clinical roles of the CHWs were limited to providing malaria tests and administering simple first aid; otherwise, they were tasked with providing information and referring community members to government health care services as needed. For family planning, CHWs provided education and advice related to family planning methods, and thereafter referred women to the community clinic to be examined by the community health officer and/or nurse (CHO/CHN). Once referred, the CHWs could continue to follow-up with the women at the households to make sure that the woman linked to the clinic and that the method worked well for them.
I’ll tell (a woman): “When you go to the [clinic] do for family planning, I can take you to my CHO, and my CHO will give you [family planning]. It will help you to go to school. When you do it, it can help you to go for nursing training and it can help you to do some work.” – CHW, Male, 24 years old
The CHO(/N) played a crucial role in the community as the primary health care provider at the clinics and therefore the primary referral point. As the immediate supervisor of the CHWs, the CHO(/N) was charged with providing supervision and support to the CHWs in their communities. Having a relationship with a CHO(/N) acts as a direct resource and linkage for community members.
Family planning was described as a highly sensitive topic that was not freely discussed in the community. Having CHWs accessible, confidential, and ready to advise women on family planning was seen as a way to facilitate discussions and decision making related to family planning. Providing education at the household level allowed women to make reproductive decisions that were best suited for their own needs. At the same time, some CHWs also reported resistance in the communities from women and household heads, which impeded their ability to provide services.
With access to healthcare services being a major issue in rural settings, CHWs were valued in their ability to be a community-level healthcare resource. CHWs were seen as making health care more accessible to the community because they lived in the community and made frequent visits to the households. Household visits allowed women to become more knowledgeable about the benefits of family planning and able to make decisions regarding their family planning choices.
Participants described times when they were having health concerns and were able to have them addressed quickly by a CHW. Being able to call or even visit a CHW’s house allowed women to get immediate assistance on their family’s health issues.
I do not have the contacts of the CHWs, but as I said one of them lives close by in my area and she passes by in front of my house to fetch water. So, when I need something, I just pay her a visit. – Beneficiary, 37 years old, currently using
Accessibility and comfort seemed to connect as values within the household discussions. Having frequent contact with CHWs in the community who were knowledgeable in health care allowed the women to feel more comfortable and willing to discuss sensitive topics. With the majority of women working as farmers or traders, they described leaving for work early in the morning and having to tend to the household at night. With busy schedules and other obstacles, some CHWs reported that making time to talk about their health was sometimes a burden for women with household responsibilities. However, many women stated that they were open to having the CHW come by because they were comfortable and trusted the person to provide relevant health education. Building relationships with the women was identified as a strength for the CHWs in being able to address family planning issues.
An ordinary person cannot come to a house and say they are coming to counsel on family planning … . It makes them trust you that, as for this man, we know him, and he has been working here for this number of years and we meet him at the Child Welfare Clinic (CWC). So, when he tells you anything you have to take it serious because it is true. I am from the Ghana Health Service and that makes them trust me. CHW, Male, 28 years old
Although the primary target of services was pregnant women and children under five, the CHWs registered the entire household and provided health education for all household members. Being able to establish relationships with the entire household facilitated comfort and familiarity that allowed the CHWs to be effective in their work.
Because the CHW stays in this community, my husband or partner knows her, so he knows we are talking about something important when the CHW visits me. He even advises me to take my time and explain things to the CHW so that she can also help me. So, he allows me to talk to her any time. – Beneficiary, 20 years old, currently using
CHWs were highly valued as confidants for health-related conversations. Many women stated that within their community, they had to be careful about discussing personal matters because it would become ‘public knowledge’, but they did not have that concern with CHWs. Confidence in the CHW was discussed in terms of knowledge of topics, their commitment to not sharing sensitive information, and the privacy that they maintained with certain topics, especially family planning.
I talk to her because she is very free with everyone and I haven’t seen her have an altercation with anyone because she gossiped about that person. She always told me at the beginning that even when she visits me and sees something, she cannot share with her colleague CHWs because family planning is a secret thing. – Beneficiary, 27 years old, currently using
In some instances, CHWs were the only people who knew that women were using family planning, even when women were married or had partners. Being able to keep family planning use a secret and discuss concerns in a discrete manner was seen as a benefit of the CHW model. Some women and CHWs even reported that they would have to seek out the CHW at late hours to get guidance on family planning to ensure their partner did not find out.
I have a lot faith in her, because even though I have told her I am still using the family planning and I haven’t told my husband, she has been able to keep that secret and my husband hasn’t found out up to date, and I haven’t heard it anywhere in the community that I am still using family planning. – Beneficiary, 40 years old, not currently using but has used in the past two years
Even though CHWs were discussed as valuable in the community by the women in the sample, CHWs reported some experiences of resistance to their workforce. Some CHWs described either hearing about or experiencing people not welcoming them into their homes, yelling at them, or not trusting them. The sensitivity of family planning, particularly by male partners, was described by one CHW: ‘The husband knows that you are the one (talking about family planning), and they insult you … They say that you are the one encouraging our wives to do family planning, (and) give them diseases’.
Additional resistance was reported about the household visits, which was perceived as an inconvenience or intrusion by some women. CHWs reported that women would sometimes request household supplies or money in exchange for the time spent accommodating the CHW during the home visits. These points further emphasised the importance of the CHW programme having the buy-in of the broader community and the CHWs establishing positive relationships within the household.
There were several recommendations made to help improve the reach of the CHWs in the district to increase family planning uptake. Increasing the CHW workforce, starting the programme with community introductions of the CHWs, and providing more commodities at the household level were the three recommendations that arose in the interviews with both CHWs and women. In addition, CHWs mentioned the need for additional programmatic support and training. Although often expressed as general recommendations, these recommendations were seen as important to improving family planning support.
Both women and CHWs expressed that the heavy workload of CHWs seemed to limit their ability to serve households. They advocated for additional CHWs to be added to the community to increase contact with households.
I think in the community I’m the only one. The community is big. If next time maybe 2 or 3 [CHWs]. I think it will help the community so that everyone will get [care]. As you see sometimes, I go to someone’s house once a month, I think it won’t help. If we were two people and the community is divided so I think one will go to the house like 3 or 4 times a month. – CHW, Female, 21 years old
CHWs discussed that when they initially started two years ago, they were met with some resistance by households, and some community members continued to view them with suspicion. CHWs felt that they would benefit from an official introduction to the community as health workers, so that community members would be more open and willing to receive services from them. CHWs felt that having an initial introduction would be especially helpful for sensitive issues like family planning and would allow them to build trust with households more quickly.
Yeah, to introduce you to the community and tell them ‘Oh this is [NAME]! She is doing this, she is doing that. So, you have to when they come to your house, you have to accept her like your sister, your brother and so on forth.’ But that didn’t happen, so I found it difficult in the first day. – CHW, Female, 26 years old
The secrecy and stigma surrounding family planning seemed to have an impact on family planning use in the district. For this reason, both women and CHWs suggested that contraceptive products should be available directly at the household, rather than requiring a visit to the healthcare facility. The two main reasons that participants preferred household delivery of family planning methods was due to a fear of gossip at the healthcare facility that could result in being stigmatised and the costs related to travelling to the facility. Allowing the CHWs to provide products to women at the household was discussed as a recurrent recommendation amongst both groups.
The CHWs who visit us in our homes should be given the commodities or methods so that when our time is due for the injection, they can readily give it to us in our homes to prevent other people from identifying people who are using the family planning. You may want to hide the fact that you are doing it but because when your time is due, you have to walk all the way to the clinic holding your family planning card like a pregnant woman for everyone to see. Also, some people are shy to go to the clinic and do the family planning, so if the CHWs are given the commodities or the methods, those people can have access to them in their houses. – Beneficiary, 40 years old, not currently using but has used in the past two years
Programmatic support was discussed mostly in relation to CHWs having better phones, consistent pay, and transportation. They complained that the phones and software provided did not always work, which limited their ability to work throughout the community. The pay was described as not always coming on schedule, which impacted the CHWs who depended on the stipend as their only source of income. CHWs’ inability to work other jobs due to time constraints and the inconsistency in pay impacted their livelihood and contributed to poor retention amongst the CHW cohort. Lastly, with communities varying in size, CHWs were expected to travel on foot or pay for transportation themselves. Implementing travel expenses into their stipend was proposed.
Yes, because we were 105 [CHWs], many people have stopped because of the condition that we are going through. And right now, I think we are left with 72 or 52 because of what we are going through. I think our salary is ($54). 54 dollars a month and it’s too much for someone to be a community health worker and take like 54 dollars a month. If they increase it many more people enjoy it. – CHW, Male, 24 years old
One seasoned CHW mentioned the need for better monitoring of the CHW programme. With inconsistencies in experiences with CHWs and retention challenges, it was suggested that increased monitoring and evaluation would be useful for the overall programme.
… I have to say it in that way if you are doing work and you don’t have a good monitoring, how are you going to see the work? I will do it as I wish, nobody is coming there to have an assessment on whether I am doing the work or not. … So, you have to have monitoring and evaluation that you come out day in and day out and check tools that you use to do the work. And all of this will boost up family planning and increase the number who do family planning, which will help my community. – CHW, Female, 23 years old
Finally, training was discussed in various ways throughout the interviews. CHWs reported that they received different amounts of training throughout the two-year programme. While some CHWs stated that they only had the initial two-week training, others reported additional training workshops provided throughout their tenure. More consistent and continuous training for CHWs was recommended.
It prepared me well. But ummm … they train us I think to do our work, so in case they should have trained us more than that so that we can understand it more. Because that one week, it puts a lot of pressure on us to understand. If they extend the days it will help us, it will be great. – CHW, Male, 24 years old
Task-shifting from formal healthcare workers to a cadre of lay providers can decrease the burden on healthcare services in rural populations where resources are scarce. Introduced in China in the 1920s, the use of lower-level health care providers has grown globally over the past few decades (WHO, 2008). In 1969, Ghana began to initiate task shifting with the introduction of medical assistants as a lower-level cadre. Although they were initially met with resistance, this lower level healthcare cadre has since been accepted as an important contributor to the healthcare workforce (McPake & Mensah, 2008). By introducing the CHW programme into their health system, the Ghana Health Service has begun to tackle issues of healthcare resources and health coverage amongst its most vulnerable populations. This study worked in the context of Ghana’s National CHW programme to explore how women and CHWs perceived the programme to support the use of family planning in the Amansie West district of Ghana. The in-depth interviews emphasised the value CHWs play in supporting the uptake and use of family planning. With programmatic challenges related to commodity provision, attrition, training, and other factors, it was clear that the CHW experience was not homogeneous and offered opportunities to improve the reach and impact of the programme.
The data highlights the value of the inter-personal relationships that CHWs are able to develop with their clients. The accessibility of CHWs living amongst the community members contributed to the comfort and confidentiality that fostered trusting interactions around sensitive healthcare topics. As CHW programmes have been implemented globally, the leverage of the CHWs’ pre-existing social networks has shown potential in facilitating health conversations, with social familiarity improving uptake of family planning (Liu et al., 2011).
Our data suggest that increased programmatic support, monitoring, and workforce of the CHW programme is necessary to expand the reach and impact of the programme, including the provision of family planning services. Monitoring and evaluation are important to address CHW retention and to document the impact that the CHW programme has on family planning use. Supervisory structures may address the variance amongst the CHWs’ experiences with training and support. Monitoring and evaluation are essential steps in the scale-up and implementation of programmes that must not be neglected (Kieffer et al., 2015). With monitoring and support, CHWs have been shown to make a difference in addressing healthcare issues to vulnerable populations in South Africa (Chola et al., 2015), Zambia (Keller et al., 2017), Tanzania (Agarwal et al., 2016), Kenya (Olawo et al., 2013) and Ghana (Appiah-Denkyira et al., 2013).
The Ghana CHW programme has expanded healthcare access to rural populations and has been able to meet the healthcare needs of rural populations. Through in-depth interviews, participants emphasised the impact of CHWs on improving health outcomes through health education in the household. Similarly, other CHW programmes have been able to increase uptake of family planning (Comfort et al., 2016; Scott et al., 2015), improve HIV/AIDS outcomes (Mundeva et al., 2018), address other physical health concerns (Rabbani et al., 2016; Shet et al., 2017; Walt et al., 1989), and address mental health (Sibeko et al., n.d.). This additional study provides an understanding of the perceptions of women and CHWs regarding the CHWs in the Ghanaian context with their relatively new CHW programme.
All of the stakeholders described the CHWs’ role as providing a broad healthcare package to households, with family planning included in that package. With limitations on their ability to provide modern family planning methods directly in the households, CHWs were restricted to serving as a bridge between the community and government clinical health services. Several participants expressed that they would prefer contraceptive services to be provided at the household and believed that it would have impacted their use of family planning. Studies have now demonstrated that CHWs can effectively deliver injectables and pills in the home environment, which can lead to increased uptake and improved method choice (Chin-Quee et al., 2013; Olawo et al., 2013). Implementing these higher-level services via CHWs in Ghana may be possible with additional training and monitoring. Additionally, the focus on family planning uptake, without acknowledgment of broader sexual and reproductive health and associated rights could limit the CHW programme’s impact and sustainability in the community. For example, CHWs could help educate men about family planning and facilitate partner discussions while also respecting women’s individual autonomy to use their methods of choice. Likewise, while promoting family planning methods, CHWs need to acknowledge some women’s experiences with known side effects and frame their family planning discussions within the context of informed choice. There is a wide range of family planning methods including barrier and natural methods and for some women, the less effective methods may be their preferred option.
This study’s use of qualitative methods to obtain differing perspectives was one of the key strengths, as it provided complementary data from both the beneficiaries and CHWs. Combined, the findings described the characteristics and perceptions of the CHW programme in addressing the community’s family planning needs. The findings, however, must be interpreted in the light of the study’s limitations. As is common for qualitative data, the topics explored across participants and the level of depth of discussion varied across participants. Interview guides were not translated into Twi, in order to allow the research assistants to guide the interviews in a natural and non-scripted manner. However, this may have also limited uniformity of discussion across participants. Extended training, continuous feedback, and daily review of post-interview debrief forms were strategies used to enhance the rigour of the study.
The use of only English-speaking researchers for the CHW interviews could have limited nuances in descriptions of phenomena and led to socially desirable responses. This may have prevented us from ascertaining differences across population groups in our study (e.g. users vs. non-users, male vs. female CHWs). The involvement of North American student researchers may have induced positive responses from CHWs. The race and nationality of the student researchers, and the privilege associated, could have also introduced biases in the analysis. The student researchers prepared themselves with coursework on research ethics and periods of reflection on their role as researchers in foreign countries. They worked in close collaboration with their Ghanaian colleagues (NEN, EA, SOD), who contributed to each stage of the research process. Lastly, the connection of this study to the Ghana Health Service’s CHW programme may have introduced social desirability bias due to fear of losing the services. Although there is not a lot of evidence that this limited the results, descriptions provided could suggest overly positive or restricted responses.
Community health workers are an important contribution to the overall goals of health system strengthening in rural areas and can improve health outcomes in a range of areas including family planning. This study suggests that CHWs were trusted sources of health education on family planning, and were able to increase knowledge and provide referrals to higher-level health services. To build on this progress, the programme must address issues of CHW availability, consider opportunities for CHWs to directly provide family planning technologies, and improve programme monitoring practices. CHWs and other health extension workers are an innovative approach to addressing the health needs of underserved populations. By establishing CHWs as a strong workforce, countries will be able to tackle the disparities presented in rural communities. Especially considering their access to these populations and the ability to foster trusting relationships with the families.
The contributing authors would like to extend their gratitude to all parties that assisted in the completion of this study. Special thanks are expressed to the members of the data collection team, local personnel who welcomed the team into the communities, and the participants. Lastly, we are grateful to Bright Asare, Emmanuel Boahen, Mary Story, and Randall Kramer for their assistance throughout the research project.
No potential conflict of interest was reported by the author(s).
The data that support the findings of this study are available from the corresponding author, MJS, upon reasonable request.
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