Accompanimeter 1.0: creation and initial field testing of a tool to assess the extent to which the principles and building blocks of accompaniment are present in community health worker programs

Figures & data

Table 1. Accompanimeter 1.0 (final iteration 3 of 3).

Building Block	Stage	Definition	Example
Top-Down (Maximizing System-Side Inputs)
Supervising and mentoring personal growth	Inadequate	Non-existent, infrequent, punitive, and/or data collection-oriented supervision.	The supervisor appears a couple of times a year to fill out a task checklist and chastise the CHW if the tasks are not achieved
	Growing	Frequent but perfunctory supervision. No recognition of career pathways, personal development, or amendments to improve care provision techniques.	The supervisor appears regularly to give support and feedback, and to encourage the CHW to do his/her best in the work.
	Aspiring	Humanized supportive supervision The job is doable and fair, structures exist to mentor and support CHWs so that they can perform as expected. Supervision is frequent, supportive, encouraging, and humanized. Ratios of CHWs per population covered, and Supervisors per CHWs are adequate to assure quality (i.e. both CHW and supervisor have the time to engage in quality interactions). There are opportunities for career advancement.	The supervisor meets on a regular basis with the CHW and is available in case of need. The supervisor not only gives feedback of activities and how to improve, but also guides CHWs toward meaningful professional and personal development, such as going to school, taking a certification course, and providing help in case the CHW is sick, etc. CHWs are supported before they are fired.
Partnering in co-creation	Inadequate	CHW tasks are purely technical (medical), designed as a means to ‘address human resources gaps’, and oriented towards ‘short-term cost savings’ for select conditions. There is no clear integration with other health system actors.	The CHWs only vaccinate children or address one disease vertically. If they find a person with another condition, they do not perform any action to help that person.
	Growing	CHWs tasks are integrated in clear ways with the duties of other actors and sectors within the health system. Tasks can be clearly mapped out as a disease-oriented care-delivery value chain. Tasks are largely technical (medical), and the scope of work, workflow and ratios (e.g. CHWs per population covered) are designed to ensure completion of such technical (medical) tasks	The CHW only sees NCDs patients and has neither time nor resources to support a patient with an acute illness; the CHW does not go out and find new cases of a disease that recently arrived to the community.
	Aspiring	Community work, not just health work The health system is built to progressively realize universal health coverage. CHWs perform tasks that adequately cure/control disease (sometimes in conjunction with tasks performed by other team members). CHWs are bridges between the community and health system, and not islands of limited interventions. CHW tasks are thoughtfully integrated with the work of nurses and doctors, as well as with other sectors such as education, finance and social development. Their scope of work, workflow, and ratios (e.g. CHWs per population covered) permit the performance of not only technical (medical) tasks but also empathetic (non-medical) tasks (i.e. social support, advocacy, community work). Structures exist for CHWs to have a voice in ongoing program reform.	The program intentionally invests in mechanisms that empowers the CHW to amplify community voice, advocate for individual patients, and perform proactive case finding. CHWs are not simply given a medicine box and asked to do ‘the best they can’ with a limited toolkit.
Incentivizing by enabling	Inadequate	Neither financial nor non-financial benefits are provided to the CHWs. The ‘Spirit of Volunteerism’ is considered the primary motivation.	The CHWs perform their duties if, and when, they have the will and the resources to do so but receive no financial support to facilitate or appreciate this work.
	Growing	Some financial or non-financial benefits are provided as a source of motivation, but not to enable or empower CHWs.	The CHWs receive a food package to acknowledge their efforts in performing their duties.
	Aspiring	Professionalization for long-term retention The CHW’s salary allows them to dedicate their full time and attention on community health work because it provides for all their material needs. Financial and non-financial benefits even facilitate a pathway out of poverty over the long-term.	The salary is at least minimum wage for a full time job. The local poverty line is defined and a life span of work will move a CHW above the poverty line. CHWs also receive benefits such as health care, vacation time, retirement support, etc.
Choosing the right people for the right job	Inadequate	CHWs are selected in a non-transparent way. There is significant risk of nepotism, and CHWs do not necessarily represent the people they serve.	A community leader decides who becomes the CHW without community input, or the community decides based on the only available people who want to become CHWs, even if the candidates do not fulfill health system and community criteria.
	Growing	CHWs represent the community and health system simultaneously. The selection process is transparent, with clear criteria oriented towards benefitting both the community and the health system.	The CHWs are perceived as the most skilled persons in the community. Minorities may not be represented in the program. The program is likely to select already empowered people.
	Aspiring	CHWs strongly represent the health system, and all the communities The selection process is transparent, and criteria for selection are clear. There are mechanisms for recruitmenting and supporting people from vulnerable populations (i.e. women, ethnic minorities, etc.).	Communities nominate candidates from a large and diverse pool during a community meeting. Program leaders then list the best candidates based on clear criteria (i.e. ability to walk to house visits, basic literacy, etc.), but also provide special supports for recruiting and preparing CHWs from vulnerable minority groups (such as literacy courses, job training, and skills training, etc).
Education for capacity building	Inadequate	The program provides training once or a few times, and the training is predominantly technical.	One baseline training is administered as a series of PowerPoint slides and/or a training session in which only the facilitator speaks. No continuing education is provided.
	Growing	Training is well-structured, responsive to needs, ongoing, and competency based. Training balances technical and empathic skills.	The CHWs receive ongoing training to perform their duties, but without a contextual and sociological frame to effect community change.
	Aspiring	Training for transformation The education offered builds over time and is clearly linked to a professional development pathway. Training integrates technical, empathic, and social justice skills, resulting in a CHW who is a “liberator,” not a “lackey.” [27]	The training helps CHWs grow not only in their role as workers performing the job assigned to them by the health system, but as partners and advocates to achieve positive social change in the community.
Bottom-Up (Maximizing Patient-Community Agency)
Supervising and mentoring personal growth	Inadequate	In general, the community has little to no engagement in determining supervision structure and measures.	The community is aware of the presence of CHWs and receives the CHWs’ services, but is not involved In monitoring or feedback.
	Growing	The community has some input in the program, which might include the election of community-based supervisors, community councils, performing patient satisfaction surveys or community meetings to discuss or approve CHWs activities. However, community-based input rarely stimulates program alterations or improvements.	A select member of the community is identified as a field-based supervisor and is tasked with predetermined supervisory duties without much agency to work with community input to improve the program.
	Aspiring	Local truth: Favoring EQ (emotional quotient) as much as IQ (intelligence quotient) Structures exist to assure that community members’ opinions are captured, heard and acted upon so that CHWs behavior is truly patient-centered and empathic. Major violations of patient trust are grounds for termination (i.e. violence, coercion, abuse, breaking confidentiality)	Patients surveys are collected by CHW supervisors on regular intervals and incorporated in regular feedback sessions. Community health committees are an integral part of decision making. There is a simple way for patients to report violations (and have their identity protected).
Partnering in co-creation	Inadequate	The program does not actively address the social environment in which CHWs operate. It neither attends to social determinants of illness nor meets ‘demand side’ barriers. The program exhibits no attempts to collaborate with other sectors.	The program performs and delivers on technical tasks but does not attend to other relevant factors that influence health.
	Growing	The program recognizes the need to address the social environment in which CHWs operate. The program attends to social determinants of illness and meets demand-side barriers, but the budget for the program and the CHWs scope of work does not equally reflect this recognition. The program addresses a few social determinants of health, but this is not considered in the budget.	A CHW might refer a patient to a social program, but this is not a crucial part of his/her duties. A policy exists that sick patients should get nutrition support (such as a TB, AIDS or cancer patient), but in reality, there is no budget allocated to food procurement.
	Aspiring	Going beyond the clinic, and the clinical The program actively addresses social determinants of illness and posits demand-side barriers to accessing healthcare, or achieving good health outcomes, as major priorities. A significant portion of the budget is dedicated to such efforts. Collaboration with other sectors is prioritized as a mechanism to achieve this goal.	The program includes transport vouchers, food programs, housing programs, water programs, jobs/skills programs, income support, or educational programs in their plans. This is often done by collaborating with other government agencies, other NGOs, cooperatives, etc.
Incentivizing by enabling	Inadequate	The community does not recognize the value of the CHW program to improve or maintain health. The community does not invest in generating social capital (enabled people to take care of others) nor support the CHWs’ work.	The community knows about the program, but is not invested in its success. If the program were to disappear, it would not cause the community much or any distress.
	Growing	The community recognizes the added value of the CHWs program to improve or maintain health, but it is not involved in a structured process to support the CHWs and to generate capital that will contribute to their motivation.	The community incentivizes the CHWs with gifts but is not part of the design and implementation of the program. For example, there are no community meetings to recognize the efforts of CHWs.
	Aspirational	This is how we value you Structures exist that help community members show appreciation to CHWs in the manner of their choosing (verbal, material, financial). This is not an obligation for community members, but rather reflects the trust and value being generated by the community health system.	The community sets salary scales, augments salaries with money or gifts, enables supports (i.e. meals, housing or water) when CHWs are in the field, publicly recognizes CHWs with award ceremonies, and/or honors CHWs during other key community events,
Choosing the right people for the right job	Inadequate	The community does not participate in developing the job description, in recruiting, or in selecting the CHWs. The entire process is managed and executed by the health system or by an institution external to the community.	Implementers external to the community carry out the entire process of recruiting CHWs without any community input.
	Growing	The community participates in the recruitment and selection processes of the CHWs; however, their suggestions are ultimately less decisive than those of program implementers, managers, funders, or policy makers.	Community members can nominate CHWs but the final decision on hiring, and the criteria used for hiring, is executed by the program implementers without additional community input.
	Aspiring	The community’s voice and vote There is a dedicated and funded mechanism that engages community members in contributing to job description development, nomination, and selection of CHWs.	Community members are in charge of nominating CHWs but are also tasked with working closely with program implementers to decide the characteristics of the ideal CHWs.
Education for capacity building	Inadequate	Community members do not participate in developing the curricula for training CHWs. Community knowledge (local wisdom) and local culture are dismissed.	A local term for a symptom is categorized as not scientific, wrong or dangerous by the CHWs’ training curricula.
	Growing	Community members are informed of the curricula and training of CHWs, but their input is not requested. Community knowledge and local culture are acknowledged, discussed, and respected by the CHWs’ training curricula but not incorporated into the program.	The program is not against local wisdom or building on the knowledge that the CHWs bring to the training seasons, but this is not actively encouraged and introduced in the curricula.
	Aspiring	Local wisdom Processes exist to actively engage with, discuss, AND incorporate local knowledge into the CHW curricula and training.	Community members can participate in building the training curricula for the CHWs, and they are enabled to do so (e.g. with a stipend). Likewise, new information is built on top of the existing knowledge that the CHWs bring to the sessions, capturing the richness of the lived experience in their unique context.

Figure 1. Review on frameworks describing elements of success in CHW programs.

Figure 2. Accompanimeter evolution.

Figure 3. Three principles and five building blocks of accompaniment in CHW program.

Figure 4. Accompanimeter 1.0.

Figure 5. Accompanimeter 1.0.

Werner D. The village health worker: lackey or liberator? Palo Alto (CA): Hesperian Foundation; 1981 Nov 28.

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