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White Multiracial. Grades 3 4 5. Proficiency Levels Proficient at Proficient at LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 1 —. For example, volunteer polio-specific community mobilizers in India were able spend more time with polio-resistant households than could the CHWs accredited social health activists, or ASHAs , who had many more duties [ 19 ].

Community-level factors are context-specific and are influenced by local histories, economic and political systems, power dynamics, and sociocultural norms. Relationships are based on networking and reciprocity, and rely on trust and acceptability [ 5 ].

CHW programmes often need to address gender discrimination and cultural sensitivities around gender existing in communities [ 9 ]. Supportive relationships between community groups, the CHW, and the local health system can positively affect behaviour change and health service utilization [ 20 ].

Potential sources of support for CHWs in the community include public sector and civil society entities such as committees, groups, and various community leaders. Examples of community groups and leaders who may or may not support CHWs include faith-based groups, self-help or mutual aid groups, schools, agricultural cooperatives, political and cultural leaders, traditional healers, traditional birth attendants, and women and youth leaders.

CHW and health sector engagement with communities may take many forms, including working with both formal and informal community-based organizations that are dedicated to health, neighbourhood concerns, or other development purposes [ 21 ]. In some countries, the tribal chief or village headman represents the lowest tier of government within the community.

In other countries, the traditional leadership structure may be powerful but not tied to the government. These institutions have the power to enable and support CHWs and their health activities or undermine them [ 20 ]. At the interpersonal level , CHWs can develop peer relationships with their clients through frequent home visits, building up trust over time. For example, in South Africa, CHW—client peer relationships were developed within the home-visit setting and were strengthened when CHWs provided clients with even further care and support [ 22 ].

Village health volunteers VHVs in Thailand were able to use their peer-status relationship with clients to provide tailored support in ways that doctors and public health officials guided by medical treatment protocols could not. A strong mutual-support peer network between CHWs could also support improved community relations, as VHVs helped each other improve problem-solving skills [ 12 ]. CHWs need to perform a very delicate balancing act in order to function effectively in both the health system and community spheres.

Addressing issues of power relations, developing trust with the community, and understanding the political, social, and economic contexts in which initiatives are supported is imperative [ 24 ]. Clarity is needed on the roles of the CHWs, the roles of CHW supervisors, and the roles of village-level health committees [ 25 ]. CHWs need skills to successfully manage their relationships with community members and with health professionals [ 26 ].

For example, during the initial phase of the Ebola outbreak in Guinea, Liberia, and Sierra Leone, there was a sharp decline in maternal, neonatal, and child health services, resulting in mistrust of CHWs by community members.

Eventually, CHWs were also able to carry out Ebola-related activities better than outsiders [ 27 ]. CHW activities included working with community leaders and going house-to-house to provide accurate information. They worked with the national health system to search for active cases and contacts.

They also helped local religious leaders to reduce transmission during funerals and burials [ 28 ]. CHWs are not a panacea for weak health systems, and they require well-structured support from the health system in order to be fully effective [ 29 ]. As we discuss elsewhere in this series of papers, CHWs need a clear role definition with well-defined tasks [ 30 ], adequate financial and nonfinancial incentives [ 31 ], proper initial and continuous training [ 32 ], and adequate supervision [ 33 ].

National-, district-, or local-level health systems are responsible for providing CHWs with supervision, for receiving clients referred by CHWs, and for supplying CHWs with the required materials to conduct their service extension roles [ 34 ].

These supporting functions are mostly performed by health staff working at local-level health facilities to which CHWs are linked, as shown for 27 countries in Appendix Table 2. This table shows the local health system linkage with CHWs and the average size of the catchment area for each CHW [ 9 ].

For example, in Brazil, four community health agents work as part of a local family healthcare team comprising a doctor, nurse, auxiliary nurse, dentist, and dental hygienist [ 35 ]. They are in almost daily contact with the rest of the team, leading to closely integrated functioning. In Nepal, nine or more female community health volunteers FCHVs work together out of a sub-health post where female maternal and child health workers and male village health workers VHWs are also based [ 36 ].

For those who test positive, the government provides these CHWs with the medicines to provide directly observed treatment [ 37 , 38 ]. Though numerous challenges exist, we highlight three particular chronic and widespread challenges related to establishing productive relationships between the CHW and the national health system: 1 level of respect for CHWs from higher-level health workers, 2 facilitation of referrals, and 3 functioning of supply chains. Several common challenges have been documented in Ethiopia, Malawi, Mozambique, and Kenya by Kok et al.

Issues of supervision are widespread. Finally, Kok and her colleagues noted that unclear roles and responsibilities of CHWs lead to doubts among community members and higher-level health workers regarding CHW competencies, resulting in disrespect toward CHWs [ 7 ].

Government ownership of the CHW programme and government affirmation of CHWs as a valuable part of the workforce are likely to facilitate a more coordinated approach and result in more supportive relationships.

In Cambodia, where government ownership is minimal, CHWs expressed the desire to have more involvement from the health system, such as endorsing their health promotion sessions, supplying them with a uniform and identification card, and sponsoring media campaigns that reinforce the messages the CHWs are promoting [ 40 ]. A study in Malawi found that unmet or unrealistic expectations as well as poor communication led to poor relationships between health workers interacting with CHWs and negatively influenced CHW performance [ 44 ].

Another systematic review on integration of CHW programmes into health systems, covering Brazil, Ethiopia, India, and Pakistan, found that CHWs sometimes reported feeling a lack of respect from health staff with whom they interact and in the way the staff talk about CHWs with their patients [ 42 ].

Health professionals may also disagree with decisions on task-shifting to CHWs, as CHWs take on functions that in the past were performed only by nurses or doctors—particularly some elements of curative care [ 45 ].

Health professionals, particularly physicians providing curative care at higher levels in the health system, may be unaware of the valuable role of CHWs in promoting healthy household behaviours and care-seeking for preventive services. The disrespect that some CHWs experience from health professionals may be reinforced by disparities in gender, socioeconomic status, and education, all of which can be aggravated by paternalistic and hierarchical attitudes [ 42 ].

It is of utmost importance that the roles of CHWs and their rationale be made clear to other cadres of health workers in the health system.

And, of course, CHWs should be adequately trained and supported to perform their tasks [ 46 ]. Some health professionals at local health facilities have sought to co-opt CHWs to become assistants for their own work within the facility and minimize their community roles [ 43 ]. Health facility-based staff in Mozambique and Zambia reported that staff deficits and poor work conditions caused heavier workloads for staff on duty, the closure of some services, and conflicts with patients, necessitating task-shifting of duties to CHWs to perform at the health facility [ 47 ].

This also occurred in Nigeria [ 48 ]. This is most unfortunate, since the greatest value of CHWs lies in reaching out beyond health facilities to people with services and health information that they would probably not obtain otherwise [ 49 , 50 ]. In many settings where access to health services is limited, especially in isolated rural areas, community members seek advice or care from CHWs when an illness arises, regardless of what training the CHW may or may not have had.

In some programmes e. However, more often, CHWs receive no such benefit but instead spend time and often their own finances in accompanying clients from their community when an emergency arises [ 52 ]. Having formal referral guidelines, such as protocols and referral slips, can help to make the link between CHWs and health facilities more effective.

Good communication links between CHWs, supervisors, and health facility staff, along with active community engagement, can facilitate better use of referral services [ 53 ]. Mobile phones have opened up new opportunities for linking clients with higher levels of care [ 54 ].

A systematic review across 42 low- and middle-income countries documented a broad range of negative maternal healthcare provider attitudes and behaviours such as verbal abuse, rudeness, and neglect affecting patient well-being, satisfaction with care, and care-seeking especially for antenatal care, facility-based delivery, and postnatal care.

Reported negative patient interactions far outweighed positive ones [ 55 ]. A common problem encountered by CHWs in large-scale programmes has been the inability to resupply medicines and other commodities when they are needed. In fact, lack of supplies was tied with lack of financing as the most frequently cited challenge that CHWs programmes face according to the recently published compendium of national CHW programmes [ 9 ].

Two recent reports further highlight this problem. These stock-outs are not unique to CHWs, but also affect the local health facilities to which they are attached.

Interviews with key informants [ 58 ] revealed that the main causes were budgetary constraints and difficulties that CHWs may have in reaching the resupply point to replenish their stocks. Sometimes the logistics system was unable to accurately estimate supply needs. In addition, when health facilities did not receive the supplies they needed for their own services, they may have prioritized their own needs over those of CHWs who come to the facility for resupply.

When stock-outs occur, CHWs are obviously unable to complete their tasks to care for patients in the community. CHWs can then lose credibility in the eyes of community members [ 7 ], jeopardizing their ongoing relationships and performance. The CHW may even be accused of stealing or selling supplies. The importance of a functioning supply system for CHW programming was convincingly demonstrated in a recent study of the effectiveness of CHWs in reducing child mortality in Tanzania [ 61 ].

Even when supplies are available at the local health facility, CHWs can still face challenges in obtaining them. In Malawi and Rwanda, CHWs reported that they needed to pay out of pocket from their own money to collect drugs and other supplies [ 62 , 63 ], as they had to pay for transport to reach the local health facility.

These types of challenges should be anticipated and addressed proactively [ 29 ]. In their systematic review of reviews of CHW programmes that have been published in the scientific literature, Scott et al. It also fosters respectful collaboration and communication between CHWs and higher-level staff, leading to acceptability and credibility of the CHW programme within the health system, trust, and beneficial relationships between actors.

Integration that fosters respectful collaboration and communication between CHWs and MOH staff can enable the health system to benefit from the unique, practical knowledge that CHWs have. In a review of national CHW programmes in Brazil, Ethiopia, India, and Pakistan [ 42 ], the authors found variable levels of integration of CHW programmes into health system elements e.

They concluded that policy-makers should design their national CHW programme scale-up strategy based on their own contextual factors [ 42 ].

In South Africa, the ward-based community outreach teams consist of a group of generalist CHWs led by a nurse. However, the team, because of its broad responsibilities for maternal and child health, HIV, TB, noncommunicable diseases, and environmental health, is also linked to specialist technical supervisors who can support them [ 48 ]. The engagement of the private sector to support CHW programmes is another strategy that some countries are using.

Outsourcing the management of district health systems to private contractors, most notably NGOs, is one option. In Afghanistan, the government has contracted NGOs to recruit, train, and support CHWs, lessening the burden on an already weak health system [ 67 ].

Cambodia is also a case in point. The programme management, training of CHWs, and delivery of services is provided by nongovernmental agencies with donor funding. This has led, however, to ill-defined ownership of the programmes and a lack of government accountability, leadership, and management [ 40 ]. Evidence indicates that CHWs can engage and mobilize the community to improve a range of health issues [ 68 ]. However, lack of community support or perceived low value of the CHW by community members are common barriers to scaling up and sustaining CHW programmes [ 39 ].

Appendix Table 3 provides an overview of the role of the community in CHW selection, programme implementation, supervision, and performance evaluation in 29 large-scale CHW programmes. According to the WHO guideline on optimizing CHW programmes, a range of community engagement strategies have been found to have a beneficial impact on CHW performance outcomes, including strategies to build trust in the CHW, to promote community awareness about the capabilities of CHWs and the limits of their capabilities, and to build support for and create a sense of ownership of CHW programmes [ 68 , 69 ].

Paper 7 in this series, which focuses on supervision of CHWs, also provides additional insights into contributions that communities can make in the supervision of CHWs [ 33 ]. However, detailed information on these issues remains limited [ 70 ]. Though numerous challenges exist, here we highlight three particular ones related to the development of supportive relationships between the CHW and community actors: 1 defining a healthy, trusting relationship with community actors, 2 involving the community in the selection of CHWs, and 3 involving the community in the work of CHWs [ 68 , 69 ].

Constraints to beneficial relationships between CHWs and the community can be both external and internal [ 71 ]. External obstacles include pressure from the donors and technical advisors to achieve quick results thereby bypassing the slower social processes that can be required for establishing stronger ties between the CHW and the community , co-optation of community participation by the government e.

Further, governments and development groups may favour investment in interventions with easily measurable indicators and may underinvest in the more intangible social processes and community participation that are critical to longer-term success and sustainability. Internal obstacles include conflicting local interest groups, gatekeeping by local elites, and local apathy. It is not uncommon for CHWs to work in communities with internal social conflicts [ 72 ]. A CHW can often do little to overcome these factors that are inherent in the system [ 71 ].

The importance of building beneficial relationships between CHWs and community actors can be easily overlooked when a CHW programme is being designed or when the programme is being adapted to meet new needs [ 73 ].

There are a variety of community participation approaches that run along a continuum from passive to transformative [ 74 ]. Not all large-scale CHW programmes only focus on passive information sharing. Even though programme consultation and collaboration with community leaders and local government is a key element for building community ownership of the CHW programme, local health staff often do not have the necessary time and energy to facilitate understandings that communities have a realistic understanding of the CHW programme both during the inception of the programme and as the programme evolves over time.

If community leaders do not facilitate support for the CHW, such as at regular community meetings, community trust and respect towards the CHWs can be undermined [ 25 , 75 ]. Government reforms and policies that support the devolution of responsibilities to local groups for example, policies that mandate inclusion of communities in programme planning may not exist [ 76 ].

Unrealistic expectations may contribute to poor CHW programme performance [ 64 , 77 ]. If community members do not see that a CHW has something to offer them, then collaboration will be difficult. For example, while development and education activities are important, community members may also expect some curative services from CHWs [ 78 ].

CHWs who are not embedded in the community have a distinct disadvantage in efforts to engage the community in supporting their work. In one systematic review, the most frequently cited factor causing community lack of acceptability and accountability of their CHW was if the recruitment of CHWs was not from and by the community [ 39 ].

However, community engagement in the selection of CHWs can also produce problems, as evidenced in the literature. Where the CHW selection process is not transparent to community members, suspicion of favouritism may arise that could lead to jealousy or loss of willingness of the community to cooperate. When CHW selection is managed by traditional kinship structures, this could aid community participation and intervention effectiveness within the kinship group, but can lead to exclusion of others [ 80 ].

Uganda decided to allow every kinship or neighbourhood group to select as many community-directed health workers as practical in its onchocerciasis programme [ 81 ]. In India, researchers found evidence of nepotism and favouritism in the selection of ASHAs by community leaders benefitting the already privileged [ 82 ].

If you find three collectible files in a set you'll unlock a bonus level. You can find these secret stages in the "collection" screen, available from the main menu. Each stage features a balloon with a man's face, for some reason which floats up towards a vacuum pipe at the top of the level. You need to ensure the balloon's safety by digging paths, pushing it with water and building icy barriers.

Watch these video tutorials if you get stuck. There's an achievement in it for you. Semi-Aquatic Where's My Perry? To find it, return to the very first menu with Perry sleeping next to a trash can and hit the settings button it looks like a cog. From here, click "Credits" and then tap on the rubber duck. This takes you to a level called Semi-Aquatic. It's super easy, but if you get stuck watch this video guide.

Once you've beaten every level, found every gnome, grabbed every file and completed every bonus stage, all you've got left is the achievements. These are shown in the game, and also appear on your Game Center profile so you'll want to get the lot if you want to show off. Here's how. You can't use the level skip cheat, so play fair. That means collecting all three gnomes, as well as completing the stage. Use the video guides above if you get stuck.

Secret Agent, Top Secret Agent, Super Secret Agent You'll get 10 points when you find one secret file, 20 for finding ten of them, and 50 for finding all Use our comprehensive guide above if you're missing any. Friend of Balloony, Best Balloony Buddy You'll get 10 points when you unlock a bonus level achieved by finding all three secret files in one set - see the secret files page for help. You'll get another 10 points if you finish all these balloon-based bonus levels. Efficient Cut All you need to do is cut the dirt with two fingers at once.

You'll get 10 Game Center points for your trouble. Confidence To get this, you need to complete level "Warning Lasers Convert Water" with only one cut. This one is more about timing than anything. Don't make your cut until the roaming gate is moving upwards, and has just cut off the laser fire. Persistence Complete a level after retrying seven times or more.