Development of a Community Health Worker Perceptual and Behavioral Competency Scale for the Prevention of Non-Communicable Diseases (COCS-N) in Japan | BMC Public Health

Non-communicable diseases (NCDs), also called chronic diseases, are long lasting and result from a combination of genetic, physiological, environmental and behavioral factors [1, 2]. In 2016, according to a report by an international organization of experts, 523 million people worldwide suffered from cardiovascular disease, 463 million from diabetes and 40 million had suffered a stroke. [3,4,5]. The incidence of cardiovascular disease has doubled in the last 30 years and that of diabetes has more than tripled in the last 10 years [3, 4]. Globally, approximately 671 million people are currently considered obese (a major primary risk factor for NCDs), 2.5 times the number recorded 30 years ago. [6]. NCDs often lead to sequelae which, on their own, can interfere with daily life and increase the risk of requiring nursing care [7]. However, early primary prevention of NCDs and their major risk factors (smoking, physical inactivity, harmful alcohol use, unhealthy diets and lifestyles) can lead to a longer and healthier life. Preventing non-communicable diseases and increasing healthy life expectancy lead to improved quality of life for individuals and better outcomes for society. It is therefore essential to address the prevention and control of NCDs at the national level due to the increasing global morbidity and mortality due to this group of diseases.

Many national NCD prevention and control programs have a strong community component. Community health workers (CHWs) are increasingly recruited to support NCD prevention at the regional level. CHWs are known by many names internationally, including community health workers, community health assistants and health advisers [8, 9]. CHWs are usually members of the communities in which they work, who are selected by their communities, accountable to those communities for their activities, and supported by the health system [10].

CHWs have four main roles and functions in NCD prevention and control: health education, social support, advocacy and coordination. Health education is used to increase the knowledge of patients and community members and help reduce NCDs and their main risk factors. Social support can be emotional, appreciative (providing information to support self-assessment), informational, or material. Advocacy and coordination focuses on supporting residents’ access to health facilities and community health professionals, and acts as a bridge for collaboration among CHWs themselves [11, 12]. Previous studies on CHWs have focused primarily on developing countries, and many studies have not examined NCDs. In developing countries, given critical shortages of health resources, CHWs often form the backbone of primary health care services [13]. CHWs are cost effective compared to other parts of the health system [14] and effective in delivering essential maternal and child health, family planning and nutrition services in developing countries [15, 16]. In developed countries, including Japan, CHWs can also be a useful part of primary health care services, especially given recent increases in health inequalities. CHWs can be particularly effective in providing NCD prevention and control services.

Japan had a Human Development Index score of 0.903 in 2016 (ranked 17th in the world) and has an exemplary human development record [17]. Every citizen in Japan has had access to universal health insurance since 1960, which means that all citizens have access to medical services without financial barriers. This has contributed to roughly equal access to health care and relatively small disparities in health status between regions and socioeconomic groups. [18]. Despite earlier achievements, however, health inequalities are now increasing and have become a challenge for Japan. The gap between the Japanese prefectures with the lowest and highest life expectancies has widened from 2.5 years in 1990 to 3.1 years in 2015, and there are concerns that the gap life expectancy in good health is also increasing [19]. The determinants of health inequalities would be linked to the physical and cognitive habits engendered by the first experiences of life, and to the surrounding environment (resources for physical and human health) [19]. It was found that many of the prefectures with the highest healthy life expectancy rankings had a high percentage of municipalities with a high level of financial support for health care activities, including the ASCs. This financial support was not necessarily linked to the tax revenue of the prefecture or the municipality. [20,21,22]. It is therefore an opportune time to examine approaches to transforming people’s perceptions and identifying human and material resources to reduce health inequalities, to help achieve the Sustainable Development Goal of “leaving no one behind”. aside”, so that good health is accessible to all. [23]. CHWs can help solve this problem.

CHWs in Japan are local residents, called community/local health promoters, who are commissioned by national and local public health organizations. There have been CHWs in Japan since the 1950s. CHWs in Japan are generally unpaid volunteers, but the provision of expenses for their activities varies from prefecture to prefecture. CHWs in Japan participate in training programs organized by local governments, either by volunteering or being recommended by local residents. Many of the applicants are stay-at-home parents whose children have left home, or retirees who join the program to use their free time to improve their own health and that of their community. They play a key role in modifying perceptual and behavioral skills to help prevent NCDs. The content of the training program varies slightly between municipalities, but generally lasts between 1 and 6 months, and includes lectures on the pathology of NCDs and associated lifestyle habits, using diet to prevent NCDs, easy exercises and local resources that can be used for the exercise [24]. CHWs span the intersection between local residents and local government and provide activities at the individual, interpersonal, group and community levels. For example, the role of CHWs can range from introducing low-salt and low-sugar meal recipes to prevent NCDs, explaining how to do strength training at home, to introducing health programs in health centers, such as medical screening in communities with high blood pressure and diabetes. The most important skill among CHWs is to be able to help community members review and improve their health Perceptions and behaviors based on basic knowledge and skills on NCD prevention [25]. However, it is not yet clear which skills among CHWs contribute to positive health outcomes. Currently, the greatest challenges in community health internationally focus on fair payment for work, integrating the work of CHWs into health systems without distracting or disrupting their positions in communities, and combining contributions of CHWs with other material social supports to produce better results with even greater returns on investment. Overcoming these challenges will require a variety of inputs, and each will be different depending on the context. To date, scales used to measure CHW competence have generally been adapted from scales for personnel requiring medical expertise, although a competence scale for community health personnel has been developed. [26]. Metrics for volunteers working in developed countries have been developed to measure motivation [27, 28], but not skills such as perceptions and behaviors. Japanese CHWs are unique in that they use their free time to prevent NCDs in themselves and in their communities in a hyper-ageing society. Their activities are important as they work to extend the healthy life expectancy of their communities. They can therefore serve as a model for other countries with aging populations, and the development of a scale to measure their competence is likely to be important for the international community.

We developed a scale composed of behavioral and perceptual aspects to help assess the skills of CHWs working to address NCDs. In turn, this tool can help decision makers and managers of community health programs in the design and improvement of these programs. The concept of competence was proposed by Spencer and Spencer in 1993. Studies of competence tend to focus on highly productive workers, examining the mechanisms that allow them to achieve results. The skills of high performers have unique characteristics, including behavioral aspects (eg, skills and knowledge) and perceptual aspects (eg, attitudes and values) [29,30,31]. The concept of competence must therefore be structured both in terms of perception and behavior. Measuring behavioral aspects can help identify how CHW efforts can be integrated into the health system and how their inputs can be combined with social support to achieve greater return on investment. Measuring perceptual aspects could be useful in considering fair compensation for work and how to prevent disruption or interference with the position of CHWs in the community. By measuring the skills of CHWs, we can consider what perceptual and behavioral programs (including new training and mentorship programs) to introduce when training or retraining CHWs. As a result, CHWs may be more likely to view NCD prevention as a difficult community health problem to address, rather than a threat to be avoided, and may also set ambitious goals and demonstrate a greater role in practice. This, in turn, could help extend healthy life expectancy and reduce health disparities. However, at present, there are no scales to measure the perceptual and behavioral competence of CHWs in the prevention and control of NCDs.

This study aimed to develop a CHW Perceptual and Behavioral Competency Scale for NCD Prevention (COCS-N) in a developed country, and to assess the reliability and validity of the scale.

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