Definition of Key Terms

Community health workers: These are paraprofessionals or lay individuals with an in-depth understanding of the community culture and language, have received standardized job-related training of a shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community [1].

Non-communicable diseases: These are chronic health conditions that are not contagious to others. They include cancer, diabetes, cardiovascular diseases, and chronic lung illnesses among others [2].

NCDs prevention and control practice: This refers to the involvement in activities which aim to prevent or control different non-communicable diseases in the community. It includes either screening, health promotion programs like community education, patient referral, or patient management and monitoring (operational definition).

Premature death: This refers to the death that occurs before the average age of death in a certain population [3].

1 Introduction

The rising burden of non-communicable diseases (NCDs) and associated mortality is of public health concern, especially in low- and middle-income countries (LMICs) [4, 5]. Globally, NCDs are the leading cause of premature mortality and morbidity, even though they can be significantly prevented [6]. The World Health Organization (WHO) outlined four major NCDs as the leading causes of mortality: cardiovascular diseases (CVD), diabetes mellitus, chronic respiratory diseases, and cancers [5]. These four diseases have four potential modifiable risk factors, namely, unhealthy diet, physical inactivity, harmful alcohol use, and tobacco use, that contribute to over 80% of NCDs' premature mortality [5, 6]. Globally, about 70% of all deaths are due to NCDs, and among them, 87% occur in LMICs [7]. By reducing or eliminating the four modifiable shared risk factors, up to 80% of CVD, type 2 diabetes mellitus, and over one-third of cancers can be prevented [8]. Almost 36 million people die every year (63% of the global deaths) because of NCDs: of these, 14 million deaths are premature. LMICs contribute up to 86% of the global NCDs' premature deaths [6].

In sub-Saharan Africa, NCDs will be the leading cause of mortality by the year 2030 [9]. In Tanzania, all NCDs caused about 31% of premature deaths in the year 2012: the four main NCDs caused 16% of the deaths [10]. The cases of NCDs in Tanzania have been increasing abruptly to the extent of needing an immediate action [11]. According to the WHO, NCDs countries' profiles report of 2018, it was estimated that NCDs account for about 33% of all deaths in Tanzania [12]. Moreover, NCDs pose a catastrophic economic burden in Tanzania [13, 14]. While Community Health Workers (CHWs) may play a pivotal role in the prevention and control of NCDs, it is unfortunate that both the national NCDs Strategic Plan of 2008–2018 and 2016–2020 in Tanzania did not clearly indicate their role [15, 16]. Of note, the current Tanzania National NCD Strategic Plan of 2021–2026 embraces a multisectoral collaboration approach with the development of NCD training manuals for primary healthcare facilities [17].

CHWs have been identified as an important part of the public health workforce globally and have been mobilized to provide primary healthcare at the community and household levels [18]. These are trained individuals that assist in providing health promotion, prevention, community empowerment, administering basic curative health services, and linking local communities with health facilities within their locality with the aim being to reduce morbidity and mortality [19]. Despite their potential role in the healthcare system, their role and contributions in many countries, including Tanzania, are mostly limited to maternal and child health like their participation in the immunization of vaccine preventable diseases as well as prevention and treatment of infectious diseases like TB and HIV while majority of their tasks are highly fragmented as their program driven [20]. CHWs are mostly trained to fill the health provider gaps in health systems and healthcare delivery, especially in developing countries due to the shortage of healthcare workers which is more vivid at the primary healthcare level like in Tanzania, whereby HRH gap is at 52% of the needed staffing level by 2021. In developing countries like Tanzania, addressing the recognized major NCDs such as CVD, cancer, diabetes, and chronic respiratory diseases is necessary at the primary care level considering the rising burden of morbidity and mortality they are causing [7, 21]. Through this, different programs and action plans for NCDs are therefore being strengthened for primary prevention and control, and CHWs have the potential to offer support in the provision of primary healthcare services [22, 23]. To address the gaps in human resources for health regarding NCDs, the mobilization of CHWs shows to have promising results [24, 25]. Evidence suggests various roles like community mobilization and screening, and the relevance of CHWs in the management of different NCDs [26].

Given the pivotal role which CHWs can play in prevention and control of NCDs in their communities, a 2017 study in Uganda showed that most of them had little awareness about most NCDs, as a result, this hindered their effectiveness [27]. Another study of 2022 in Uganda reported that the majority of CHWs (75.3%) had general awareness about different NCDs [28]. Moreover, more than half of the study participants reported being involved in NCDs activities like community mobilization in their communities. Several studies have shown that the majority of CHWs had significant knowledge on prevention and control measures toward some NCDs [28, 29]. Importantly, most CHWs admitted the fact that NCDs burden is a significant public health problem and they have a key role to play in prevention and control [27, 28].

Despite the fact that there are limited studies on the proportion of CHWs engaging in the practice of NCDs prevention and control in their communities, the study in Uganda reported that 63.1% of CHWs were involved in NCDs activities even though only few of them participated in community mobilization (20.9%) and referral of patients (20.6%) [28]. Another study reported that more than half of the participants were involved in community education and counseling on cervical cancer among all NCDs [29].

In one study, CHWs reported that lack of knowledge, lack of training, and negative community perception of NCDs among community members as challenges which prevent them from being effective in addressing NCDs in their communities even though another study reported that lack of financial remuneration was not a barrier in providing NCDs-related services [27, 28]. Some studies pointed contrary that financial remuneration plays a role in CHWs participation in fighting NCDs [30, 31].

Despite other countries like India having established the role of CHWs in NCDs prevention and control, the role of CHWs in delivering primary prevention and control interventions for NCDs in Tanzania is limited [32-34]. Most CHWs are willing and wish to participate in different NCDs intervention programs but do not have knowledge on NCDs to enable them offer required preventive and control measures despite easy availability of online WHO community-based guidelines resources which includes prevention and control of NCDs [WHO Package for Essential Non-communicable (PEN) diseases interventions for primary healthcare] [35, 36]. Moreover, evidence suggests that CHWs are interested in delivering NCDs' prevention services within their communities and thus it is crucial to understand their level of knowledge, attitudes, and perceived role in addressing NCDs as part of the feasibility of involving them in the prevention and control of these diseases [37, 38]. Information on the knowledge and attitudes of CHWs regarding NCDs would provide insights into the competencies and training needs for them to perform their tasks effectively. This study will assess the involvement of CHWs in the prevention and control of NCDs in northern Tanzania with a focus on their knowledge, attitudes and practices, and finding out related determinants. Results will enable policymakers and community health-related stakeholders to formulate and implement informed interventions in providing CHWs with a conducive and enabling environment toward the prevention and control of NCDs in their communities.

2 Materials and Methodology

The reporting of this study has followed the STROBE guideline [39].

3 Results

3.3 CHWS' Attitudes Toward NCD Burden, Prevention, and Control

Majority (152, 79.6%) of the CHWs agreed that NCDs are now common among Tanzanians including CVDs, diabetes, and cancer. In total, 99.5% of the CHWs agreed that early detection of NCDs plays an important role in their prevention and control. Most of the CHWs (97.9%) agreed that they have a very important role to play in NCDs' prevention and control in their communities (Table 4). Generally, all CHWs (100%) had favorable attitude.

Table 4. CHWs' attitudes toward NCD burden, prevention, and control (N = 191).

Statement	Strongly agree (%)	Agree (%)	Neutral (%)	Disagree (%)	Strongly disagree (%)
NCDs are common among Tanzanians	58 (30.4)	94 (49.2)	8 (4.2)	28 (14.7)	3 (1.6)
Cardiovascular diseases are becoming more common in Tanzania	64 (33.5)	117 (61.3)	4 (2.1)	6 (3.1)	0 (0)
Diabetes is becoming more common in Tanzania	75 (39.3)	108 (56.5)	4 (2.1)	4 (2.1)	0 (0)
Cancer is becoming more common in Tanzania in general	77 (40.3)	99 (51.8)	7 (3.7)	7 (3.7)	1 (0.5)
Early detection plays an important role in NCDs prevention and control	94 (49.2)	96 (50.3)	1 (0.5)	0 (0)	0 (0)
As a community health worker, I have a very important role to play in NCDs prevention and control in my community	71 (37.2)	116 (60.7)	4 (2.1)	0 (0)	0 (0)

Attitudes toward NCDs burden, prevention, and control		n		%
Favorable attitude		191		100
Unfavorable attitude		0		0

Figure 1 highlights the roles which CHWs identified they can play in prevention and control of NCDs. The vast majority (95.3% and 93.7%) identified that they have a role to play in providing health education and community mobilization, respectively, while 66.5% believed they had a role to play in NCD screening and early detection.

4 Discussion

The aim of this study was to determine knowledge, attitude, practice, and determinants toward CHWs' involvement in NCDs prevention and control in northern Tanzania. Study findings show that majority of CHWs in northern Tanzania have general knowledge on different NCDs while all of them had favorable attitude toward the burden of NCDs in Tanzania and their involvement as among stakeholders. While more than half of CHWs (63.4%) were found to have been involved themselves in NCDs prevention and control activities, only 26.7% and 46.1% of CHWs were involved in screening activities and had attended NCDs-related training or seminar, respectively.

More than half of CHWs had good overall knowledge of different NCDs and had been involved in prevention and control activities as it has been reported in several studies done in Uganda [28, 29]. Moreover, most of the CHWs had favorable attitude toward the burden of NCDs in their communities and the role they can play as it was found in previous studies [27, 28]. This portrays interest, willingness, and readiness of CHWs to involve themselves in NCDs prevention and control activities which is a key step in ensuring healthcare for all and sustainability in terms of availability of primary healthcare services at the community level. This will not only enhance early prevention and control of NCDs but also will enable community members to access routine screening, respective health counseling and referrals, community-based treatment, and palliative care support for different NCDs for free at no cost while at home. Furthermore, this might significantly reduce NCDs economic burden in Tanzania and enhance health-seeking behaviors such as routine health checkups against NCDs and related complications among community members [13, 14]. On the other hand, the finding that only 46.1% had attended NCDs-related training contradicts with the fact that the majority had good overall NCDs knowledge. This might be attributed to reporting and self-desirability bias as this conclusion was based on self-reported knowledge.

Investing in CHWs as a community-based strategy for NCD prevention and control is a cost-effective approach that delivers significant benefits [19, 24-26]. In India, delivery of home-based screening for NCDs by trained CHWs was found to be feasible and acceptable [34]. While screening for NCDs and their respective complications is the key in early detection and control of different NCDs, it is only nearly a quarter of CHWs (26.7%) in northern Tanzania have been involved in screening activities. This might be due to the finding that only 36.1% of participants reported to have access to NCDs screening tools.

Despite the fact that majority of CHWs had good overall knowledge of NCDs (92.1%), favorable attitude on NCDs burden and their involvement (100%) and overall practice involvement confidence (69.6%), still on assessing the enabling factors for their involvement in NCDs prevention and control, only less than half (46.1%) reported to have attended a training or seminar on NCDs while 36.1%, 19.9%, and 48.2% reported to have access to tools for NCDs' screening, patient management, and palliative care, respectively. These findings highlight the possible areas of interventions to facilitate the CHWs' involvement in NCD prevention and control.

Regarding challenges faced by CHWs toward their involvement in NCDs prevention and control practice, one study reported poor remuneration as a barrier while another study reported contrary findings [27, 28, 30, 31]. This study found that despite the fact that poor remuneration was reported by majority CHWs as a barrier toward their involvement in NCDs prevention and control practice, but it was not statistically a significant determinant. Most CHWs reported inadequate NCD knowledge, negative community perception toward NCDs as among challenges toward their involvement in NCDs prevention and control as reported in a study in Uganda [28]. Of note, one of the striking findings is that lack of sufficient knowledge of NCD prevention and control was the major challenge acknowledged by 84.3% of the CHWs, however, the overall knowledge was seen to be high which is contrary to the expectations. This discrepancy could be attributed to the reporting and self-desirability bias credited by the self-reporting nature of the study.

Among statistically significant determinants of CHWs involvement toward NCDs prevention and control; access to NCDs screening tools, professional training to practice as CHWs, frequency of home visits per week, CHW's involvement confidence, NCDs special training or seminar attendance and access to screening tools were strongly associated with CHWs involvement in NCDs prevention and control activities. This might be due to the fact that all these factors directly enable CHWs and increase the chances of their participation.

5 Conclusion and Recommendation

CHWs are useful toward prevention and control of different NCDs. Majority of CHWs showed overall good knowledge, favorable attitude, and high involvement in NCDs prevention and control in northern Tanzania. However, only a few of them were involved in community mobilization and screening of different NCDs. Their limited involvement is attributed secondary to several factors including inability to access NCDs screening tools and lack of training tailored to NCDs–CHWs context.

Several CHWs-based programs tailored against NCDs should be implemented to maximize CHWs involvement and effectiveness toward NCDs prevention and control in their local communities. Public health stakeholders, including respective government institutions, should design and implement capacity-building programs among CHWs in terms of trainings for both skills and knowledge acquisition. This should also be incorporated in the national NCDs strategic plans. NCDs training manuals developed in Tanzania for primary healthcare facilities should also be applied toward CHWs. On top of that, these programs should ensure accessibility of tools for screening, patient management, and palliative care among CHWs. Health facilities should work in partnership and harmony locally with CHWs in enabling their involvement toward NCDs prevention and control.

Additionally, professional training to practice as a CHWs should be prioritized in both in service and new enrolled CHWs. This will enhance their knowledge toward their role as CHWs and their involvement in NCDs prevention and control. Since the WHO have made the prevention and control practice guideline (PEN) available to enable CHWs involvement in NCDs prevention and control practice, this guideline should be incorporated among CHWs professional trainings and made available to every CHWs in Swahili format.

Author Contributions

Harold L. Mashauri: conceptualization, data curation, formal analysis, methodology, investigation, project administration, writing – original draft, visualization. Cornel M. Angolile: data curation, methodology, investigation, formal analysis, writing – original draft, visualization. Florida J. Muro: conceptualization, methodology, investigation, formal analysis, writing – review and editing, supervision. All authors have read and approved the final version of the manuscript.

Ethics Statement

Ethical approval was sought from Kilimanjaro Christian Medical University College Research and Ethics Review Committee (KCMUCo-CRERC) with certificate registration number 2610. Permission letters to conduct a study were obtained from local government authorities in Moshi and Arusha Municipals.

Consent

Written informed consent was obtained from each participant after explaining to them and reading the study information prior to start filling the survey so that they can make an informed decision to participate or withdraw from the study without losing their dignity.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author Harold L. Mashauri affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.