The WHO and other organizations have encouraged CHV involvement in palliative care delivery. In 2020, MacRae et al. addressed this issue in LMIC and found only 13 studies appropriate for their review [10]. For a more recent evaluation, we performed an OVID search (https://www.wolterskluwer.com/en/solutions/ovid) on February 14, 2024 using the keywords Community Health Workers (CHW), CHV, and Palliative Care and found 27 references. Searching CHW, CHV and Hospice did not add any additional references. The majority of publications were from high income countries where CHV expressed a positive attitude towards end-of-life care and including CHV in PC delivery may decrease medical costs [14, 15]. CHV were successful in to promoting advance care planning, utilization of hospice and palliative medicine, particularly in underserved populations [16,17,18,19,20,21,22,23,24]. Culturally based care was also an important factor in improving PC outcomes [25]. Most of the CHV in high income countries were supplementing an existing palliative care workforce. In contrast, CHV may be the only resource available for home-based care in LMIC and there are few publications addressing their role in palliative care delivery. Over a decade ago, Uganda developed national policies that included adding palliative care to the scope of CHV activities and other countries have followed suit [26] (2). A national PC policy in South Africa promotes CHV involvement but a report in 2022 recommended a needs assessment [27]. The study also noted CHV expressed uncertainty regarding their role in home-based palliative care. In general, publications recognize that adding PC to CHV practice represents a change from their current focus on preventative and general primary care needs. While publications have highlighted the need for research studies [10, 12, 27], our report is one of the few addressing CHV PC training and implementation in the LMIC setting.

The training curriculum described here was designed to cover the three main domains of PC which include physical symptom assessment and treatment, spiritual and social care and grief and bereavement care. Special emphasis was placed on the communication skills used in discussing difficult topics. The manuscript present pre- and post-assessments of training. CHV found the training of value, increased referrals to PC providers, and empowered the CHVs to alter their practice by providing a variety of PC services.

CHVs live within the community they serve and have been selected by the members of the same community, speak the same language and are from the same cultural background which is an added advantage in performing their roles [8]. In Kenya, their key roles and responsibilities include making home visits to assess health situations, share health improvement and prevention information from the MOH, treat common minor illnesses and injuries, and address maternal, newborn health and childhood health issues [8, 9]. The study found that with additional training and linkage to palliative care providers, CHVs can identify the PC needs of their community and appropriately act within their scope of practice. This includes a role in providing psychosocial and spiritual support as well as newly learned clinical care skill.

Following the training the CHVs used the training manuals and assessment forms provided to them during their community visits. We believe that these documents provided a stepwise guide to community member assessment and intervention and positively impacted the knowledge and confidence to initiate telephone consultations with PC mentors.

CHVs reported that through the training they have learnt new skills and the importance of biopsychosocial nature of chronic illnesses which they incorporated into their practice. They also appropriately identified patients for referral. At one year follow up, the CHVs also reported an increase in the number of PC consults they received from community members. In the FGD, several CHVs commented that by applying their new skills the respect shown to them by the community improved. The CHVs recognized the benefit of tapping into the existing community resources to help the sick community members. The CHVs trained caregivers who were then able to care for their sick family member and others in the community. This is consistent with the study by Soderhamn et al. showing a network of volunteers (beyond CHVs) can address patient needs and mobilized resources in the community [14].

This survey has shown a statistically significant overall improvement in knowledge and confidence in conducting basic nursing procedures like cleaning and dressing of wounds, stoma care, change of urine bag and feeding procedures except for patient referral. We believe that this can reduce unnecessary hospital visits especially for bedbound patients and reduce transport and procedure costs, but the clinical and financial impact will require further study. Greater access to home PC has the potential to allow patients with no access to home hospice to remain at home as they near end-of-life. A population-based study done in Kenya reported that approximately 50% favored dying at home [15]. Interestingly, 23.7% stated dying at home was the least preferred place, which some credited to the low availability of resources. This suggests an unmet care needs that CHVs could fulfill [15].

There were a number of limitations to our study. CHVs are familiar with patient referral as this is part of their monthly reporting requirements. They rated this skill the highest in terms of pre training confidence. This could explain the reason patient referral was not statistically significant and suggests this part of the training curriculum could be revised in future trainings. CHVs embraced teleconsultation which was facilitated by the robust telecommunication infrastructure in Kenya where the number of subscribers per capita is higher than most countries, including the United States (https://data.worldbank.org/indicator/IT.CEL.SETS.P2). The provision of PC by CHV may be less effective in countries will limited telecommunication coverage. Our training also empowered CHVs to train other CHVs but the impact of the peer training on patient care is unknown. CHV also were within counties that had an active palliative care clinic that was part of a larger hub and spoke model of PC support, areas where access to PC providers is limited may decrease the effectiveness of training. The availability of a 24-hour PC hotline and the small amount of financial support for phone fees are also components that could impact replication of our findings. We also had cooperation from the MOH in allowing CHV to participate in the training, which was likely influence by the Kenya Palliative Care Policy 2021–2030 which sets goals for increasing access to PC. Sustainability will require continued support by the MOH in allowing CHVs to incorporate PC into their other duties. Adding palliative care services to the CHV skill set may cause a negative impact on performing existing responsibilities as an unintended consequence. While this was not directly assessed in questionnaires, CHVs did not mention this as a limitation during semi-structured interviews.