Background
Lay health workers (LHWs) perform functions related to healthcare delivery, receive some level of training, but have no formal professional or paraprofessional certificate or tertiary ...education degree. They provide care for a range of issues, including maternal and child health. For LHW programmes to be effective, we need a better understanding of the factors that influence their success and sustainability. This review addresses these issues through a synthesis of qualitative evidence and was carried out alongside the Cochrane review of the effectiveness of LHWs for maternal and child health.
Objectives
The overall aim of the review is to explore factors affecting the implementation of LHW programmes for maternal and child health.
Search methods
We searched MEDLINE, OvidSP (searched 21 December 2011); MEDLINE Ovid In‐Process & Other Non‐Indexed Citations, OvidSP (searched 21 December 2011); CINAHL, EBSCO (searched 21 December 2011); British Nursing Index and Archive, OvidSP (searched 13 May 2011). We searched reference lists of included studies, contacted experts in the field, and included studies that were carried out alongside the trials from the LHW effectiveness review.
Selection criteria
Studies that used qualitative methods for data collection and analysis and that focused on the experiences and attitudes of stakeholders regarding LHW programmes for maternal or child health in a primary or community healthcare setting.
Data collection and analysis
We identified barriers and facilitators to LHW programme implementation using the framework thematic synthesis approach. Two review authors independently assessed study quality using a standard tool. We assessed the certainty of the review findings using the CerQual approach, an approach that we developed alongside this and related qualitative syntheses. We integrated our findings with the outcome measures included in the review of LHW programme effectiveness in a logic model. Finally, we identified hypotheses for subgroup analyses in future updates of the review of effectiveness.
Main results
We included 53 studies primarily describing the experiences of LHWs, programme recipients, and other health workers. LHWs in high income countries mainly offered promotion, counselling and support. In low and middle income countries, LHWs offered similar services but sometimes also distributed supplements, contraceptives and other products, and diagnosed and treated children with common childhood diseases. Some LHWs were trained to manage uncomplicated labour and to refer women with pregnancy or labour complications.
Many of the findings were based on studies from multiple settings, but with some methodological limitations. These findings were assessed as being of moderate certainty. Some findings were based on one or two studies and had some methodological limitations. These were assessed have low certainty.
Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and health system constraints. Programme recipients were generally positive to the programmes, appreciating the LHWs’ skills and the similarities they saw between themselves and the LHWs. However, some recipients were concerned about confidentiality when receiving home visits. Others saw LHW services as not relevant or not sufficient, particularly when LHWs only offered promotional services. LHWs and recipients emphasised the importance of trust, respect, kindness and empathy. However, LHWs sometimes found it difficult to manage emotional relationships and boundaries with recipients. Some LHWs feared blame if care was not successful. Others felt demotivated when their services were not appreciated. Support from health systems and community leaders could give LHWs credibility, at least if the health systems and community leaders had authority and respect. Active support from family members was also important.
Health professionals often appreciated the LHWs’ contributions in reducing their workload and for their communication skills and commitment. However, some health professionals thought that LHWs added to their workload and feared a loss of authority.
LHWs were motivated by factors including altruism, social recognition, knowledge gain and career development. Some unsalaried LHWs wanted regular payment, while others were concerned that payment might threaten their social status or lead recipients to question their motives. Some salaried LHWs were dissatisfied with their pay levels. Others were frustrated when payment differed across regions or institutions. Some LHWs stated that they had few opportunities to voice complaints.
LHWs described insufficient, poor quality, irrelevant and inflexible training programmes, calling for more training in counselling and communication and in topics outside their current role, including common health problems and domestic problems. LHWs and supervisors complained about supervisors’ lack of skills, time and transportation. Some LHWs appreciated the opportunity to share experiences with fellow LHWs.
In some studies, LHWs were traditional birth attendants who had received additional training. Some health professionals were concerned that these LHWs were over‐confident about their ability to manage danger signs. LHWs and recipients pointed to other problems, including women’s reluctance to be referred after bad experiences with health professionals, fear of caesarean sections, lack of transport, and cost. Some LHWs were reluctant to refer women on because of poor co‐operation with health professionals.
We organised these findings and the outcome measures included in the review of LHW programme effectiveness in a logic model. Here we proposed six chains of events where specific programme components lead to specific intermediate or long‐term outcomes, and where specific moderators positively or negatively affect this process. We suggest how future updates of the LHW effectiveness review could explore whether the presence of these components influences programme success.
Authors' conclusions
Rather than being seen as a lesser trained health worker, LHWs may represent a different and sometimes preferred type of health worker. The close relationship between LHWs and recipients is a programme strength. However, programme planners must consider how to achieve the benefits of closeness while minimizing the potential drawbacks. Other important facilitators may include the development of services that recipients perceive as relevant; regular and visible support from the health system and the community; and appropriate training, supervision and incentives.
Similar protocols are already in place and used by CHWs in diverse settings—eg, as part of the Integrated Management of Newborn and Childhood Illness.5 Additionally, home visits for vulnerable people ...would allow CHWs to assess whether individuals have adequate supplies of food and medicines for long-term conditions, are aware of basic hygiene precautions, and whether they have mental health problems. Marco Di Lauro/Stringer/Getty Images Entry criteria could include occupations that provide basic training in first aid or assessing medical emergencies, such as flight attendants, or registration on a health professional training programme. CHWs in Brazil have been established for many years, are well integrated into their communities, and provide a wide range of health and social care support activities to each of the 100–150 households that they are responsible for. ...in Brazil, additional roles for preventing the spread of and supporting those infected with COVID-19 or in self-isolation could be integrated into the work of CHWs.
Men in hardhats were once the heart of America's working class; now it is women in scrubs. What does this shift portend for our future? Pittsburgh was once synonymous with steel. But today most of ...its mills are gone. Like so many places across the United States, a city that was a center of blue-collar manufacturing is now dominated by the service economy—particularly health care, which employs more Americans than any other industry. Gabriel Winant takes us inside the Rust Belt to show how America's cities have weathered new economic realities. In Pittsburgh's neighborhoods, he finds that a new working class has emerged in the wake of deindustrialization.As steelworkers and their families grew older, they required more health care. Even as the industrial economy contracted sharply, the care economy thrived. Hospitals and nursing homes went on hiring sprees. But many care jobs bear little resemblance to the manufacturing work the city lost. Unlike their blue-collar predecessors, home health aides and hospital staff work unpredictable hours for low pay. And the new working class disproportionately comprises women and people of color.Today health care workers are on the front lines of our most pressing crises, yet we have been slow to appreciate that they are the face of our twenty-first- century workforce. The Next Shift offers unique insights into how we got here and what could happen next. If health care employees, along with other essential workers, can translate the increasing recognition of their economic value into political power, they may become a major force in the twenty-first century.
Abstract
Of the millions of Community Health Workers (CHWs) serving their communities across the world, there are approximately twice as many female CHWs as there are male. Hiring women has in many ...cases become an ethical expectation, in part because working as a CHW is often seen as empowering the CHW herself to enact positive change in her community. This article draws on interviews, participant observation, document review and a survey carried out in rural Amhara, Ethiopia from 2013 to 2016 to explore discourses and experiences of empowerment among unpaid female CHWs in Ethiopia’s Women’s Development Army (WDA). This programme was designed to encourage women to leave the house and gain decision-making power vis-à-vis their husbands—and to use this power to achieve specific, state-mandated, domestically centred goals. Some women discovered new opportunities for mobility and self-actualization through this work, and some made positive contributions to the health system. At the same time, by design, women in the WDA had limited ability to exercise political power or gain authority within the structures that employed them, and they were taken away from tending to their individual work demands without compensation. The official rhetoric of the WDA—that women’s empowerment can happen by rearranging village-level social relations, without offering poor women opportunities like paid employment, job advancement or the ability to shape government policy—allowed the Ethiopian government and its donors to pursue ‘empowerment’ without investments in pay for lower-level health workers, or fundamental freedoms introduced into state-society relations.
To establish a validated, standardized set of core competencies for community health workers (CHWs) and a linked workforce framework.
We conducted a review of the literature on CHW competency ...development (August 2015), completed a structured analysis of literature sources to develop a workforce framework, convened an expert panel to review the framework and write measurable competencies, and validated the competencies (August 2017) by using a 5-point Likert scale survey with 58 participants in person in Biloxi, Mississippi, and electronically across the United States.
The workforce framework delineates 3 categories of CHWs based upon training, workplace, and scope of practice. Each of the 27 competencies was validated with a mean of less than 3 (range = 1.12-2.27) and a simple majority of participants rated all competencies as "extremely important" or "very important."
Writing measurable competencies and linking the competencies to a workforce framework are significant advances for CHW workforce development. Public Health Implications. The standardized core competencies and workforce framework are important for addressing health disparities and maximizing CHW effectiveness.
This study sought to synthesize and critically review evidence on costs and cost-effectiveness of community health worker (CHW) programmes in low- and middle-income countries (LMICs) to inform policy ...dialogue around their role in health systems.
From a larger systematic review on effectiveness and factors influencing performance of close-to-community providers, complemented by a supplementary search in PubMed, we did an exploratory review of a subset of papers (32 published primary studies and 4 reviews from the period January 2003-July 2015) about the costs and cost-effectiveness of CHWs. Studies were assessed using a data extraction matrix including methodological approach and findings.
Existing evidence suggests that, compared with standard care, using CHWs in health programmes can be a cost-effective intervention in LMICs, particularly for tuberculosis, but also - although evidence is weaker - in other areas such as reproductive, maternal, newborn and child health (RMNCH) and malaria.
Notwithstanding important caveats about the heterogeneity of the studies and their methodological limitations, findings reinforce the hypothesis that CHWs may represent, in some settings, a cost-effective approach for the delivery of essential health services. The less conclusive evidence about the cost-effectiveness of CHWs in other areas may reflect that these areas have been evaluated less (and less rigorously) than others, rather than an actual difference in cost-effectiveness in the various service delivery areas or interventions. Methodologically, areas for further development include how to properly assess costs from a societal perspective rather than just through the lens of the cost to government and accounting for non-tangible costs and non-health benefits commonly associated with CHWs.
Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in lowand middle-income countries (LMICs). Many ...factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review.
A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance.
When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.
Le personnel de santé communautaire (PSC) est de plus en plus reconnu comme élément prépondérant du personnel de santé nécessaire pour atteindre les objectifs de santé publique dans les pays à faible et moyen revenu. Beaucoup de facteurs influencent les performances des PSC. Nous avons mené une revue systématique pour identifier les facteurs lors de la conception d’initiatives qui ont une influence sur les performances des PSC. Nous avons cherché systématiquement dans six bases de données provenant d’études quantitatives et qualitatives incluant les PSC travaillant pour la promotion, la prévention et les soins curatifs dans les services de santé primaires pour les pays à faible et moyen revenu. Nous avons trouvé 140 études correspondant aux critères d’inclusion et dont la qualité a été évaluée ainsi qu’une relecture pour extraire les données pertinentes pour la conception de programmes de PSC. Un cadre préliminaire contenant des facteurs influençant la performance des PSC ainsi que les caractéristiques des performances des PSC (telles que la motivation et les compétences) a permis de diriger la recherche de documents et leur analyse. Un mixe d’incitations financières ou non financières, prévisibles pour le PSC, semble être une stratégie efficace pour améliorer la performance, spécialement pour les PSC qui ont plusieurs rôles. Les incitations financières pour encourager la performance peuvent parfois entrainer une négligence sur les t âches non rémunérées. La conception des initiatives, qui implique une supervision fréquente et une formation continue, a entrainé une meilleure performance des PSC dans certains cas. La supervision et la formation ont souvent été mentionnées comme éléments facilitateurs mais peu d’études ont testé quelle approche marchait le mieux et quel est le meilleur moyen de les mettre en place. L’intégration du PSC dans la communauté et dans le système de santé a permis de diminuer la charge de travail et d’augmenter la crédibilité du PSC. Le fait de clairement définir le rôle du PSC et d’introduire un processus de communication clair entre les différents niveaux du système de santé pourrait renforcer la performance du PSC. Lorsque les programmes de santé communautaire sont conçus, les éléments qui favorisent l’amélioration des performances du PSC dans des contextes comparables doivent être pris en compte. Nous avons besoins d’initiatives supplémentaires afin de développer un meilleur cadre pour une formation efficace, pour des mécanismes de supervisions ainsi que pour des recherches qualitatives afin d’informer les législateurs du développement des initiatives du PSC.
在低收入和中等收入国家（LMICs）中，为了达到公共医疗 目标，社区医疗工作者（CHWs）越来越多得被认为是医疗 工作者的一个组成部分。很多因素影响社区医疗工作者的绩 效。本文对这些影响因素做了一个系统评价。我们对六个数 据库定量和定性的研究进行了系统搜索，包括了在低收入和 中等收入国家中在促进、预防和基础医疗服务领域工作的社 区医疗工作者。达到我们标准的 140 个研究被进行了质量评 估，并被再次阅读提取出与社区医疗工作者项目设计相关的 数据。我们提前设计好了一个框架来指导文献搜索和综述工 作，框架里包括了影响社区医疗工作者绩效的因素和绩效的 特点（比如动机和能力）。
经济和非经济动机的混合，可以预见到，是提高绩效的有效 措施，特别是对于有多项工作的社区医疗工作者来说。以绩 效为基础的经济刺激有时会导致对一些不支付金钱的工作的 忽视。在一些情景中，包含了经常性监督和持续培训的干预 措施的设计能够带来更好的绩效。监督和培训是经常被提到 的影响因素，但是很少有研究试验哪种方式最有效或者如何 实施最有效。将社区工作者融入社区和医疗系统中能减少工 作量并增加社区工作者的可信度。清晰地界定社区工作者的 角色和引入医疗系统中不同层面的人的对话机制也能加强绩 效。
当设计以社区为基础的医疗项目时，应该考虑在对比情境下 增加社区医疗工作者绩效的因素。还应该进行额外的干预措 施研究建立一个证据库用以找出最有效的培训和监督机制和 为政策制定者设计干预措施提供定性研究。
Los trabajadores de salud comunitaria (TSCs) son reconocidos cada vez más como un componente integral del personal de la salud necesario para lograr los objetivos de la salud pública en los países de ingresos bajos y medianos (PIBMs). Muchos factores influyen en el rendimiento de los TSCs. Se realizó una revisión sistemática para identificar los factores relacionados con el diseño de la intervención que influyen en el rendimiento de los TSCs. De forma sistemática usamos seis bases de datos para buscar estudios cuantitativos y cualitativos que incluyeron los TSCs que trabajan en servicios promocionales, preventivos o curativos de atención primaria de salud en PIBMs. Ciento cuarenta estudios cumplieron los criterios de inclusión y fueron evaluados en materia de calidad. Se hizo doble lectura para extraer datos relevantes al diseño de programas de los TSCs. Un marco preliminar que contiene los factores que influyen en el rendimiento de los TSC y sus características de rendimiento (tales como motivación y competencias) orientaron la búsqueda bibliográfica y la revisión.
Una combinación de incentivos financieros y no financieros, previsibles para los TSCs, resultó ser una estrategia efectiva para mejorar el rendimiento, especialmente para aquellos TSCs con múltiples tareas. Los incentivos financieros basados en el rendimiento resultaron a veces en el abandono de las tareas no pagadas. Los diseños de las intervenciones que implicaron la supervisión frecuente y la formación continua llevaron a un mejor rendimiento de los TSC en ciertos contextos. La supervisión y la capacitación se mencionaron a menudo como factores facilitadores, pero pocos estudios probaron cual enfoque funcionó mejor o cómo éstas se implementaron de mejor manera. Se encontró que el arraigamiento de los TSCs en los sistemas comunitarios disminuyó la carga de trabajo y aumentó su credibilidad. Funciones de los TSCs claramente definidas y la introducción de procesos claros para la comunicación entre los diferentes niveles del sistema de salud podrían fortalecer el rendimiento de los TSCs.
Al diseñar los programas de salud basados en la comunidad, los factores que aumentan el rendimiento de los TSCs en contextos comparables deben ser tenidos en cuenta. Son necesarias investigaciones adicionales sobre la intervención para desarrollar una mejor base de pruebas sobre los mecanismos de formación y supervisión más eficaces, e investigaciones cualitativas para informar a los responsables de las políticas en el desarrollo de las intervenciones de los TSCs.
The Female Community Health Volunteer (FCHV) Programme in Nepal has existed since the late 1980s and includes almost 50,000 volunteers. Although volunteer programmes are widely thought to be ...characterised by high attrition levels, the FCHV Programme loses fewer than 5% of its volunteers annually. The degree to which decision makers understand community health worker motivations and match these with appropriate incentives is likely to influence programme sustainability. The purpose of this study was to explore the views of stakeholders who have participated in the design and implementation of the Female Community Health Volunteer regarding Volunteer motivation and appropriate incentives, and to compare these views with the views and expectations of Volunteers. Semi-structured interviews were carried out in 2009 with 19 purposively selected non-Volunteer stakeholders, including policy makers and programme managers. Results were compared with data from previous studies of Female Community Health Volunteers and from interviews with four Volunteers and two Volunteer activists. Stakeholders saw Volunteers as motivated primarily by social respect, religious and moral duty. The freedom to deliver services at their leisure was seen as central to the volunteer concept. While stakeholders also saw the need for extrinsic incentives such as micro-credit, regular wages were regarded not only as financially unfeasible, but as a potential threat to the Volunteers’ social respect, and thereby to their motivation. These views were reflected in interviews with and previous studies of Female Community Health Volunteers, and appear to be influenced by a tradition of volunteering as moral behaviour, a lack of respect for paid government workers, and the Programme’s community embeddedness. Our study suggests that it may not be useful to promote a generic range of incentives, such as wages, to improve community health worker programme sustainability. Instead, programmes should ensure that the context-specific expectations of community health workers, programme managers, and policy makers are in alignment if low attrition and high performance are to be achieved.
Community health worker motivation is an important consideration for improving performance and addressing maternal, newborn, and child health in low and middle-income countries. Therefore, ...identifying health system interventions that address motivating factors in resource-strained settings is essential. This study is part of a larger implementation research project called Nigraan, which is intervening on supportive supervision in the Lady Health Worker Programme to improve community case management of pneumonia and diarrhea in rural Pakistan. This study explored the motivation of Lady Health Supervisors, a cadre of community health workers, with particular attention to their views on supportive supervision.
Twenty-nine lady health supervisors enrolled in Nigraan completed open-ended structured surveys with questions exploring factors that affect their motivation. Thematic analysis was conducted using a conceptual framework categorizing motivating factors at individual, community, and health system levels.
Supportive supervision, recognition, training, logistics, and salaries are community and health system motivating factors for lady health supervisors. Lady health supervisors are motivated by both their role in providing supportive supervision to lady health workers and by the supervisory support received from their coordinators and managers. Family support, autonomy, and altruism are individual level motivating factors.
Health system factors, including supportive supervision, are crucial to improving lady health supervisor motivation. As health worker motivation influences their performance, evaluating the impact of health system interventions on community health worker motivation is important to improving the effectiveness of community health worker programs.
Background. The specific objectives of the study were to determine the; individual factors, health facility-related factors, and medicines-related factors contributing to dispensing errors among ...health workers. Methodology. A descriptive cross-sectional study design was used to address the relationship between the study variables from 50 respondents with a simple random technique to select the study participants. Results. 56% had ever experienced preventable dispensing errors, 75% didn’t report it, 54% got tempted to be distracted at work, 66% said the quality of prescription writing of fellow workmates was fair, 72% were satisfied with their jobs, 68% noted that their fellow workmates are friendly and 50% had fair computer skills. 52% didn’t have enough dispensers as per the ratio of patients,92% reported that the condition of their working environment was organized, 58% reported that sometimes workmates from different departments accessed the dispensing unit, 70% reported that medicines were assembled on shelves according to pharmaceutical therapeutic order, 60% never had enough space between medicines on shelves in their dispensing units, 90% agreed that the facility had policies related to dispensing. 58% agreed that they had ever experienced drug strength confusion during dispensing, 59% reported endocrine system agents as the classes of medicines they had ever experienced drug strength confusion during dispensing, 78% had never dispensed expired medicines accidentally, 48% had fair labelling strength for medicines, 54% agreed that the packaging of the medicine was decent. Conclusion. Poor reporting systems, distraction at work, quality of handwriting skills, unauthorized access to dispensing units, the inadequacy of dispensers as per the ratio of patients, lack of enough space, and drug strength confusion were factors contributing to dispensing errors among health workers. Recommendations. The administration should minimize the work overload, limit unauthorized access to dispensing units, and enforce protocol for patient identification and verification of drugs dispensed.
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