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Table 3 CHW capacities for delivering specific health interventions

From: What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers

Health issue Setting
High-income countries Low- and middle-income countries
 Multiple primary health care interventions Most CHW programs focused on underserved populations in HICs (such as ethnic/racial minorities, economically marginalized, rural populations or immigrant groups) [25, 45, 90, 104, 106, 108, 109]. CHW interventions, such as through peer-support telephone calls [69] or home visits [110], can be effective for a wide range of health issues, including increasing knowledge about parenting [110], disease prevention (moderate strength of evidence) [25], influenza prevention [110], promotion of home safety [110], increasing parenting self efficacy [110], patient enrollment in research [99], uptake of early intervention services [99], increasing access to primary health care for screening [108], improving workplace safety (low strength of evidence) [25] and disease prevention (mixed evidence) [25], and reducing urgent care visits [110]. CHWs can reduce obesity among postpartum teens [110], improve nutritional eating habits [99]; and increase physical activity [98]. CHW programs can promote equity of healthcare access and utilization by reducing inequities relating to place of residence, gender, education and socio-economic position, and supporting more equitable uptake of referrals [111] (low-quality evidence from Brazil [112]). Deploying lay refugees/internally displaced persons as CHWs to provide basic health services to women, children, and families in camps can increase service coverage, knowledge about disease symptoms and prevention, uptake of treatment and protective behaviors, and access to reproductive health information (some evidence, weak quality) [113]. There was no clear evidence for equitable quality of services provided by CHWs, and there was limited information regarding the role of CHWs in generating community empowerment to respond to social determinants of health [111]. There is some evidence (moderate quality) that CHWs are effective in providing health education [114] and psychosocial support [114]. There is an absence of evidence on CHW potential to support community-based palliative care [75].
Reproductive, maternal, neonatal and child health
 Neonatal/child health CHW interventions can be effective in increasing infant-stimulating home environment scores [110], reducing psychiatric diagnoses among children [110], improving child development [99], and improving child well-being (mixed evidence) [25]. CHWs providing community-based care for infants and children in resource-limited settings can reduce neonatal, infant and child mortality and morbidity (e.g., from malaria, pneumonia and diarrhea) [35, 42, 46, 84, 85, 91, 93, 115,116,117,118]. While there is high-quality evidence that home-based neonatal care reduces neonatal and perinatal mortality in South Asian settings with high neonatal mortality rates and poor access to health facility-based care [91, 116] other reviews reported mixed results, with some individual empirical studies included in reviews not showing improvements in CHW intervention areas [85]. Evidence of the impact of CHW interventions on neonatal outcomes is promising but of moderate quality [46] and on CHW capacity to provide skilled birth care is of low quality [46]. Antenatal and neonatal practice indicators significantly improved [116]. Compared to physicians, trained CHWs may screen for possible bacterial infection in young infants with relatively high sensitivity but somewhat lower specificity [119]. There is some evidence of moderate quality that CHWs are effective in the promotion of essential newborn care [114], including skin-to-skin care for newborns [114]. CHWs can perform effective case management of child pneumonia [76], although pneumonia management performance is mixed when pneumonia management is integrated with malaria diagnosis and treatment [33]. The use of CHWs, compared to usual healthcare services, may increase the number of parents who seek help for their sick child [118]. Women’s groups (facilitated by CHWs) practicing participatory learning and action, compared with usual care, have a positive impact on reducing neonatal mortality in low-resource settings (but no evidence of impact on reducing stillbirths) [105]. Trained traditional birth attendants (TBAs) compared to untrained TBAs showed significant increases in safe delivery practices and appropriate referral knowledge and practice [94] and are associated with small but significant decreases in perinatal mortality and neonatal mortality due to birth asphyxia and pneumonia [94]. However, another review [82] concludes that there is insufficient evidence to establish the potential of TBA training to improve perinatal and neonatal mortality. CHWs in Brazil have demonstrated effectiveness in increasing the frequency of child weighings [112].
 Maternal health Peer-support can be effective for reducing depressive symptoms in mothers with postnatal depression [69] and can positively impact women’s perinatal mental health [72]. One study on addressing stress and mental health among pregnant women on Medicaid in the USA found that adding a CHW to a nurse home visit program increased the number of at-risk women reached [106]. One review reported that almost all of the intervention studies involving CHWs showed a significant impact on reducing maternal mortality and on improving perinatal and postpartum service utilization indicators [35]. Another found that community-based intervention packages, which almost always involved CHWs, may have a possible effect on reducing maternal mortality, although the pooled result just crossed the line of no effect [93]. Women’s groups (facilitated by CHWs) practicing participatory learning and action, compared with usual care, have a positive impact on reducing maternal mortality in low-resource settings [105]. In settings characterized by high mortality and weak health systems, trained TBAs can contribute to reducing mortality through participation in key evidence-based interventions [94]. There is some evidence of moderate quality that CHWs are effective in providing psychosocial support [114]. CHWs were effective in delivering psychosocial and educational interventions to reduce maternal depression [73]. Non-specialist providers (a classification that includes CHWs) may be effective in reducing perinatal depression [54].
 Immunization CHW programs increase the number of children whose vaccinations were up to date (moderate quality) [16]. There is evidence, but low quality or inconsistent, that CHWs can increase immunization coverage through promoting vaccination [16, 94, 118, 120] and providing vaccination themselves [16]. There is low-quality evidence that health professionals are confident that CHWs can deliver vaccines or other medicines using compact pre-filled auto-disposal devices [121].
 Contraception CHW interventions have been found to reduce unplanned repeat births among adolescents [110, 122] but there was no significant association detected in terms of repeated pregnancies [122]. CHWs were able to deliver injectable contraception safely and effectively, with high quality and with high levels of patient satisfaction [81, 123], and initiate their use (which involves screening women and counseling them on side effects), with no difference in the quality of counseling on side effects between CHWs and clinic-based providers [81]. Most (93%) studies indicated that CHW family planning programs increased the use of modern contraception and most (83%) reported an improvement in knowledge and attitudes concerning contraceptives [80]. CHWs can provide counseling on contraceptives, provide contraceptives, and refer to health facilities for more specialized care [80].
 Breastfeeding CHW interventions can be effective for increasing breastfeeding continuation [58, 69], attempts and duration [110], initiation, duration, and exclusivity [124]. The use of lay health workers, compared to usual healthcare services, probably increases breastfeeding [118] and there is some evidence of moderate quality that CHWs are effective in exclusive breastfeeding promotion [114]. CHWs in Brazil have demonstrated effectiveness in increasing the prevalence of breastfeeding [112] and delaying the introduction of bottle feeding [112].
Non-communicable diseases (NCDs)
 Diabetes There is weak evidence that CHW interventions improve knowledge of medication-label reading among diabetics [25]; improve self-management [60] (low strength of evidence) [25]; decrease glycaemia [60] (mixed evidence) [90] (modest reduction) [125]. There is no evidence that telephone interventions provided by lay and peer-support workers improve mental health or quality of life among diabetics [60]. For children with type 1 diabetes, CHWs improved glycemic control and decreased hospitalizations [56]. CHW capacity in addressing diabetes in LMICs was not reported in the systematic review literature.
 Cancer CHW interventions (peer support phone calls [69], home visits [110]) can be effective in increasing cancer screening rates [69, 99, 108, 110, 126]; knowledge about prostate cancer (but not screening) [110]; cancer screening (moderate evidence) [25]; planned use of cancer screening tests (mixed evidence) [25]; breast self-examination (mixed evidence) [25]. Only one non-systematic review [79] discussed the potential of CHW to address cancer in LMICs, and did not provide evidence on CHW capacity.
 Mental health CHW interventions can reduce depression [110] and stigma toward depression treatment (one study) [106], improve depression knowledge and efficacy to seek treatment [106], and produce beneficial changes in health status measures in many, but not all, studies [127]. CHW interventions in children with chronic conditions may lead to modest improvements in parental psychosocial outcomes [56] and parental quality of life [56]. CHW-led interventions can reduce the burden of mental, neurological and substance-use disorders, including depression and post-traumatic stress disorder among adults (evidence from 3 studies) [97]; and can also improve child mental health outcomes (evidence from four studies) [97]. Non-specialist providers, usually CHWs, are more effective than usual care or delayed treatment (waitlisted) groups in the provision of mental health treatments, generally for depression or post-traumatic stress [128]. Non-specialist health workers, which in this review [54] included both professionals (e.g., doctors, nurses, and social workers) and CHWs (22 of the 38 studies), compared with usual healthcare services, have some promising benefits in improving outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol-use disorders, and outcome for patients with dementia and their caretakers (evidence mostly of low or very low quality) [54].
 Asthma Peer-support telephone calls can be effective for increasing the number of asthma-free days [110] as well as the use of bedding encasements for asthma patients (moderate strength of evidence) [25]. While some CHW interventions for children with asthma decreased rapid breathing episodes, activity limitation, and asthma exacerbations, and increased the number of symptom-free days, results were inconsistent and risk of bias was often unclear [56]. Lay and peer interventions for adolescents with asthma could lead to small improvements in asthma-related quality of life (weak evidence) but there was insufficient evidence on asthma control, exacerbations and medication adherence [129]. CHW capacity in addressing asthma in LMICs was not reported in the systematic review literature.
 Other NCDs (chronic disease, hypertension) Peer-support telephone calls can be effective for diet change in post-myocardial infarction patients [69]. CHW interventions may improve chronic disease management among children (modest improvements in reduced urgent care use [56], decreased symptoms [56], and fewer missed work and school days [56]) and adults [108], including improvements in blood pressure among adults with hypertension [43, 99], in self-management behaviors (including appointment keeping and adherence to antihypertensive medications [43]), and in healthcare utilization (e.g., fewer emergency visits and an increased proportion of patients having a nurse or physician) [43]. CHW capacity in addressing other NCDs in LMICs was not reported in the systematic review literature.
Infectious diseases
 HIV Task shifting to CHWs may enhance emotional support and increase retention in care, and better link people with HIV to care (one qualitative study) [39, 95, 96]. Task shifting from higher-level providers and clinic-based care to CHWs was generally acceptable to individuals living with HIV [39, 95]. This may enhance dignity and quality of life [50] and increase retention in care [50, 95], without decreasing the quality of care [52] or patient outcomes (such as virologic failure and mortality) [50, 53, 107]. Task shifting and community-based outreach involving CHWs effectively links people living with HIV to care [96].
 Malaria CHW capacity in addressing malaria in HICs was not reported in the systematic review literature. There is some evidence of moderate quality that CHWs are effective in malaria prevention [35, 114]. CHWs can perform rapid diagnostic tests with high sensitivity and specificity, and display high levels of adherence to treatment guidelines [21, 33, 61, 76, 86]. There was insufficient research to enable an effect on morbidity or mortality to be estimated [21].
 Other infections Home visits from CHW can be effective in increasing hepatitis B testing [110] and increasing hepatitis B virus testing uptake (moderate quality evidence) [109]. CHW interventions have helped decrease the incidence of tuberculosis [35] and contributed to the control of neglected tropical diseases [130]. They can support the control of Buruli ulcer in sub-Saharan Africa [47]. CHWs probably increase the number of people with tuberculosis who are cured, though they do not appear to affect the number of people who complete preventive therapy [118].
  1. Lassi et al. [93] included 26 studies on community-based interventions for maternal health, of which only one was from a HIC (Greece). Chapman et al. [124] included 26 studies on breastfeeding, of which only one was from an LMIC (Mexico). Raphael et al. [56] included 17 studies on pediatric chronic disease, of which all appear to be from the USA although this is not specified. Kew et al. [129] included five studies on adolescent asthma, of which three were from HICs, while the remaining two were from Jordan. Costa et al. [98] included 26 studies on physical activity promotion, of which only one was from an LMIC (Brazil)