Lay health workers in primary and community health care: A systematic review of trials pdf

Lay health workers in primary and community

health care: A systematic review of trials

Lewin SA, Babigumira SM, Bosch-Capblanch X, Aja G, van Wyk B, Glenton C, Scheel I,

Zwarenstein M, Daniels K

November 2006

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Author affiliations

Simon A Lewin MBChB PhD, Specialist Scientist, Health Systems Research Unit, Medical

Research Council of South Africa, Cape Town, South Africa and Senior Lecturer, Department

of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK

Susan M Babigumira MD, Researcher, Norwegian Knowledge Centre for the Health Serv￾ices, Oslo, Norway

Xavier Bosch-Capblanch MD MSc, Public Health specialist. Honorary Lecturer, Liverpool

School of Tropical Medicine, Liverpool, UK

Godwin Aja MCH, Associate Professor, Babcock University, Ilishan-Remo, Nigeria

Brian van Wyk DPhil, Lecturer, School of Public Health, University of the Western Cape,

Cape Town, South Africa

Claire Glenton PhD, Researcher, Norwegian Knowledge Centre for Health Services, Oslo,

Norway

Inger Scheel PhD, SINTEF Health Research, Oslo, Norway

Merrick Zwarenstein MBBCh MSc, Principal Investigator, Knowledge Translation Program

and Senior Scientist, Institute for Clinical Evaluative Sciences, University of Toronto, To￾ronto, Canada

Karen Daniels MPH, Researcher, Health Systems Research Unit, Medical Research Council

of South Africa, Cape Town, South Africa

Acknowledgements

Our thanks to the contact editor, Andy Oxman, for his support and advice; to Marit Jo￾hansen for assistance with designing and running the database search strategies; to Jan

Odgaard-Jensen for statistical guidance; to Meetali Kakad and Elizabeth Paulsen for their

assistance regarding inclusion assessments; and to the staff at the Cochrane EPOC Review

Group base for their valuable feedback. Two peer reviewers also provided helpful feedback.

Funding

The Norwegian Agency for Development Cooperation (NORAD), through support for pre￾paration for the International Dialogue on Evidence-informed Action to Achieve Health

goals in developing countries (IDEAHealth); The Medical Research Council, South Africa.

Competing interests

None known. Author affiliations are listed above.

Address for correspondence

Dr Simon Lewin

Department of Public Health and Policy

London School of Hygiene and Tropical Medicine

Keppel Street

London WC1E 7HT, UK

E-mail: [email protected]

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Table of Contents

ABSTRACT 3

1. BACKGROUND 5

2. OBJECTIVE 7

3. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW 8

4. SEARCH METHODS FOR IDENTIFICATION OF STUDIES 11

5. METHODS OF THE REVIEW 13

6. DESCRIPTION OF STUDIES 16

7. METHODOLOGICAL QUALITY 20

8. RESULTS 21

9. DISCUSSION 31

10. CONCLUSIONS 37

REFERENCES 38

APPENDIX I: SEARCH STRATEGY FOR MEDLINE 44

APPENDIX II: QUORUM FLOW CHART 46

APPENDIX III: META-ANALYSIS – FOREST PLOTS 47

APPENDIX IV: GRADE EVIDENCE PROFILE TABLES 52

APPENDIX V: METHODOLOGICAL QUALITY SUMMARY SCORES FOR

ALL INCLUDED STUDIES 56

APPENDIX VI: SUMMARY TABLES OF INCLUDED STUDIES 57

APPENDIX VII: SUMMARY TABLES OF OUTCOMES FOR STUDIES

NOT INCLUDED IN META-ANALYSIS SUBGROUPS 63

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Abstract

Background

Increasing interest has been shown in the use of lay health workers (LHWs) for the deliv￾ery of a wide range of maternal and child health (MCH) services in low and middle in￾come countries (LMICs). However, robust evidence of the effects of LHW interventions in

improving MCH delivery is limited.

Objective

To review evidence from randomized controlled trials (RCTs) on the effects of LHW inter￾ventions in improving MCH and addressing key high burden diseases in LMICs.

Methods

Search strategy: multiple databases and reference lists of articles were searched for RCTs

of LHW interventions in MCH. RCTs identified in an earlier systematic review were in￾cluded in this report where appropriate.

Selection criteria: a LHW was defined by the authors of this report as a health worker de￾livering health care, who is trained in the context of the intervention but has no formal

professional certificate or tertiary education degree. RCTs were included of any interven￾tion delivered by LHWs (paid or voluntary) in primary or community health care and

intended to promote health, manage illness or provide support to patients. Interventions

needed to be relevant to MCH and/or high burden diseases in LMICs. No restrictions were

placed on the types of consumers.

Data collection and analysis: data were extracted for each study and study quality as￾sessed. Studies comparing broadly similar types of interventions were grouped together.

Where feasible, the results of the included studies were combined and an estimate of ef￾fect obtained.

Results

48 studies met the review’s inclusion criteria. There was evidence of moderate to high

quality of the effectiveness of LHWs in improving immunisation uptake in children (RR

1.22, p = 0.0004); and in reducing childhood morbidity (RR 0.81, p = 0.001) and mortality

(RR 0.74, p = 0.04) from common illnesses, compared with usual care. LHWs are also effec-

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tive in promoting exclusive breastfeeding up to six months of age in LMICs (RR 3.67, p =

0.001, evidence of moderate quality), and had some effect on promoting any breastfeed￾ing (RR 1.22, p = 0.02) and exclusive breastfeeding up to six months (RR 1.5, p=0.04) in

high income countries. However, this evidence was of low quality. LHWs appear to be

effective in improving TB treatment outcomes compared with institution-based directly

observed therapy (RR 1.21, p = 0.05, evidence of moderate quality). Evidence related to

the effects of using LHWs for other health interventions is unclear.

Conclusions

The use of LHWs in health programmes shows promising benefits, compared to usual

care, in promoting immunization and breastfeeding uptake; in reducing mortality and

morbidity from common childhood illnesses; and in improving TB treatment outcomes.

Little evidence is available regarding the effectiveness of substituting LHWs for health

professionals or the effectiveness of alternative training strategies for LHWs.

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1. Background

Lay health workers (LHWs) perform diverse functions related to health care delivery. Whi￾le LHWs are usually provided with informal job-related training, they have no formal

professional or paraprofessional tertiary education, and can be involved in either paid or

voluntary care. The term ‘LHW’ is thus necessarily broad in scope and includes, for ex￾ample, community health workers, village health workers, cancer supporters and birth

attendants.

In the 1970s the initiation and rapid expansion of LHW programmes in low and middle

income settings was stimulated by the primary health care approach adopted by the

WHO at Alma-Ata (Walt 1990). However, the effectiveness and cost of such programmes

came to be questioned in the following decade, particularly at a national level in devel￾oping countries. Several evaluations were conducted (Walt 1990; Frankel 1992) but most

of these were uncontrolled case studies that could not produce robust assessments of

effectiveness. The 1990s saw further interest in community or LHW programmes in low

and middle income countries (LMICs). This was prompted by the AIDS epidemic; the re￾surgence of other infectious diseases; and the failure of the formal health system to pro￾vide adequate care for people with chronic illnesses (Maher 1999; Hadley 2000). The

growing emphasis on decentralisation and partnership with community based organisa￾tions also contributed to this renewed interest.

In industrialised settings, a perceived need for mechanisms to deliver health care to mi￾nority communities and to support consumers for a wide range of health issues (Witmer

1995) led to further growth in a wide range of LHW interventions.

More recently, growing concern regarding the human resource crisis in health care in

many LMICs has renewed interest in the roles that LHWs may play in extending services

to ‘hard to reach’ groups and areas and in substituting for health professionals for a

range of tasks (WHO Task Force on Health Systems Research 2005). This cadre of health

workers, as Chen (2004) and Filippi (2006) suggest, may be able to play an important role

in achieving the Millennium Development Goals for health

The growth of interest in LHW programmes, however, has generally occurred in the ab￾sence of robust evidence of their effects. Given that these interventions have consider-

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able direct and indirect costs, such evidence is needed to ensure they do more good than

harm.

In 2005, Lewin published a Cochrane systematic review examining the global evidence

from randomised controlled trials (RCTs) published up to 2001 on the effects of LHW in￾terventions in primary and community health care (Lewin, 2005). This review indicated

promising benefits, in comparison with usual care, for LHW interventions for immunisa￾tion promotion; improving outcomes for selected infectious diseases; and for breastfeed￾ing promotion. For other health issues, the review suggested that the outcomes were too

diverse to allow statistical pooling.

This document updates the 2005 systematic review, focusing on the effects of LHW in￾terventions in improving maternal and child health (MCH) and in addressing key high

burden diseases such as tuberculosis (TB). To our knowledge, this constitutes the only

global systematic review of rigorous evidence of the effects of LHW interventions.

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2. Objective

To review evidence from randomized controlled trials (RCTs) on the effects of LHW inter￾ventions in improving MCH and in addressing key high burden diseases in LMICs.