Factors influencing the performance of community health volunteers working within urban informal settlements in low- and middle-income countries: a qualitative meta-synthesis review

Populations living in urban informal settlements are often characterized by rapid population growth [1], a high burden of disease [2, 3] and limited access to healthcare [4‐6]. To increase healthcare access to such underserved populations and with renewed calls for universal health coverage (UHC), governments have rolled out various community health programmes using Community Health Volunteers (CHVs) as a link between the formal healthcare system and the community [7]. This cadre of workers are referred to using differing terms depending on context such as Community Health Workers (CHWs), Accredited Social Health Activists (ASHAs), CHVs, lay health workers, etc., but for this paper we will be using the term CHV to broadly refer to them. In this study, a CHV is one who is involved in health service delivery with limited training necessary for the implementation of the different primary healthcare interventions [7].

In some countries such as Bangladesh and India [8, 9], CHVs are paid while in others such as Kenya they are not [9]. Studies show that the success of such programmes depends on programme design factors (features of the programme or intervention such as renumeration, recruitment, supervision, workload); health system factors (such as health system financing and governance) and broad contextual factors (for instance gender roles, norms, cultural practices and legislation) surrounding the workings of such programmes [10‐12].

Several reviews have examined factors that influence the performance of CHVs in LMICs [7, 12‐16]. Nonetheless, the majority of these have focused on rural areas [17]; with less attention paid to CHVs working in urban or peri-urban informal settlements [18]. Literature shows that context matters when it comes to the performance of CHVs. In particular, contextual factors related to the community, economy, environment and health system policy and practice can interact to shape CHV performance [19]. It is, therefore, important to have specific understanding of factors influencing CHV performance in urban contexts. In this study, an urban area was defined as, “a city or town with a high population density and built up features compared to the surrounding areas” (p. 3) [20]. A peri-urban area was defined as, “an area that borders an urban area, between the suburbs and the countryside” (p. 3) [20]. Whereas an informal settlement was defined as, “a residential area where the inhabitants had no security of tenure for their lands or dwellings”, lacked “basic services and city infrastructure, and their housing did not comply with the planning and building regulations” in addition to “being situated in geographically and environmentally sensitive locations” (p. 30) [20].

The current review explored the implementation dynamics including the challenges and successes of CHV-programmes within urban informal settlements, with a focus on CHV performance at individual level. Measurable elements at this level included the behavioural, affective, and cognitive changes in the individual CHV such as self-esteem, motivation, attitudes, competencies, job satisfaction and adherence with standards and procedures [10].

The objective of this study was therefore to identify programme design and contextual factors (broader and health system factors) that influence the performance of CHVs working within urban informal settlements in LMICs. The study adopted a qualitative approach for the review since qualitative approaches are well-suited in analysing human experiences, cultural and social phenomena [21]. Purely qualitative studies plus mixed methods studies that used qualitative methods for data collection and analysis were included.

This systematic review adapted a qualitative meta-synthesis type of review using meta-aggregation technique of data synthesis and reporting [22].

This section begins by presenting an overview of the screening results followed by a description of the findings of the systematic review organized into broad thematic areas (programme design factors and broad contextual factors). The sub-themes identified under the programme design factors included financial and non-financial incentives, training, supplies and resources, health system linkage, family support, supportive supervision, and CHV characteristics. While the sub-themes identified under the broad contextual factors included both the community and economic contextual factors. Each of these are discussed in turn below.

This is one of the few reviews that have documented factors that influence the individual-level performance of CHVs working within urban and peri-urban informal settlements in LMICs. Key factors found to influence the performance of CHVs working in these settings included: financial and non-financial incentives; training; the availability of supplies and resources; relationship between the CHVs and other healthcare workers; relationship between CHVs and their families; availability of supportive supervision; personal safety issues and demand for material and economic support by households at the community level. All these factors have been reported amongst CHVs working in the rural setting [17] except those to do with the broader context. These include insecurity (personal safety of CHVs) and the demand for material and economic support by households, which were reported in this review to be predominant amongst CHVs working in urban and peri urban informal settlements.

From the review, CHVs working in urban informal settlements mainly depended on CHV work to financially care for their families [9, 36, 40, 41, 43, 44]. As a result of this dependence, CHVs dropped out of programmes with no financial incentives in preference of personal income generating activities [43]. This finding supports previous reviews by Bhutta et al., (2010) [14], Lehmann & Sanders (2007) [7] and Kok et al., (2014) [10]. According to Bhutta et al., and Lehmann & Sanders’ reviews both conducted in LMIC settings, CHVs were mostly poor people living in low-income communities; and as such could not overlook opportunities to earn an income for voluntary work. Consequently, they were easily demotivated when a programme did not offer financial incentives and dropped out of CHV programmes. To control for such attrition, Bhutta et al. recommended regular, performance based financing incentives or hiring CHVs as full-time waged employees, rather than as part time volunteers [14]. Nonetheless, given the significant resource constraints and system challenges experienced in LMICs, sustainability of such monetary incentives are bound to face challenges due to insufficient funding or irregular payments [7]. Furthermore, evidence from literature suggests that approaches like performance based incentives sometimes resulted in neglect of unpaid tasks [10], or over-reporting of tasks by CHVs [49]. Therefore, for such motivational incentives to work, there is a need for a mix of both financial and non-financial incentives taking context into account, given the high cost of living in the urban settings.

Non-monetary incentives such as community trust, respect, appreciation, and acknowledgment were noted to be important to the success of CHV programmes. In this review, they brought a sense of job satisfaction, respect, self-identity and status to the CHVs [9, 36, 38, 40, 46]. This finding mirrors that of Glenton et al., (2013) [27]. In their review, CHVs especially those from LMICs were motivated by the respect and social status that they received from their own homes and communities. The social recognition accorded to the CHVs was because of their training, moral standing as ‘good-hearted volunteers’ and social importance. This implies that CHV programmes can build on these non-financial incentives and intrinsic motivators to strengthen CHV programmes and ensure their success and continuity.

As in this review, Glenton et al., and Sarma et al., also found that some CHVs hoped that the community role would lead to future employment [50] or further education [27]. To maintain these incentives in the community, there is need to strengthen the community’s trust in the CHVs and CHV programmes in general. This can partly be achieved by having good, visible relationships between the CHVs and the formal healthcare system [27]. Such good working relationships include visits from supervisors, visible contact with health professionals, making referrals to health facilities and accompanying programme recipients to referral facilities [51‐54].

Training increased CHVs’ knowledge and awareness levels on the different aspects of their roles thus giving them more confidence and credibility to carry out their work in the community. This finding supports previous works by Glenton et al., [16], Jaskiewicz et al.,[15], Bhutta et al.,[14], Kane et al. [13], and Lehmann & Sanders [7]. In these reviews, training complemented by practical skills improved CHVs’ knowledge and performance. Nonetheless, in a Kenyan study, it was found that CHVs working in both urban and peri-urban informal settlements who received training from NGOs focused on task-specific knowledge and as such lacked uniformity in approaches, content and length despite all the CHVs working in the same setting [43]. This difference in training amongst CHVs in the same setting resulted in knowledge gaps for some CHVs, on some of their roles. This could in turn negatively impact on their credibility given the difference in competency levels. Thus adversely impacting on their abilities to deliver on existing tasks [55]. There is, therefore, a need for more integrated training programmes that cover a wide range of tasks, and that draw on existing national CHWs training manuals.

CHVs lost their credibility as a result of low/no supplies in health facilities [36]. This finding mirrors that of Jaskiewicz et al., and Sarma et al., [15, 50]. In the review by Jaskiewicz et al., CHVs lost the respect of the community because of the disruption in hospital supplies, medicines, and equipment. According to both Sarma et al., and Jaskiewicz et al., CHVs need the trust of the community and whenever that trust is compromised, CHVs become ineffective [15, 50]. Additionally, exposure to risks due to lack of personal protective equipment and loss of identity due to lack of branded clothing or badges [42, 43] and job aids [37] also impacted on the CHVs’ level of performance. This finding concurs with studies by Jaskiewicz et al., [15], Sunguya et al., [56] and Scott et al., [17]. In these studies, regular supply of required resources was needed to ensure that CHVs were effective in their roles and were trusted and respected by their respective communities.

Lack of acknowledgment and recognition by formal healthcare staff demotivated CHVs [36, 44, 46]. According to Lehmann & Sanders and Glenton et al., the relationship between CHVs and the formal health workers is dependent on how CHV programmes are introduced to the different stakeholders [7, 27]. In case they are introduced without proper engagement or involvement of the different stakeholders, then there are bound to experience some resistance [57]. For instance, a study by Woodgate (2007) showed that health professionals viewed CHVs as an extra workload, whereas others saw them as a threat to their authority. This in turn made healthcare workers have a negative attitude towards CHVs [57, 58]. According to Kok et al., negative attitudes between formal healthcare workers and CHVs resulted in communication challenges between the two groups, and adversely affected the community-health facility referral process [12]. There is therefore a need for all relevant stakeholders to be engaged when introducing CHV programmes at the primary healthcare level. During engagement, there is a need for proper briefing. Programmes should also have appropriate communication systems in place to ensure smooth transfer of information at all levels of the health system. It is important to note that the closer the collaboration between CHVs and formal healthcare workers, the better the working relationship [27].

Family support of the role played by a CHV was found to be critical for the success of any CHV programme. Disapproval of any CHV by the family led to CHV dropout [9, 36, 40]. This finding supports that by Kok et al., [12]. In their 2015 review, it was reported that husbands, mothers-in-law and grandmothers were the primary family decision-makers. As such CHVs, who were mostly married women, had to consult the relevant ‘family authority’ before making any decisions. This finding also concurs with the review by Lehmann & Sanders, and two other studies from Bangladesh, which found that for CHVs to be accepted in their communities, the roles played had to respond to the local, cultural and societal norms and customs [7, 50, 59]. This implies that to improve the CHVs performance, there is need to sensitize local community leaders including family heads on the role of CHVs to elicit their buy-in.

In the present review, support from supervisors and other formal health workers was reported to be an important source of motivation for CHVs working in urban informal settlements. The review by Glenton et al., reported similar findings in which CHV credibility in the community was strengthened by their connection to the formal health system [27]. Other authors have also demonstrated that lack of visible support from the health system weakened the CHVs’ credibility, thus negatively impacting on community trust [60].

CHV individual characteristics did not emerge strongly as a key theme in the reviewed papers, except for studies from India and Bangladesh [9, 36, 40]. It is unclear why this was the case. However, one potential reason could be that study authors did not deliberately inquire on the influence of such characteristics in the role of CHVs and the subsequent impact on performance. According to Kok et al., one of the CHVs’ characteristics with a positive influence on CHV performance was the CHVs’ prior experience with the health condition that they focused on. The age of a CHV had mixed effects on CHV performance [12]. It was also noted to be an important predictor by Sarma et al. although not always [50].

Personal safety at the community level was noted to be of concern to CHVs who lived and worked in dangerous neighbourhoods with high criminal activities such as prostitution, drug use and violence. Personal safety of CHVs was especially of concern when they had to work late into the evenings. This finding supports that of Glenton et al., which noted that safety was of concern amongst CHVs working in urban settings, as a result of poverty-related and social problems such as violence and drug use [27].

Specifically, in Kenyan urban and peri-urban informal settlements, the community expected ‘tangible support’ such as monetary aid from CHVs. As such, out of sympathy, some CHVs dipped into their own pockets to provide this support. This was to increase their acceptance in the community. Those CHVs who were not able to meet the households’ demand lost favour with the community thus causing them to dropout. To our knowledge, this finding has not been discussed elsewhere in the literature and should be interrogated in other LMICs.

Only studies published in English were included in this review due to time and resource constraints. This resulted in exclusion of studies from some regions such as Latin America. This might have contributed to the low number of studies recorded. Nonetheless, the low numbers were indicative of a need for more in-depth qualitative studies, on factors that influence the performance of CHVs working in urban informal settlements.

Despite the above limitations, this review used an expert medical librarian in designing the search string. In addition, the review used three reviewers to standardize the data extraction process as well as the CASP, MMAST and CERQual approaches to assess for the quality and confidence of the review findings.

This systematic synthesis of evidence highlights the programme design factors and broader contextual factors that CHV programmes being implemented in urban informal settlements should take into consideration to ensure success. These include adequate remuneration of CHVs; integrated and holistic training; supportive supervision; positive family support; appropriate health system linkages including adequate resources and supplies; personal safety issues; and community expectations such as the need for fiscal support to community households.