Background
Methods
Conceptual framework
Key Definitions CHW: Any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or degree in tertiary education (page 7 [13]). Equitable CHW programme: CHW services contribute towards eliminating unnecessary and avoidable differences in health, where the whole population has equal access to CHW services with appropriate uptake of referral to health facility according to need, utilisation of CHW services according to need and equal quality of CHW services for all [4] contributing towards community empowerment to tackle underlying social determinants of health, so that everyone can attain their full health potential. Access to CHW services: The delivery of community health services in a timely manner within the client’s home or community, including coverage of services. Utilisation of CHW services: The acceptance and use of community health services provided by CHW either within the home or a local village health post. Uptake of referral: The acceptance and use of services provided at a health facility following referral by a CHW. Quality of CHW services: The delivery of community health services by a CHW which adhere to an evidence base resulting in improved health outcomes in an efficient manner, with optimal safety for clients and which take into account client preferences and aspirations [64]. Community empowerment: Both individuals and communities are involved in active participation in community health activities by building capacity and confidence in order to address and tackle power and control over their lives [69]. |
Definitions and search strategy
Selection Criteria
Data extraction and quality assessment
Data synthesis
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Pro-equity = improvement in outcome for vulnerable groups (vulnerable groups based upon PROGRESS plus criteria) compared with the general population / no difference in the outcome between vulnerable groups and the rest of the population
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Anti-equity = vulnerable groups have lower/ deteriorating outcomes compared with general population as a consequence of the CHW programme
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Mixed equity = some improvement in an outcome for a vulnerable group but inequities still persist.
Results
What evidence is there of (in)equity in CHW programmes?
Article and Country | Type of CHW | CHW intervention | Study design and overall quality | Equity Stratifier |
---|---|---|---|---|
(Atkinson & Haran, 2005); Brazil | Community Health Worker | Comprehensive family health programme, including CHW component (not well explained) | Cross-sectional household survey; High | Quality – Place of residence - |
(Baqui et al., 2009); Bangladesh | Community Health Worker | Maternal and Neonatal health programme with CHW treatment for neonatal infections in intervention areas | Cluster randomised controlled trial; High | Access – Socio-economic status (SES) + |
Utilisation – SES + | ||||
Utilisation – Education + | ||||
(Baqui et al., 2008); India | Community Health Worker | NGO facilitation of government Maternal and child health programme | Controlled before and after study; High | Empowerment – SES + |
(Bell, Go, Miguel, Parks, & Bryan, 2005); Philippines | Village health worker | Malaria control and case management, community education and bednet distribution | Cross-sectional household survey (including villages with and without resident VHW); Medium | Access - Place of residence - |
Access – Education – | ||||
Access – SES- | ||||
Utilisation – Place of residence – | ||||
Utilisation – Gender + | ||||
Utilisation – Education + | ||||
Utilisation – Social capital - | ||||
(Callaghan-Koru et al., 2013); Malawi | Health Surveillance Assistant | Maternal and newborn health programme, including antenatal and postnatal home visits by HSA | Before and after study, with no comparison; High | Access – SES - |
Utilisation – SES ? | ||||
Empowerment – SES + | ||||
(Dalal et al., 2013) Kenya | Counsellor | Home Based Testing and Counselling Programme | Longitudinal study; Medium | Utilisation – Gender - |
Utilisation – Age + | ||||
Utilisation – Place of residence - | ||||
(DasGupta, Mansuri, Nistha, & Vishwanath, 2007) Pakistan | Lady health worker | Maternal and neonatal health programme offering health and family planning services | Cross-sectional study (used data from Pakistan Integrated Household Survey); Low | Access – Education - |
Utilisation – Gender + | ||||
Utilisation – Education + | ||||
(Fort, Grembowski, Heagerty, Lim, & Mercer, 2012) Guatemala | Community Nurse Auxilliary | Comprehensive family health programme | Longitudinal prospective cohort; Medium | Utilisation – Language + |
Utilisation- Education ? | ||||
Utilisation – Place of residence - | ||||
Utilisation – risk + | ||||
Utilisation – SES + | ||||
Utilisation – Age | ||||
Utilisation – Religion – | ||||
Utilisation – Family type – | ||||
Utilisation – Occupation + | ||||
Quality – Age - | ||||
Quality – Language + | ||||
Quality – Education + | ||||
(Fylkesnes et al., 2013); Zambia | Counsellor | Home Based Testing and Counselling programme | Cluster randomised controlled trial; High | Utilisation – Education + |
Utilisation – Gender + | ||||
Utilisation – Age + | ||||
(Hasegawa, Yasuoka, Ly, Nguon, & Jimba, 2013); Cambodia | Village malaria worker | Child health programme providing malaria case management and child health services | Cross-sectional study; High | Utilisation – Place of residence + |
(- those over 25 km away) | ||||
Utilisation – SES + | ||||
Utilisation – Education + | ||||
Utilisation – Age + | ||||
Utilisation – Occupation + | ||||
(Helleringer, Kohler, Frimpong, & Mkandawire, 2009); Malawi | Counsellor | Home Based Testing and Counselling survey | Cross-sectional study; Medium | Utilisation – SES + |
Utilisation – Age + | ||||
Utilisation – Gender - | ||||
Utilisation – Marital status - | ||||
Utilisation – Education - | ||||
(Hossain, Khuda, & Phillips, 2004) Bangladesh | Female Welfare Assistant | Family Planning programme | Retrospective re-analysis of longitudinal data; Low | Access – Place of residence – Quality- |
(Kamiya, Yoshimura, & Islam, 2013) Bangladesh | Family Welfare Volunteer | Maternal and neonatal health programme, including community mobilisation through community support groups | Controlled, non-randomised before and after study; High | Utilisation - SES + (non CHW-) |
Self Help Group | ||||
(Katabarwa et al., 2010); Uganda | Community distributors | Onchocerciasis control using kinship enhanced delivery model | Controlled cross-sectional study (kinship vs non-kinship); High | Access – Social capital - |
Quality – Social capital – | ||||
Empowerment – Social capital + | ||||
(Kisia et al., 2012) Kenya | Community Health Worker | Malaria case management for children under 5 years | Before and after study, no comparison; High | Utilisation – SES + |
Utilisation – Education + | ||||
Utilisation – Village size - | ||||
Utilisation – Age + | ||||
Utilisation – Household size + | ||||
(Littrell, Moukam, Libite, Youmba, & Baugh, 2013) Cameroon | Community Health Worker | Community Case Management for children under 5 years | Quasi-experimental study, with comparison group; High | Utilisation – SES + |
(Matovu et al., 2005); Uganda | Counsellor | Home Based Testing and Counselling survey | Cross-sectional survey; Medium | Utilisation – Age + |
Utilisation – Education + | ||||
Utilisation - Gender + | ||||
Utilisation – Marital status + | ||||
(Anthony K Mbonye, Bygbjerg, & Magnussen, 2007); Ugandaa
| Mixed | Intermittent presumptive treatment malaria in pregnancy provided by a range of community based providers | Before after with comparison | Utilisation – Age |
Qualitative study; High | Utilisation – Place of residence | |||
Utilisation – Education + | ||||
(A K Mbonye, Schultz Hansen, Bygbjerg, & Magnussen, 2008) Uganda a
| Mixed | Intermittent presumptive treatment malaria in pregnancy | Before after with comparison; Medium | Utilisation – Age - |
Utilisation – Education + | ||||
Utilisation – Occupation + | ||||
Utilisation – Place of residence + | ||||
Utilisation – Marital status + | ||||
(Mukanga et al., 2012); Uganda | Community Health Worker | Community Case Management for pneumonia and fever | Cross-sectional survey; High | Access – Place of residence + |
Utilisation – Place of residence + | ||||
Utilisation - Education - + | ||||
Utilisation – SES + | ||||
Utilisation – Occupation + | ||||
(Mulogo, Abdulaziz, Guerra, & Baine, 2011) Uganda | Counsellor | Home Based Testing and Counselling | Longitudinal study with cross sectional and investigative phases; High | Utilisation – Gender – |
Utilisation – Education + | ||||
Utilisation – Place of residence + | ||||
Utilisation – Marital status – | ||||
Utilisation – SES - | ||||
(Mumtaz et al., 2013); Pakistan | Lady health worker | Maternal and child health programme providing door step family planning, antenatal and child health services | Cross-sectional study | Access – Social capital - |
Qualitative study; High | Access – SES + | |||
Quality – Social capital - | ||||
(Mutale, Michelo, Jürgensen, & Fylkesnes, 2010) Zambia | Counsellor | Home Based Testing and Counselling | Cross-sectional study; Medium | Utilisation – Place of residence + |
Utilisation – Gender + | ||||
Utilisation – Education + | ||||
Access – Age + | ||||
(Naik, Tabana, Doherty, Zembe, & Jackson, 2012); South Africa | Counsellor | Home Based Testing and Counselling | Cluster randomised trial with comparison, comparing home based HTC with facility based; High | Utilisation – Gender - |
Utilisation – Age + | ||||
(Nsungwa-Sabiiti et al., 2007); Uganda | Drug distributor | Malaria case management and malaria counselling | Quasi-experimental before after study with comparison group; Medium | Utilisation – SES - |
Utilisation –Gender + | ||||
Utilisation – Education + | ||||
(Onwujekwe, Ojukwu, Shu, & Uzochukwu, 2007) Nigeria | Community Health Worker | Malaria case management | Before after study, no comparison; Medium | Access – SES – |
Access – Number household residents – | ||||
Access – Age - | ||||
Utilisation – SES - | ||||
Quality – SES - | ||||
(Perry, King-Schultz, Aftab, & Bryant, 2007); Haiti | Animatrice | General health programme involving household peer to peer education | Cross-sectional study | Access – Place of residence – |
Matrons | Exit interview; Low | |||
Health Agents | ||||
Monitrices | ||||
(Quayyum et al., 2013); Bangladesh | Shasthaya Shebika Shasthya Kormi | Maternal and neonatal health programme providing maternal health services and education at home | Quasi-experimental, before after study with comparison area; High | Utilisation – SES + (non CHW +/-) |
Newborn Health workers | ||||
(Quinley & Govindasamy, 2007); Nepal | Female Community Health Volunteer | Child health (no details provided) | Cross-sectional study (additional analysis of Demographic Health Survey data); Low | Utilisation – SES - |
Utilisation – Place of residence + | ||||
(Siekmans et al., 2013); Kenya | Community Health Worker | Malaria case management for under fives | Before after study, no comparison area; High | Access – SES + |
Utilisation – SES + | ||||
Empowerment – SES + | ||||
(D. O. Simba, 2005) Tanzania b
| Community based distributor | Family Planning provision of contraceptives and information of sexual and reproductive health | Descriptive cross-sectional study; Medium | Utilisation – Age - |
Utilisation – Occupation + | ||||
Utilisation - Gender + | ||||
Utilisation – Religion + | ||||
Utilisation – SES + | ||||
Quality – SES – | ||||
Empowerment – SES + | ||||
(D. Simba, Schuemer, Forrester, & Hiza, 2011); Tanzaniab
| Community Based Agent | Family Planning provision of contraceptives and information of sexual and reproductive health | Cross-sectional descriptive study; Low | Utilisation – Place of residence + |
Quality – SES + | ||||
(Wolff et al., 2005) Uganda | Counsellor | Home Based Testing and Counselling | Repeated cross-sectional study | Utilisation – Age + |
Qualitative study; Medium | Utilisation – Gender + | |||
(Wringe et al., 2008); Tanzania | Counsellor | Voluntary Counselling and Testing offered at purpose built hut following household questionnaire | Repeated cross-sectional study; High | Utilisation – Gender - |
Utilisation – Education - | ||||
Utilisation – Religion - | ||||
Utilisation – Race - | ||||
Utilisation – Place of residence – | ||||
Utilisation – Age - |
What influences how equitable CHW programmes are in terms of access, utilisation, quality and community empowerment?
Barrier | How CHW intervention can overcome barrier | Equity considerations for CHW programme planners |
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Supply side (CHW services)
| ||
Low number of health workers in hard-to-reach areas | Local recruitment of CHWs, including recruitment of CHWs from marginalised groups | Ensure CHWs are recruited locally, not centrally |
Consider options to include illiterate CHWs in areas where education levels are low | ||
Ensure CHW selection reflects community – inclusion of CHWs from marginalised groups | ||
Time taken to reach service location | Provision of services within the client’s home | CHW intervention planning to consider geographic features – reduced household numbers per CHW where households are far apart/ difficult terrain |
Cost of services | Free service provision | Payment for services can continue to present a barrier to service use, even if CHW services are provided within the home |
Demand side (CHW services)
| ||
Demand for services and information about health care | Developing improved client knowledge about CHW role as health care providers through home visits, sensitisation meetings and community mobilisation | Consider comprehensive package of services, rather than single disease specific intervention |
Weak sensitisation and community mobilisation around CHW intervention can lead to limited demand for services | ||
Consider alternative approaches for certain groups – e.g. HTC provision by a non-resident CHW for youth and work based HTC (rather than home based) for migrant men | ||
Waiting time for services, indirect costs (transport), opportunity costs | Provision of curative services and provision of HTC within the home | Ensure strong supply chain for commodities to all CHWs |
Need for supportive supervision | ||
Need for strong referral links between community and health facility | ||
Education | Reducing the knowledge/ behaviour gap between richest and poorest community members through one-to-one and group education | Need to plan for behaviour change communication within CHW programme design |
Household expectations and community and cultural preferences | Provision of services within the home in cultural contexts where women are reluctant to seek care outside their home. | Need for consideration of existing social relationships between clients and CHW |
Demand side (Health facility services)
| ||
Demand for services and information about health care | CHW led demand creation strategies, community engagement and action planning | Consider the package of services provided at community level and whether this could reduce use of services by skilled provider at health facility (e.g. ANC) |
CHW training in problem solving | ||
Use of a household risk assessment by CHW to ensure high risk households receive more frequent home visits to advise about for clinic attendance | ||
Waiting time for services, indirect costs (transport), opportunity costs | Reimbursement for transportation | Transport and opportunity costs will still exist, even where community is empowered and so community funds/ transport refunds are useful tools to overcome this barrier |
Community funds | ||
Education | Reducing the influence of education on health facility service utilisation among those with limited formal education through one-to-one and group education | Failure to develop community empowerment through support groups may hinder use of services at health facility level |
Household expectations and community and cultural preferences | CHW accompaniment during referrals | Consider incentive for CHW to refer and accompany clients to health facility |