Lay health workers in primary care and community prevention
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
We address the following question:
Are lay health workers effective in improving the delivery of health care and health care outcomes?
With regard this question, we address the following comparisons:
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A. LHW interventions compared to no intervention.
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LHW interventions involving activities not currently being carried out by health professionals and delegated to LHWs compared to no intervention.
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LHW interventions involving activities not currently being carried out adequately by health professionals and delegated to LHWs compared to no intervention.
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LHW interventions involving activities currently being carried out by health professionals but delegated to LHWs to reduce resource consumption compared to the same activities being carried out by health professionals.
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The effectiveness of the lay health worker intervention related to intensity of training.
Background
The 1970s saw the initiation and rapid expansion of community health worker (CHW) programmes at country and local levels, stimulated by the primary health care approach adopted at Alma‐Ata (Walt 1990). By the mid‐1980s, however, questions were being raised regarding their effectiveness and cost, particularly at a national level, resulting in a number of evaluations (Walt 1990; Frankel 1992). Most of these evaluations, while useful, were uncontrolled case studies making measurement of intervention effects difficult due to the usual problems of selection bias and confounding. Economic recession and political and policy changes throughout the developing world in the 1980s and 1990s led to reduced investments in primary health care, including CHW programmes. In the 1990s, however, the growth of the AIDS epidemic and the resurgence of other infectious diseases, combined with a new emphasis on decentralisation and partnership with community based organisations, has revived interest in community or lay health worker programmes (Maher 1999; Hadley 2000). The inability of the formal health system to provide adequate care for patients with HIV and other chronic illnesses such as cancer, epilepsy and mental illness has resulted in the initiation of a wide range of lay health worker interventions, from home‐based care to treatment support and counselling. Some of these have received very positive evaluations (Dick 1997; Zwarenstein 2000; Barnes 1999). Overall, however, the growth of interest in lay health worker interventions has occurred despite a relatively poor understanding of their effects. To our knowledge, only two systematic reviews have specifically examined the effects of lay health worker interventions, these focusing on support during pregnancy and childbirth (Hodnett 2001a; Hodnett 2001b). As new policies, for example on home‐based care, treatment supporters and other forms of voluntary outreach workers, are being developed (Foster 1996; Masood 1999; Unaids 1999), reliable reassurance that these interventions result in more good than harm should be sought. The direct and indirect costs of such interventions are also very considerable. We therefore propose to carry out a systematic review to examine the effects of lay health worker (paid and voluntary) interventions in primary care and community prevention on health care behaviours, patients' health and wellbeing, and patients' satisfaction with care.
Objectives
We address the following question:
Are lay health workers effective in improving the delivery of health care and health care outcomes?
With regard this question, we address the following comparisons:
-
A. LHW interventions compared to no intervention.
-
LHW interventions involving activities not currently being carried out by health professionals and delegated to LHWs compared to no intervention.
-
LHW interventions involving activities not currently being carried out adequately by health professionals and delegated to LHWs compared to no intervention.
-
LHW interventions involving activities currently being carried out by health professionals but delegated to LHWs to reduce resource consumption compared to the same activities being carried out by health professionals.
-
The effectiveness of the lay health worker intervention related to intensity of training.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials.
Types of participants
Types of health care providers: Any lay health worker (paid or voluntary) including community health workers, village health workers, cancer supporters, birth attendants etc.
For the purposes of this review, a 'lay health worker' will be defined as any health worker:
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carrying out functions related to health care delivery
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trained in some way in the context of the intervention
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has no formal professional or paraprofessional certificated or degreed tertiary education.
This excludes, for example, formally trained nurse aides, medical assistants, physician assistants, paramedical workers in emergency and fire services and others who are self‐defined health professionals or health paraprofessionals. Lay health workers may receive training which is recognised by their Ministry of Health or other certifying education, but this training does not form part of a tertiary education certificate or degree.
Interventions involving patient support groups only will be excluded as these interventions can be seen as different to LHW interventions. Another review is examining this area.
Types of consumers:
There are no restrictions on the types of patients / recipients for whom data will be extracted. Data about their health care, health outcomes and subjective assessments of their interactions with lay health workers will be extracted.
Types of interventions
Any intervention delivered by lay health workers and intended to promote health, manage illness or provide support to patients. An intervention will be included if the description of the intervention is adequate to allow reviewers to establish that it is a lay health worker intervention (see definition above).
Types of outcome measures
(1) Utilisation of lay health worker services
(2) Consultation processes
(3) Health care behaviours such as types of care plans agreed, adherence to care plans (medication, dietary advice etc), attendance at follow‐up consultations and health service utilisation.
(4) Health care outcomes. These may be assessed by a variety of measures including physiological measures such as blood pressure or blood glucose levels, clinical measures such as wound healing, patient self‐reports of symptom resolution or quality of life, patient self‐esteem.
(5) Consumer satisfaction with care.
(6) Health professional satisfaction with care.
(7) Cost
(8) Social development measures.
Search methods for identification of studies
The following electronic databases will be searched:
Medline (1966 ‐ June 2000)
CENTRAL and specialised Cochrane Registers (EPOC; Consumers and Communication)
Science Citations
Embase (1980 ‐Aug 2001)
Cinahl ( 1982‐ June 2001)
Healthstar (1975‐2000)
Amed (1985‐ Aug 2001
Leeeds Health Education Effectiveness Database (private database http:// www.hubley.co.uk)
We aim to retrieve documents that include both one or more terms relating to lay health workers and one or more terms suggesting a RCT. Search strategies will be tailored to each database. The strategy for Medline is presented as an example.
Bibliographies of studies assessed for inclusion will also be searched. Authors of included studies will be contacted and asked if they are aware of any other published and ongoing studies that would meet our review criteria.
MEDLINE search strategy
1 randomized controlled trial.pt.
2 controlled clinical trial.pt.
3 randomized controlled trials.sh.
4 random allocation.sh.
5 double blind method.sh.
6 single‐blind method.sh.
7 1 or 2 or 3 or 4 or 5 or 6
8 (animal not human).sh.
9 7 not 8
10 clinical trial.pt.
11 exp clinical trials/
12 (clin$ adj25 trial$).ti,ab.
13 ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).ti,ab.
14 placebos.sh.
15 placebo$.ti,ab.
16 random$.ti,ab.
17 research design.sh.
18 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17
19 18 not 8
20 19 not 9
21 comparative study.sh.
22 exp evaluation studies/
23 follow up studies.sh.
24 prospective studies.sh.
25 (control$ or prospectiv$ or volunteer$).ti,ab.
26 21 or 22 or 23 or 24 or 25
27 26 not 8
28 26 not (9 or 20)
29 9 or 20 or 28
30 community health aides/
31 home health aides/
32 exp voluntary workers/
33 home nursing/
34 community networks/
35 ( lay adj5 ( worker? or visitor? or attendant? or aide? or support$ or personnel)).tw
36 ( birth adjl attendants?).tw
37 monitrice?.tw
38 (train$ adjl volunteer? ).tw
39 paraprofessional.tw
40 ( (health or care or healthcare) adjl workere?.tw
41 ( (health or medical or care or nurs$ or psychiatric) adjl (aide or aides)) .tw
42 ( (health or medical or care or nurs$ or psychiatric) adjl attendant?) .tw
43 ( ( nurs$ or care or home) adjl support) .tw
44 ( support adjl (program$ or service? or social )) .tw
45 or/30‐44
46 29 and 45
Data collection and analysis
Selection of trials
Reviewers will determine the eligibility of the intervention by examining the introduction to the study report and the description of the intervention. If necessary, additional papers describing the intervention will be retrieved to help determine the eligibility of the study.
One reviewer will assess the potential relevance of all titles and abstracts identified from the electronic searches. Full text copies of all articles that are identified as potentially relevant from the titles and abstracts will be retrieved.
Two reviewers will independently assess the retrieved articles for inclusion. The assessment of the eligibility of interventions is likely to vary between reviewers and so each full paper which is assessed will be assessed by at least two reviewers.
Data relating to the following will be extracted from all included studies:
(1) participants (lay health workers and patients). For LHWs this would include information on incentives, level of training, level of support and monitoring, degree of focus (specialised or general), complexity of tasks and level of education.
(2) clinical setting; country; level of economy
(3) study design and the key features of studies (eg. whether allocation to groups was at the level of individual health care provider or village/suburb);
(4) intervention (stated theoretical/conceptual basis, aims, how delivered/who delivered by, duration and timing etc). A full description of the intervention will also be extracted;
(5) results (effects), organised into 4 areas (utilisation of lay health worker services, health care behaviours, health status and well being, patient satisfaction with care);
(6) Intensity of training;
(7) Whether consumers were involved in the design of the intervention (consumer initiated; professional initiated with consumer involvement; no consumer involvement).
For each study, the intensity of training will be independantly assessed by 2 reviewers using a predefined checklist.
Assessment of methodological quality
The quality of all eligible trials will be assessed using the criteria described by the EPOC group.
Data collection
Full descriptions of the interventions will be extracted by one reviewer only onto a standard form. The standard forms will then be sent to one of the other reviewers who will check this descriptive data and then independently extract the rest of the data. Any discrepancies between the two reviewers' data extraction sheets will be discussed by the data extractors and resolved by consensus. If necessary, other members of the review team will consider and discuss problems.
If data are missing, attempts will be made to contact the authors of the studies to obtain the information. Studies that are so compromised by flaws in their design or execution as to be unlikely to provide reliable data will be excluded. The reasons for such exclusions will be listed in the table of excluded trials.
Data analysis:
Where possible, dichotomous outcomes were reported as relative risks and risk differences with 95% confidence intervals. For any continuous outcome, the mean percentage change difference between baseline and post‐intervention measurements was calculated.
Where appropriate, studies were combined using a random effects model. Sensitivity analysis of methodological quality on pooled estimates was performed.
Data synthesis:
Where feasible, the results of included studies will be combined and an estimate of effect obtained. If appropriate, we will conduct sub‐group reviews of the effects of lay health worker interventions within the following areas: TB/HIV; malaria; maternal and child health; mental health; non‐communicable diseases (cancer; epilepsy etc); and health promotion. We will also attempt to compare the effects of lay health worker interventions across the following subgroups: industrialised versus developing countries; rural versus urban; paid versus unpaid lay health workers; community‐based or health facility based lay health workers; single task versus multiple tasks.
