Optimising Community Health Worker Programmes
A Search Strategy for 15 Systematic Reviews
Developed for the WHO
Prepared by: Aron Shlonsky; Patrick Condron; Bianca Albers; Loyal Pattuwage;
April 2017
Centre for Evidence and Implementation Level 6, 250 Victoria Parade, East Melbourne VIC 3002 Web: cei.org.au Twitter: @CEI_org
Optimising Community Health Worker Programmes A Search Strategy for 15 Systematic Reviews i
Contents
1. Overarching Research Aims ...... 3 2. Defining Community Health Workers...... 4 3. Search Strategy and Brief Description of Synthesis Methods ...... 5 3.1. The search ...... 5 3.2. Databases ...... 6 3.3. PICOS specific searches ...... 7 3.4. Inclusion and exclusion criteria ...... 11 3.5. Screening ...... 14 3.6. Data extraction ...... 15 3.7. Data synthesis ...... 17 4. References ...... 19
Optimising Community Health Worker Programmes A Search Strategy for 15 Systematic Reviews ii
1. Overarching Research Aims
In the last few years, there has been growing interest and attention in the potential of various types of community health workers (CHWs) in reducing inequities in access to essential health services, particularly in under-served or excluded, vulnerable populations. The emerging “WHO Global Strategy on Human Resources for Health (HRH): Workforce 2030” encourages countries to adopt a diverse, sustainable skills mix, harnessing the potential of community-based and mid-level health workers in inter-professional primary care teams.1 The contribution of CHWs in successful delivery of population-based health interventions has been highlighted in several areas such as neonatal and child health, infectious diseases, non- communicable diseases tropical diseases. 4-7 There is also evidence that provision of; education and training, some form of remuneration, supervision, ongoing training and establishment of their role in the health care system may improve their integration into the system. 7-9 The support for community health workers and their integration into the health system, however, remain uneven across and within countries. This is hindering the full realization of their potential contribution to the implementation of health policies based on primary health care. Although they should be considered as an integral part of the health system, CHW programmes are often fraught with challenges, including: poor planning; unclear roles and education pathways; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision, quality control and support; and under-recognition of CHWs’ contribution.10 Optimizing the design and performance of CHW programs requires streamlined nomenclature, clarity on competencies and roles of community health workers, and agreed criteria for sustainable support by and integration in local and national health systems and plans.11,12 The WHO aims to address these issues through the development of new guidelines on health policy and system support. The purpose of these guidelines is to improve CHW programmes by identifying optimal training and working conditions for the CHWs and enhance their functions. The guidelines will assist national governments as well as national and international partners in improving the design, implementation, performance and evaluation of CHW programmes, by providing recommendations in the areas of CHW selection, education, continuing training, linkage with other health workers, management, supervision, performance enhancement, incentives, remuneration, governance, health system integration. To inform the guideline development, WHO has commissioned 15 systematic reviews examining the current best evidence on optimal training and working conditions for CHWs. This document details the search strategy for the conduct of these reviews. It has been informed by key guidance on the conduct of narrative synthesis developed for research teams that conduct systematic reviews for policy and practice 20 . This guidance will also inform later steps in the review process.
Optimising Community Health Worker Programmes A Search Strategy for 15 Systematic Reviews
2. Defining Community Health Workers
The term “community health workers” is often used in a non-specific way, referring to a diverse typology of lay and formally educated, formally and informally assigned, paid and unpaid health workers. 2 A repository of terms such as “lay health workers”, “frontline health workers”, “close-to- community providers” that are somewhat synonymous to CHWs can currently be found in the literature but, these terms can also denote some variance in their scope of practice, training, and their relation to the health system. Olaniran et al. (2017) 3 identified 119 publications that describe and define roles of CHWs. These differ widely, based on e.g. how CHWs were selected, their roles and tasks, training received and wages (if any). 90 of the publications described the role of CHWs in relation to the roles and tasks performed in the community or health care facility. Twenty-one publications also included educational qualifications or pre-service training in CHW descriptions and definitions. In some of these studies, CHWs were defined as unpaid volunteers and in others as a cadre service providers that received a salary, an allowance, or performance-based incentives. Differences like these make it difficult to find a universally accepted single definition of CHWs. The international standard classification of occupations by the International Labour Office states: “Community health workers provide health education, referral and follow-up, case management, basic preventive health care and home visiting services to specific communities. They provide support and assistance to individuals and families in navigating the health and social services system” 13 (p. 192). WHO has used the following definition: “Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers” 14 (p. 5). A similar approach is reflected in a recent systematic review of reviews by Scott et al. 2, who also include a generally lower level of education as a key characteristic of CHWs, who are described as “… frontline health care providers who live in the community they serve and receive lower levels of formal education and training than professional health care workers such as nurses and doctors” (p 5). The commonalities aligning these definitions are that CHWs have a supportive function in health service delivery, including the provision of direct health services, health advocacy, and community agency. Furthermore, community health workers are directly connected to the communities they serve – they live in them and are accountable to them – and have lower levels of education when compared to trained health workers such as doctors and nurses. These characteristics will be operationalised in the search strategy presented below.
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3. Search Strategy and Brief Description of Synthesis Methods
The search strategy is summarised in table 1 below. Subsequently, we present each of the steps in greater detail, including a brief description of methods for data extraction and synthesis. A complete protocol will be developed and submitted after search methods are finalised.
Table 1: The search strategy
PICOS Category Approach
Population Included in this project will be studies that focus on CHWs as defined through specific inclusion criteria (see section 3.3). This overarching search will be applied to all PICOS that are part of this project and is detailed below in section 3.1
Intervention PICOS specific search strings will be developed to capture the different interventions included in each of the 15 systematic reviews. Each of these specific search strategies will be combined with the overarching search to form the final search strategy for each systematic review topic.
Comparison No further search terms will be utilised to limit the output to specific comparison conditions. All studies will be included, irrespective of the comparisons reported.
Outcomes No further search terms will be utilised to limit the output to specific outcomes. Instead, we will retrieve all publications, irrespective of the outcomes reported.
Study Design Any study design will be included in the 15 systematic reviews
3.1. The search As indicated in the original proposal, all 15 systematic reviews will be underpinned by a primary search to broadly identify all possible studies involving CHWs across all countries. The example in table 2 is developed for Ovid Medline and will be tailored to suit other databases. This primary search will remain the same for all 15 PICOS driving each of the reviews. Methodological filters will not be applied.
Table 2: CHW Search Terms No. Search Term
1 community health workers/exp
2 “frontline health worker*”.mp
3 ((community or lay or volunteer or voluntary or family or rural or village or lady or basic or frontline) adj (health or healthcare or health care or medical or care or drug or nutrition) adj (worker* or aide* or distributor* or surveyor* or assistant* or promoter* or agent* or auxiliar* or motivator* or helper* or representative* or volunteer* or provider* or officer*)).mp
4 ((chw or chws or lhw or lhws or vhw or vhws) not "liquid hot water").mp
5 "health promoter*".mp
6 ("community health" adj1 worker*).mp
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No. Search Term
7 "community volunteer*".mp
8 "peer educator*".mp
9 "outreach worker*".mp
10 "health agent*".mp
11 (Promotora or promotoras) .mp
12 "community practitioner*".mp 13 "health assistant*".mp
14 Anganwadi.mp
15 "health extension worker*".mp
16 "barefoot doctor*".mp
17 "accredited social health activist*".mp
18 kader.mp
19 "malaria agent*".mp
20 "community based practitioner*".mp
21 "health auxiliar*".mp
22 "health surveillance assistant*".mp
23 (("community healthcare" or "community health care") adj1 worker*).mp
24 animator.mp
25 "nutrition counselor*".mp
26 "family welfare assistant*".mp
27 (child adj (health or healthcare or "health care") adj worker*).mp 28 (Behvarz or Monitora or "barangay health worker*" or Accompagnateur* or Activista or Sevika or Brigadista or Animatrice or Socorrista or "Agente comunitario de salud" or "Agente comunitario de saude" or "agentes de saude" or "Colaborador voluntario" or "Shastho karmis" or "Shastho shebika" or "Shasthya Shebika").mp
29 ("close to community provider*" or "Lead Mother*" or "community imci" or "outreach educator*" or "community resource person*" or "nutrition agent*" or "Mobile Clinic Team*" or "Mother coordinator*" or "village drug-kit manager*" or "Bridge- to-Health Team*" or "female multipurpose health worker*" or "community case management worker*" or "community surveillance volunteer*").mp
30 (("family planning" or "health promotion") adj (worker* or aide* or distributor* or surveyor* or assistant* or promoter* or agent* or auxiliar* or motivator* or helper* or representative* or volunteer* or provider* or officer*)).mp
31 Or/1-30
3.2. Databases The following databases will be searched as part of this project: Ovid Medline: Epub Ahead of Print, In-Process & Other Non-Indexed Citations and 1946 to Present EMBASE Cochrane CINAHL PsycINFO LILACS Global Index Medicus POPLINE
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Furthermore, the grey literature will be searched for further relevant publications. These searches will be based on the following databases: OpenGrey TROVE Google Scholar
In addition, the research team will reach out to relevant organisations and agencies to solicit grey literature that may not be available online. The selection of these organisations and agencies will be confirmed with WHO. Finally, the references of included articles will be examined for relevant citations.
3.3. PICOS specific searches To identify relevant literature for each PICOS, the primary CHW focused search string will be combined with each of the search strings presented in table 3 below. These search strings were developed with a focus on the particular intervention included in each PICOS.
Table 3: PICOS specific search strategies Question Search Terms
Q1: In CHWs being 1. Primary CHW search selected for pre- 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or service training, what employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural strategies for selection or remote or village or villages or local) adj4 (health or service or services or program or of applications for practice)))).mp. CHWs should be adopted over what 3. 1 OR 2 other strategies? 4. ((selection or employment or recruitment) adj2 (criteria or process or reasons or characteristics)).mp. 5. ("personnel selection" or "entry requirement*" or "job requirement*").mp. 6. (attribute* or applicant*).mp. 7. OR/4-6 8. 3 AND 7
Q2: For CHWs 1. Primary CHW search receiving pre-service 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or training, should the employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural duration of training be or remote or village or villages or local) adj4 (health or service or services)))).mp. shorter versus longer? 3. 1 OR 2 4. (training or course or class or classes or education or learning).mp. 5. education.fs. 6. 4 OR 5 7. 3 AND 6 8. (duration or length or “period of time”).mp. 9. ((hour or hours or day or days or week or weeks) adj3 (training or course or courses or education)).mp. 10. 8 OR 9 11. 7 AND 10
Q3: For CHWs 1. Primary CHW search receiving pre-service 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or training, should the employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural curriculum address or remote or village or villages or local) adj4 (health or service or services)))).mp. specific versus nonspecific 3. 1 OR 2 competencies? 4. (training or course or class or classes or education or learning).mp. 5. education.fs. 6. 4 OR 5
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Question Search Terms 7. 3 AND 6 8. (curriculum or curricula or "educational activit*" or "educational strateg*").mp. 9. (competency or competencies or certification or approval or accreditation or registration).mp. 10. community health workers/st 11. standards.mp. or standards.fs. 12. OR/8-11 13. 7 AND 12
Q4: For CHWs 1. Primary CHW search receiving pre-service 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or training, should the employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural curriculum use specific or remote or village or villages or local) adj4 (health or service or services)))).mp. delivery modalities versus not? 3. 1 OR 2 4. (training or course or class or classes or education or learning).mp. 5. education.fs. 6. 4 OR 5 7. 3 AND 6 8. ("community based" or "hospital based" or "health facility based").mp. 9. ("flexible learning" or "field placement" or "service training" or "distance education" or "distance learning" or mooc or moocs).mp. 10. ((training or course or class or classes or education or learning) adj3 (delivery or modality or modalities)).mp. 11. (("face to face" or online or blended or mobile or "web based" or electronic) adj3 (training or course or class or classes or education or learning)).mp. 12. OR/8-11 13. 7 AND 12
Q5: In CHWs who have 1. Primary CHW search received pre-service 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or training, should employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural competency-based or remote or village or villages or local) adj4 (health or service or services)))).mp. formal certification be used versus not used? 3. 1 OR 2 4. certification or approval or accreditation or "competency based").mp. 5. ("work performance" or "job performance").mp. 6. community health workers/st 7. health manpower/st 8. ("skill level" or retraining or "performance evaluation" or "performance assessment").mp. 9. ("refresher training" or "continuous education" or "education, continuing").mp. 10. OR/4-9 11. 3 AND 10
Q6: In the context of 1. Primary CHW search CHWs programmes, 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or what strategies of employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural supportive supervision or remote or village or villages or local) adj4 (health or service or services)))).mp. should be adopted over what other 3. 1 OR 2 strategies? 4. (supervision or supervisor or supervisors or supervisory).mp. 5. (coach or coaching or coaches).mp. 6. ("personnel system" or "personnel structure" or manager or managers or mentor or mentors).mp. 7. (autonomy or accountability).mp. 8. OR/4-7 9. 3 AND 8
Q7: In the context of 1. Primary CHW search CHWs programmes, 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or should practicing employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural CHWs be paid for their or remote or village or villages or local) adj4 (health or service or services)))).mp. work versus not? 3. 1 OR 2 4. (payment or salary or salaries or "salaries and fringe benefits" or pay or paid).mp. 5. remuneration or incentive or incentives or financial or finance or income or compensation or wage or wages).mp. 6. ("employee retention" or "personnel retention" or "community health worker retention" or
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Question Search Terms "CHW retention" or attrition).mp. 7. (voluntary or volunteer or volunteers or free or unpaid or “in kind” or “non paid”).mp. 8. OR/4-7 9. 3 AND 8
Q8: In the context of 1. Primary CHW search CHWs programmes, 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or should practicing employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural CHWs have a career or remote or village or villages or local) adj4 (health or service or services)))).mp. ladder opportunity/ framework versus not? 3. 1 OR 2 4. "career ladder*".mp. 5. ((career or job or staff) adj1 (advancement or opportunit* or framework or development)).mp. 6. "career path" or "career pathway*").mp. 7. ("career plan*" or "career structure*").mp. 8. "professional development".mp. 9. ("personnel turnover" or "retaining staff" or "retaining personnel" or retention).mp. 10. OR/4-9 11. 3 AND 10
Q9: In the context of 1. Primary CHW search CHWs programmes, 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or should practicing employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural CHWs have a formal or remote or village or villages or local) adj4 (health or service or services)))).mp. contract versus not? 3. 1 OR 2 4. "employment contract".mp. 5. "work contract".mp. 6. "terms of understanding".mp. 7. "conditions of work".mp. 8. "work conditions".mp. 9. "written agreement".mp. 10. (agreement adj5 (work or employment or labour or labor or working or employed or employee*)).mp. 11. "employment conditions".mp. 12. "conditions of service".mp. 13. ("job expectation*" or "work expectation*" or "employment expectation*").mp. 14. "personnel loyalty".mp. 15. "contract of employment".mp. 16. "employee contract*".mp. 17. or/4-16 18. (contract or contracted or contracts).mp. 19. 3 and 17 20. 3 and 18 21. 19 or 20
Q10: In the context of 1. Primary CHW search CHW programmes, 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or should there be a employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural target population size or remote or village or villages or local) adj4 (health or service or services)))).mp. versus not? 3. 1 OR 2 4. (coverage or "target population" or catchment).mp. 5. ("client number" or "client numbers" or "number of clients").mp. 6. workload.mp. 7. ((worker* or employee* or volunteer*) adj2 distribution).mp. 8. ("time management" or "personnel staffing and scheduling").mp. 9. (proximity adj2 (service or services)).mp. 10. (travel or "spatial access").mp. 11. (deploy or deployed or deployment).mp. 12. (per adj1 (population or inhabitants or persons)).mp. 13. or/4-12 14. 3 and 413
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Question Search Terms
Q11: In the context of 1. Primary CHW search CHWs programmes, 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or should practicing employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural CHWs collect, collate, or remote or village or villages or local) adj4 (health or service or services)))).mp. and use health data versus not? 3. 1 OR 2 4. ((data or record or records or information) adj2 (collection or collector or collectors or collate or collation or collating or "use" or quality or capture)).mp. 5. ((cell or mobile or smart or cellular) adj1 (phone* or telephone* or device* or tablet*)).mp. 6. smartphone*.mp. 7. ("mobile health" or mhealth).mp. 8. ("record keeping" or "report writing" or reporting or documentation or "health record*" or "medical record*").mp. 9. feedback.mp. 10. "activity report*".mp. 11. or/4-10 12. 3 and 11
Q12: In the context of 1. Primary CHW search CHWs programmes, 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or should practicing CHW employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural work in a multi-cadre or remote or village or villages or local) adj4 (health or service or services)))).mp. team versus in a single cadre CHW system? 3. 1 OR 2 4. (specialist* or specialisation or specialization or specialised or specialized).mp. 5. (cadre or cadres or multicadre*).mp. 6. (polyvalent or multivalent or monovalent or "poly valent" or "multi valent" or "mono valent").mp. 7. (team or teams or teamwork).mp. 8. (generalist or general).mp. 9. advanced.mp. 10. multimodal.mp. 11. ((work or workforce or employee* or worker*) adj2 (role or roles)).mp. 12. or/4-11 13. 3 and 12
Q13: In the context of 1. Primary CHW search practicing CHW 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or programmes, are employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural community or remote or village or villages or local) adj4 (health or service or services)))).mp. engagement strategies effective in improving 3. 1 OR 2 CHW program 4. ((community or village) adj2 (engagement or engaged or committee* or participation or performance and participatory or involved or involvement or liaison or group or groups or network* or utilisation? ownership or learning or collaboration or relations)).mp. 5. committee*.mp. 6. ((mother or mothers or father or fathers or parent or parents or youth or religious or support or development or savings or credit or farmers or rural or health or project) adj1 (group or groups)).mp. 7. "local participation".mp. 8. (build* adj1 relationship*).mp. 9. social network*.mp. 10. ((peer adj1 leader*) or "change agent*").mp. 11. or/4-10 12. 3 and 11
Q14: In the context of 1. Primary CHW search CHWs programmes, 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or should practicing CHW employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural mobilize wider or remote or village or villages or local) adj4 (health or service or services)))).mp. community resources for health vs. not? 3. 1 OR 2 4. (mobilisation or mobilization).mp. 5. (community adj2 (knowledge or empowerment or promotion or help or helping or support)).mp. 6. (community adj2 (informant* or leader* or stakeholder*)).mp. 7. (((priority or objective or objectives or goal or goals) adj1 (set or setting)) or prioritisation or prioritization).mp.
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Question Search Terms 8. (coordinate or coordination or "co ordinate" or "co ordination").mp. 9. ((outcome or program) adj1 evaluation).mp. 10. (disseminate or dissemination or spread).mp. 11. (link or linking or linkage or linkages).mp. 12. or/4-11 13. 3 and 12 Q15: In the context of 1. Primary CHW search practicing CHWs 2. ((workforce or manpower or employment or (occupation or occupations) or (employee or programmes, what employees) or "labor force") adj10 ("community health" or ((voluntary or volunteer* or rural strategies should be or remote or village or villages or local) adj4 (health or service or services)))).mp. used for ensuring adequate availability 3. 1 OR 2 of commodities and 4. (acquisition or acquire or logistics or logistical or provide or provision or available or consumable supplies availability).mp. over what other 5. (stock or resupply or transport or transportation or distribution or handling or storage or strategies? purchasing or allocation or purchase).mp. 6. (goods or commodity or commodities or supplies or materials or equipment or consumables or consumable).mp. 7. (4 or 5) and 6 8. ((medicine or medicines or drug or drugs or pharmaceutical*) adj1 (management or supply or distribute or access)).mp. 9. "supply chain".mp. 10. supply & distribution.fs. 11. 7 or 8 or 9 or 10 12. 3 and 11
3.4. Inclusion and exclusion criteria
The yielded titles and abstracts of the database search will be screened using a combination of (a) general inclusion and exclusion criteria applicable to all PICOS and (b) PICOS specific inclusion and exclusion criteria. Table 4 below summarises the general criteria, whereas PICOS specific criteria are listed in table 5.
Table 4: General inclusion and exclusion criteria
Included Excluded
Publications that report a study Publications that do not report a study, e.g. opinion pieces, editorials, conference abstracts; single case studies; letters; advocacy materials
Studies focused on practicing Community Health Studies focused on non-Community Health Workers Workers: such as nurses, doctors, formally trained nurse-aids; Medical assistants, physician assistants; paramedical = health care workers who carry out population- workers in emergency and fire services; others who based, health-related activities in their community are auxiliaries, e.g.mid-level workers and self-defined = these activities take place in a community they are health professionals or health paraprofessionals; directly connected to (they live in the community; traditional, faith and complementary healers and are accountable to the community) traditional birth attendants
= workers, who have received no or only basic formal Studies focused on non-practicing (i.e. retired or training; this training may be recognised by health unemployed) community health workers services or a certification authority, but it is not a
Optimising Community Health Worker Programmes A Search Strategy for 15 Systematic Reviews 11
Included Excluded part of a formal tertiary education programme or qualification (e.g. degree, diploma, title, certificate course).
Studies conducted in high income countries, and in low and middle income countries
Studies conducted in underserved community settings Studies conducted in well-served community settings
Studies conducted in general population settings Studies conducted in specific population settings (e.g. refugee camps, nomadic populations etc.)
Each PICOS focuses on a particular aspect of CHWs’ training and working conditions that will guide the definition of specific inclusion and exclusion criteria for each systematic review. These are summarised below.
Table 5: PICOS specific inclusion and exclusion criteria Research Question Included Excluded Q 1: In CHWs being selected for Studies reporting on the role of Studies reporting on the role of pre-service training, what pre-service training training other than pre-service strategies for selection of training (e.g., professional applications for CHWs should be development, ongoing support, adopted over what other other forms of training) strategies? Studies reporting on strategies for Studies reporting on strategies for selecting applicants for pre- selecting job applicants only [no service training pre-service training involved]; for selecting trainees for ongoing training, on-the-job training or other types of training Q 2: For CHWs receiving pre- Studies reporting on the role of Studies reporting on the role of service training, should the pre-service training training other than pre-service duration of training be shorter training (e.g., professional versus longer? development, ongoing support, other forms of training) Studies reporting on the role of Studies reporting on other factors duration of the pre-service related to the conduct of pre- training, including e.g. length, service training (e.g., structure (conduct in one vs. certification, aptitude)) several sessions), dosage etc. Q 3: For CHWs receiving pre- Studies reporting on the role of Studies reporting on the role of service training, should the pre-service training training other than pre-service curriculum address specific versus training (e.g., professional non-specific competencies? development, ongoing support, other forms of training) Studies reporting the content of a curriculum describing the subjects and content that comprise the course of the pre- service training. Studies specifying the Studies specifying the competencies of CHWs promoted competencies of others than through a pre-service curriculum. CHWs promoted through a pre- service curriculum.
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Research Question Included Excluded Q 4: For CHWs receiving pre- Studies reporting on the role of Studies reporting on the role of service training, should the pre-service training training other than pre-service curriculum use specific delivery training (e.g., professional modalities versus not? development, ongoing support, other forms of training) Studies reporting on the modalities of a curriculum delivery (e.g. face-to-face, electronic, in family settings etc.) Q 5: In CHWs who have received Studies reporting on the role of Studies reporting on the role of pre-service training, should pre-service training other than pre-service training competency-based formal (e.g., professional development, certification be used versus not ongoing support, other forms of used? training) Studies reporting on approaches to formal certification including e.g., level of formality, accrediting body, core criteria for accreditation, etc. Q 6: In the context of CHWs Studies reporting on practices of Studies focused on other forms of programmes, what strategies of supervision, including coaching professional support of CHWs supportive supervision should be and consultation, e.g., individual (e.g. on-the-job training, study or adopted over what other vs. group; peer vs. professional reading groups, etc.) strategies? supervision; supervisor role; supervision frameworks; supervisor training etc. Q 7: In the context of CHWs Studies reporting on approaches programmes, should practicing to compensate CHWs for their CHWs be paid for their work work, including salaries, versus not? payment, remuneration, wage, reimbursement, non-financial compensation through e.g. advancement etc. Q 8: In the context of CHWs Studies reporting on opportunities programmes, should practicing for advancement for CHWs and CHWs have a career ladder describe e.g. career pathways, opportunity/ framework versus structures for professional not? development etc. Q 9: In the context of CHWs Studies reporting on contracting programmes, should practicing conditions for CHWs including CHWs have a formal contract information about level of versus not? formality; form (written or not); contracting body (formal authority or other) etc. Q 10: In the context of CHW Studies providing information programmes, should there be a about the optimal population size target population size versus not? for individual or groups of CHWs, including community population sizes, case load, agency load etc. Q 11: In the context of CHWs Studies reporting on the role of programmes, should practicing data collection as part of CHWs CHWs collect, collate, and use work routines, e.g. processes of health data versus not? regular data collection, regular data use etc. including those related to either written, oral or electronic data reporting to peers, supervisors or others Q 12: In the context of CHWs Studies reporting on CHW teaming programmes, should practicing structures and team composition CHWs work in a multi-cadre team including information on the
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Research Question Included Excluded versus in a single -cadre CHW degree of specialisation and the system? presence of competencies in team members and teams. Q 13: In the context of practicing Studies reporting on the role of CHW programmes, are community community engagement strategies engagement strategies effective in delivering community health in improving CHW program programmes through community performance and utilisation? health workers – e.g. through village groups and committees; community networks; community wide action plans; community involvement in decision making etc. Q 14: In the context of CHWs Studies reporting on CHWs’ programmes, should practicing practices for resource CHW mobilize wider community mobilisation in their community, resources for health vs. not? e.g. through resource identification and mapping; service coordination and streamlining; strengthening of referral pathways; utilisation of research resources etc. Q 15: In the context of practicing Studies reporting on CHWs’ CHWs programmes, what practices for ensuring the strategies should be used for availability of commodities and ensuring adequate availability of consumable supplies, including commodities and consumable e.g. through the utilisation of supplies over what other national supply planning, stock strategies? management tools, mobile phone applications and social media, coordination of re-supply procedures, etc.
3.5. Screening Each review team involved in this project will be assigned 1-4 PICOS and will be responsible for the conduct of these reviews with oversight from the PI and advisory group. The distribution of reviews across teams is summarised in table 6 below.
Table 6: Distribution of reviews across research teams
Review team No of reviews Team lead
University of Adelaide 3 Zohra Lassi
University of Newcastle 2 Luke Wolfenden
University of Sydney 1 Katie Conte
University of Toronto 1 Peter Newman
University of Melbourne 2 Sharon Licqurish
Aga Khan University 4 Jai Das
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Review team No of reviews Team lead
Centre for Evidence and Implementation 2 Bianca Albers
Covidence will be the joint work platform for these review teams. The Centre for Evidence and Implementation (CEI) will be responsible for administering the literature searches and supporting review teams in their use of Covidence . Upon de-duplication, studies will be uploaded to Covidence , and review teams assigned to PICOS. During title and abstract screening, two reviewers will independently screen each study for inclusion. Any disagreements will be resolved by the review team lead (as per table 6 above). The full texts of agreed citations will be retrieved and uploaded to Covidence . Two independent reviewers will screen full texts for inclusion. Any discrepancies will be resolved by the responsible review team lead. As part of the screening process, the research team will establish a cross-PICO mechanism for passing excluded studies from one review to another. This will ensure that a reviewer, who works on one PICO and identifies and excludes a study of potential relevance to another PICO passes this study on to the relevant PICO team. This will create an additional layer of security that relevant studies will not be missed. The final selection of included studies will be prepared for data extraction to be conducted independently by each review team.
3.6. Data extraction The review teams will use a standardised approach to extracting data from included studies. The components of this extraction will be modified based on the final included studies and may differ between different questions/topics. At a minimum, the following general information will be extracted from each study. • Study details, including: author, year, location, study design, delivery setting (high versus low and middle income; community or health facility; etc.), sector (primary or secondary health; allied health; etc.), participants (type of CHW and others), sample size • Intervention details, including Interventions delivered (programmes, practices), core components of interventions, delivery mode and location, other characteristics as relevant • Outcomes for quantitative studies, we will extract data related to each outcome accordingly. We will report measures of intervention effects in the same way the study authors have reported. If necessary, comparisons will be made using standardised measures of effect such as mean standardised difference (SMD) or Odds Ratios (OR). We may also use a standardised scale to facilitate comparisons across studies along the dimension of quality. For qualitative studies, we will extract the major themes reported by the study authors. In addition to this general data extraction, each PICOS implies the extraction of data specifically tailored to the different research questions. Table 6 below lists information that, if present in a
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study, should be extracted. This list is not exhaustive and will be expanded as new findings emerge from studies.
Table 6: PICOS specific data extraction Research Question Potential stratifiers for sub-group analysis
Q 1: In CHWs being selected for pre- Literacy level based service training, what strategies for Gender based selection of applications for CHWs should be adopted over what other Marital status based strategies? Age based Membership of the community of interest Preference to volunteer Preference for certain type of work by potential CHWs Availability of time
Q 2: For CHWs receiving pre-service Training depending on the complexity of the task (i.e. promotive, preventative, data training, should the duration of collection, health education) training be shorter versus longer? Competency requirements Q 3: For CHWs receiving pre-service Technical competencies for CWEs that will work in biological or medical environments training, should the curriculum (i.e. basic human physiology for identifying issues and arranging referrals, basic address specific versus non-specific pharmacology for identifying vitamin supplements) competencies Counselling and motivational skills Understanding of the health system to direct patients Basic knowledge and skills about household preventative habits
Q 4: For CHWs receiving pre-service Face to face delivery training, should the curriculum use Classroom delivery specific delivery modalities versus not? Electronic, web-based, telephone, paper-based training Training in community or an educational facility away from the community
Q 5: In CHWs who have received Formal certification/accreditation pre-service training, should Competency based competency-based formal certification be used versus not Approval of regulatory bodies, government authorities, approval by academic used? institutions
Q 6: In the context of CHWs Coaching programmes, what strategies of Supervisor-supervisee ratios supportive supervision should be adopted over what other strategies? Checklists Category of supervisors (dedicate, non-dedicated, peers as supervisors) Supervisor visits, observation Q 7: In the context of CHWs Payments programmes, should practicing CHWs Salary be paid for their work versus not? Remuneration package Formal contract Absorption into health force Q 8: In the context of CHWs Career ladder / pathways programmes, should practicing CHWs Career opportunities have a career ladder opportunity/ framework versus not? Promotions
Q 9: In the context of CHWs Formal contract programmes, should practicing CHWs Written document have a formal contract versus not? Legal contract/document Document issued by a formal authority stipulating working conditions, rights and responsibilities, job description or terms of remuneration (if any)
Q 10: In the context of CHW Threshold size for the target population programmes, should there be a Caseload information target population size versus not?
Q 11: In the context of CHWs Collection and submission of data during their routine activities programmes, should practicing CHWs e-health data collection and transmission platforms collect, collate, and use health data versus not? The data may be used to receive feedback and supervision and motivation
Q 12: In the context of CHWs Single cadre of CHWs
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Research Question Potential stratifiers for sub-group analysis programmes, should practicing CHWs Two or more cadre s CHWs work in a multi-cadre team versus in Multi cadre CHWs a single cadre CHW system?
Q 13: In the context of practicing Engagement with: CHW programmes, are community community health committees engagement strategies effective in improving CHW program village development committees performance and utilisation? community liaison committees facility-liaison committees hygiene and sanitation committees mothers’ groups fathers’ groups youth groups religious groups support groups savings and credit or farmers’ groups community health action planning activities involvement of community representatives in decision making, planning and, budgeting processes
Q 14: In the context of CHWs Some of the activities the studies may report on the engagement of CHWs in the programmes, should practicing CHW community: mobilize wider community resources identifying priority health and social problems for health vs. not? mobilizing and helping coordinate relevant, local resources representing different stakeholders, sectors and civil society organizations to address priority health problems participating in evaluating and disseminating outcomes of interventions strengthening linkages between community and health facility
Q 15: In the context of practicing Inclusion of relevant commodities in the programme (e.g. condoms in sexual health CHWs programmes, what strategies programmes) should be used for ensuring Maintenance and management of stocks using basic procedures adequate availability of commodities and consumable supplies over what Making sure to replenish stock through re-supply procedures other strategies? Use of social media to inform community Co-ordination, supervision and standardization of resupply procedures, checklists and incentives Use of mobile phone applications
3.7. Data synthesis If possible and relevant, meta-analyses will be conducted to obtain an overall estimate of the effect of an intervention when more than one study has examined similar interventions using similar methods, the studies have been conducted in similar populations, and outcomes were measured and are similar. For each meta-analysis, we will test for heterogeneity and, if present, will use a random-effects model for synthesis. For qualitative studies, we will conduct a narrative synthesis, grouping the findings by the type of intervention, population, delivery context and outcome(s). Furthermore, relevant stratifiers such as • Volunteer vs. paid; • Level of training; • Polyvalent vs. monovalent; • Full time vs part time; • Expert client/patient; • Type of CH work [preventive/promotive/curative]
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will be included as part of sub-group analyses. Not all literature may allow for this analyses but to the degree possible, the research team will emphasise this part of the analysis. The process of data synthesis will involve the utilisation of the GRADE 19 (Grading of Recommendations Assessment, Development and Evaluation) approach, a well-developed formal process to rate the quality of scientific evidence in systematic reviews. The goal of assessing the strength of the evidence identified through included studies is to provide clearly explained, well-reasoned judgments about reviewers’ confidence in their systematic review conclusions so that decision makers in developing guidelines can use them effectively 17,18 . Grading the strength and quality of evidence requires assessment of within-study risk of bias (methodological quality), directness of evidence, heterogeneity, precision of effect estimates and risk of publication bias 15 .
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4. References
1. WHO. Global strategy on human resources for health: Workforce 2030, DRAFT for the 69th World Health Assembly; The World Health Organisation. (URL: http://www.who.int/hrh/resources/global_strategy2030en-printversion.pdf) , [Accessed: 21/04/2017]. 2016. 2. Scott K, Beckham S, Gross M, Pariyo G, Rao K, Perry H. Systematic Review of Existing Reviews of Community-based Practitioners (Including Community Health Workers and Close-to-Community Practitioners) and Their Integration with Health Systems: Complete Report; Department of International Health Johns Hopkins Bloomberg School of Public Health. 2017 Jan. 3. Olaniran A, Smith H, Unkels R, Bar-Zeev S, van den Broek N. Who is a community health worker? – a systematic review of definitions. Global Health Action. 2017;10(1):1272223. 4. Gilmore B, McAuliffe E. Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review. BMC Public Health. 2013;13:847. 5. Glenton C, Scheel IB, Lewin S, Swingler GH. Can lay health workers increase the uptake of childhood immunisation? Systematic review and typology. Tropical medicine & international health : TM & IH. 2011;16(9):1044-1053. 6. Mwai GW, Mburu G, Torpey K, Frost P, Ford N, Seeley J. Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review. J Int AIDS Soc. 2013;16:18586. 7. Vouking MZ, Takougang I, Mbam LM, Mbuagbaw L, Tadenfok CN, Tamo CV. The contribution of community health workers to the control of Buruli ulcer in the Ngoantet area, Cameroon. Pan Afr Med J. 2013;16:63. 8. GHWA W. Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for scaling up. 2010. 2014. 9. Raphael JL, Rueda A, Lion KC, Giordano TP. The role of lay health workers in pediatric chronic disease: a systematic review. Acad Pediatr. 2013;13(5):408-420. 10. Tulenko K, Mgedal S, Afzal MM, et al. Community health workers for universal health-care coverage: from fragmentation to synergy. Bulletin of the World Health Organization. 2013;91(11):847-852. 11. Campbell J, Buchan J, Cometto G, et al. Human resources for health and universal health coverage: fostering equity and effective coverage. Bulletin of the World Health Organization. 2013;91(11):853- 863. 12. Dahn B, Woldemariam AT, Perry H, et al. Strengthening primary health care through community health workers: Investment case and financing recommendations. 2015. 13. ILO. International Standard Classification of Occupations Structure, group definitionsand correspondence tables; ISCO-08, International Labour Office, Geneva. (URL: http://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/--- publ/documents/publication/wcms_172572.pdf); [Accessed: 21/04/2017]. 2012. 14. WHO. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. World Health Organisation, Evidence and Information for Policy, Department of Human Resources for Health Geneva, January 2007. 2007. 15. Higgins JP, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Bmj. 2011;343:d5928. 16. Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Department of Epidemiology and Community Medicine, University of Ottawa, Canada. www ohr i ca/programs/clinical_ epidemiology/oxford htm. 2012. 17. Atkins D, Fink K, Slutsky J, Agency for Healthcare R, Quality, North American Evidence-based Practice C. Better information for better health care: the Evidence-based Practice Center program and the Agency for Healthcare Research and Quality. Ann Intern Med. 2005;142(12 Pt 2):1035-1041. 18. Berkman ND, Lohr KN, Ansari M, et al. Grading the Strength of a Body of Evidence When Assessing Health Care Interventions for the Effective Health Care Program of the Agency for Healthcare Research and Quality: An Update. Methods Guide for Effectiveness and Comparative Effectiveness Reviews . Rockville (MD) 2008. 19. GRADE. The Grading of Recommendations Assessment, Development and Evaluation, The GRADE WOrking Group, (URL: http://www.gradeworkinggroup.org/) , Accessed [20/04/2017]. 2017.
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20. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, Britten N with Katrina Roen and Steven Duffy. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews - A Product from the ESRC Methods Programme, York 2006
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Our mission We are dedicated to using the best evidence in practice and policy to improve the lives of children, families and communities facing adversity.
How we achieve this We work with a diverse range of key stakeholders who want to achieve social impact for children and families facing adversity. We bring specialist skills in: • Supporting sustained change in the behaviour of systems, organisations and individuals. We put a strong emphasis on supporting and strengthening the core components of effective program implementation. • Providing knowledge translation to policymakers, and relevant stakeholders, so they can access – and use – research for evidence-informed decision-making. • Program design – selecting and creating evidence- informed programs and services to achieve outcomes for children, family and communities. • Conducting rigorous evaluations, and assessing the long-term effect of outcomes.
Working with us Through national and international collaborations, we conduct a range of activities to achieve our mission.
Centre for Evidence and Implementation Level 6, 250 Victoria Parade, East Melbourne VIC 3002 Web: cei.org.au Twitter: @CEI_org