Cochrane review summary: barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis

Review question

What factors affect the implementation of lay health worker (LHW) programmes for maternal and child health?

Relevance to primary care and nursing

Midwives and health visitors are involved in providing care to improve the health and well-being in pregnancy, postnatal care and for children less than five years of age (National Institute for Health and Care Excellence, 2014). Identifying factors that make LHW programmes effective may help develop programmes that are acceptable to patients and enhance the provision of care.

Characteristics of the evidence

There is a growing interest in the involvement of trained LHWs to deliver interventions that would provide adequate care for people with a wide range of unmet health needs.

This is a Cochrane systematic review containing a thematic analysis of 53 qualitative studies of LHW programmes (Glenton et al., 2013). An LHW was defined as a lay person trained to deliver health-care services but is not a health professional. Participants (stakeholders) from included studies were LHWs, programme recipients, health professionals working with the LHWs, programme staff, supervisors, community leaders and policy makers.

Interventions

LHW programmes aimed to improve maternal or child health, and most offered health care to low-income populations. High-income populations were offered health promotion, counselling and support. In addition to these, LHWs in poor countries also distributed food supplements, contraceptives, treated common childhood diseases or managed women in uncomplicated labour.

Settings and providers

Studies were conducted in low-income countries (n=17), middle-income countries (n=19) and high-income countries (n=17), in primary or community health-care setting. Providers were LHWs including community health workers, village health workers, birth attendants, peer counsellors, nutrition workers and home visitors.

Outcomes

Experiences and attitudes of participants about LHW programmes in any country.

Summary of key evidence

Thematic analysis, guided by a theoretical framework was used to synthesise qualitative data. An interpretive explanation was developed to complement a Cochrane review of effectiveness of LHW programmes. Findings were based on studies from different settings and methodological limitations. They were graded for certainty using CerQual approach (appropriate for qualitative studies). Most studies were assessed as of moderate certainty owing to weaknesses in quality. Findings based on only one or two studies with methodological problems were assessed as low certainty.

Results

Key themes: (1) programmes acceptability, appropriateness and feasibility; (2) LHW motivations and incentives; (3) LHW training, supervision and working conditions; (4) patient flow processes; (5) service integration; and (6) social and cultural conditions.

Barriers and facilitators included these factors:

1. (1) Attitudes on programme acceptability, appropriateness and credibility (LHW–recipient relationship), knowledge and skills and motivation to change amongst all stakeholders:

   1. (a) LHW were more appreciated than health professionals because of their availability and kindness.

   2. (b) They responded to needs of the community and helped with the health professionals’ workload.

   3. (c) However, there appeared to be a misunderstanding between the health professional’s and LHW’s roles and difficulties in managing emotional relationships.

      Motivations and incentives included monetary, non-monetary, altruism, social recognition, career development.

2. (2) Health systems constraints (eg, accessibility of care, resources, communications, management, patient flow processes, strengthening service integration) through better understanding of LHW’s roles.

3. (3) Social and political constraints and cultural influences (eg, economic hardships, lack of responsiveness to community needs in some countries). Training issues, reflecting lack of services, importance of social recognition and respect were more often reported in low- to middle-income countries, with visible community support influencing the credibility of LHWs. The importance of LHW was emphasised in high-income countries, which received regular payment.

Implications for practice

Trained LHWs may be preferred over other health workers, and programme planners need to consider the positive relationship between LHWs and recipients. They could build on the facilitators such as developing services that recipients perceive as relevant, providing regular and visible support from the health system and the community, and providing appropriate training, supervision and incentives.

Implications for research

Further research from a broader group of stakeholders (including programme planners and mangers, policy makers and community leaders) is required to explore factors that influence the establishment and management of LHW programmes. Future trials of effectiveness should consider how LHWs are selected and trained, the impact of incentives and how the LHW programmes are integrated into health services. LHW–recipient relationship may influence outcomes and measuring this in future trials of LHW programme effectiveness would be useful.