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Review
, 2010 (3), CD004015

Lay Health Workers in Primary and Community Health Care for Maternal and Child Health and the Management of Infectious Diseases

Affiliations
Review

Lay Health Workers in Primary and Community Health Care for Maternal and Child Health and the Management of Infectious Diseases

Simon Lewin et al. Cochrane Database Syst Rev.

Abstract

Background: Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions.

Objectives: To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases.

Search strategy: For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers.

Selection criteria: Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients.

Data collection and analysis: Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained.

Main results: Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective.

Authors' conclusions: LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.

Conflict of interest statement

JOJ, MZ, SL, and SMB are editors for the Cochrane Effective Practice and Organisation of Care Review Group. SL and CG are editors for the Cochrane Consumers and Communication Review Group. MJ is a trial search coordinator for the Cochrane Effective Practice and Organisation of Care Review Group. MZ was the principal investigator on one of the included trials (Zwarenstein 2000).

Figures

Figure 1
Figure 1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Figure 2
Figure 2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Figure 3
Figure 3
Forest plot of comparison: 1 LHW interventions to promote immunisation uptake in children under five compared with usual care, outcome: 1.5 Immunisation schedule up to date.
Figure 4
Figure 4
Forest plot of comparison: 1 LHW interventions to promote immunisation uptake in children under five compared with usual care, outcome: 1.8 Immunisation schedule up to date (excl. Gökcay and Krieger).
Figure 5
Figure 5
Forest plot of comparison: 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, outcome: 3.2 Mortality among children < 5 years old.
Figure 6
Figure 6
Forest plot of comparison: 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, outcome: 3.3 Mortality among children < 5 years old (excluding Pence 2005).
Figure 7
Figure 7
Forest plot of comparison: 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, outcome: 3.5 Neonatal mortality.
Figure 8
Figure 8
Forest plot of comparison: 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, outcome: 3.7 Morbidity; reported illness in children.
Figure 9
Figure 9
Forest plot of comparison: 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, outcome: 3.9 Morbidity; care‐seeking practice.
Figure 10
Figure 10
Forest plot of comparison: 2 LHW interventions to promote breastfeeding compared with usual care, outcome: 2.6 Initiated Breastfeeding ‐ adjusted for clustering.
Figure 11
Figure 11
Forest plot of comparison: 2 LHW interventions to promote breastfeeding compared with usual care, outcome: 2.7 Any breastfeeding ‐ adjusted for clustering.
Figure 12
Figure 12
Forest plot of comparison: 2 LHW interventions to promote breastfeeding compared with usual care, outcome: 2.8 Exclusive breastfeeding ‐ adjusted for clustering.
Figure 13
Figure 13
Forest plot of comparison: 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, outcome: 4.10 Cure for smear positive TB patients (new and retreatment) ‐ adjusted for clustering.
Figure 14
Figure 14
Forest plot of comparison: 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, outcome: 4.1 Cure for smear positive TB patients (new and retreatment), excluding Mohan 2003 and Clarke 2005 ‐ adjusted for clustering.
Figure 15
Figure 15
Forest plot of comparison: 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, outcome: 4.11 New smear positives cured ‐ adjusted for clustering.
Figure 16
Figure 16
Forest plot of comparison: 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, outcome: 4.13 Combined cure and treatment completion for all pulmonary TB patients ‐ adjusted for clustering.
Figure 17
Figure 17
Forest plot of comparison: 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, outcome: 4.14 TB Preventive therapy with Isoniazid ‐ completed therapy.
Analysis 1.1
Analysis 1.1
Comparison 1 LHW interventions to promote immunisation uptake in children under five compared with usual care, Outcome 1 Immunisation schedule up to date ‐ unadjusted.
Analysis 1.2
Analysis 1.2
Comparison 1 LHW interventions to promote immunisation uptake in children under five compared with usual care, Outcome 2 Immunisation schedule up to date ‐ adjusted for clustering.
Analysis 1.3
Analysis 1.3
Comparison 1 LHW interventions to promote immunisation uptake in children under five compared with usual care, Outcome 3 Immunisation schedule up to date (excl. Gökcay and Krieger).
Analysis 2.1
Analysis 2.1
Comparison 2 LHW interventions to promote breastfeeding compared with usual care, Outcome 1 Initiated Breastfeeding.
Analysis 2.2
Analysis 2.2
Comparison 2 LHW interventions to promote breastfeeding compared with usual care, Outcome 2 Any Breastfeeding.
Analysis 2.3
Analysis 2.3
Comparison 2 LHW interventions to promote breastfeeding compared with usual care, Outcome 3 Exclusive breastfeeding (6 weeks ‐ 6 months).
Analysis 2.4
Analysis 2.4
Comparison 2 LHW interventions to promote breastfeeding compared with usual care, Outcome 4 Initiated Breastfeeding ‐ adjusted for clustering.
Analysis 2.5
Analysis 2.5
Comparison 2 LHW interventions to promote breastfeeding compared with usual care, Outcome 5 Any Breastfeeding ‐ adjusted for clustering.
Analysis 2.6
Analysis 2.6
Comparison 2 LHW interventions to promote breastfeeding compared with usual care, Outcome 6 Exclusive Breastfeeding ‐ adjusted for clustering.
Analysis 3.1
Analysis 3.1
Comparison 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, Outcome 1 Mortality among children < 5 years old ‐ unadjusted.
Analysis 3.2
Analysis 3.2
Comparison 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, Outcome 2 Mortality among children < 5 years old.
Analysis 3.3
Analysis 3.3
Comparison 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, Outcome 3 Mortality among children < 5 years old (Excl. Pence).
Analysis 3.4
Analysis 3.4
Comparison 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, Outcome 4 Neonatal mortality ‐ unadjusted.
Analysis 3.5
Analysis 3.5
Comparison 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, Outcome 5 Neonatal mortality.
Analysis 3.6
Analysis 3.6
Comparison 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, Outcome 6 Morbidity; reported illness in children ‐ unadjusted.
Analysis 3.7
Analysis 3.7
Comparison 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, Outcome 7 Morbidity; reported illness in children.
Analysis 3.8
Analysis 3.8
Comparison 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, Outcome 8 Morbidity; care‐seeking practice ‐ unadjusted.
Analysis 3.9
Analysis 3.9
Comparison 3 LHW interventions to reduce mortality/morbidity in children under five compared with usual care, Outcome 9 Morbidity; care‐seeking practice.
Analysis 4.1
Analysis 4.1
Comparison 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, Outcome 1 Cure for smear positive TB patients (new and retreatment) ‐ adjusted for clustering.
Analysis 4.2
Analysis 4.2
Comparison 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, Outcome 2 Cure for smear positive TB patients (new and retreatment).
Analysis 4.3
Analysis 4.3
Comparison 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, Outcome 3 Cure for smear positive TB patients (new and retreatment) ‐ adjusted for clustering.
Analysis 4.4
Analysis 4.4
Comparison 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, Outcome 4 New smear positives cured ‐ adjusted for clustering.
Analysis 4.5
Analysis 4.5
Comparison 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, Outcome 5 Combined cure and treatment completion for all pulmonary TB patients.
Analysis 4.6
Analysis 4.6
Comparison 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, Outcome 6 Combined cure and treatment completion for all pulmonary TB patients ‐ adjusted for clustering.
Analysis 4.7
Analysis 4.7
Comparison 4 LHW interventions to improve TB treatment outcomes compared with other forms of adherence support, Outcome 7 TB Preventive therapy with Isoniazid ‐ completed therapy.

Update of

  • Lay Health Workers in Primary and Community Health Care
    SA Lewin et al. Cochrane Database Syst Rev (1), CD004015. PMID 15674924. - Review
    LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other …

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