Description of the condition
The Millennium Development Goals 4, 5 and 6 aim to reduce child mortality, improve maternal health and combat HIV/AIDS, malaria and other diseases. A key obstacle to the achievement of these goals is the chronic shortage and poor distribution of health workers in many countries (WHO 2010). One important approach to this problem is the moving of tasks to health workers with less training, or “task-shifting” (sometimes referred to as “optimising”), for instance by transferring certain tasks from doctors to nurses, midwives, or lay health workers. By re-organising the health workforce in this way, policy makers hope to make more efficient use of the human resources already available and thereby expand and strengthen coverage of key health interventions (WHO/PEPFAR/UNAIDS 2007; WHO 2012).
Description of the intervention
Lay health workers (LHWs) perform diverse functions related to healthcare delivery. While LHWs are usually provided with job-related training, they have no formal professional or paraprofessional tertiary education and can be involved in either paid or voluntary care. The term LHW is thus necessarily broad in scope and includes, for example, community health workers, village health workers, treatment supporters and birth attendants.
The primary healthcare approach adopted by the World Health Organization (WHO) at Alma-Ata promoted the initiation and rapid expansion of LHW programmes in low and middle income country (LMIC) settings in the 1970s, including a number of large national programmes (Walt 1990). However, the effectiveness and cost of such programmes came to be questioned in the following decade, particularly at a national level in the LMICs. Several evaluations were conducted and these indicated difficulties in the scaling up of LHW programmes, as a consequence of a range of factors. Important constraints included inadequate training and ongoing supervision; insecure funding for incentives, equipment and drugs; failure to integrate LHW initiatives with the formal health system; poor planning; and opposition from health professionals (Frankel 1992; Walt 1990). These constraints led to poor quality care and difficulties in retaining trained LHWs in many of the programmes.
The 1990s saw renewed interest in community or LHW programmes in LMICs. This was prompted by a number of factors including the growing AIDS epidemic; the resurgence of other infectious diseases; and the failure of the formal health system to provide adequate care for people with chronic illnesses (Hadley 2000; Maher 1999). The growing emphasis on decentralisation and partnership with community-based organisations also contributed to this renewed interest. In high income country settings, a perceived need for mechanisms to deliver health care to minority communities and to support people with a wide range of health issues (Hesselink 2009; Witmer 1995) led to further growth in a variety of LHW interventions.
More recently, the growing focus on the human resource crisis in health care in many LMICs has re-energised debates regarding the roles that LHWs may play in extending services to 'hard to reach' groups and areas; and in substituting for health professionals for a range of tasks (Chopra 2008; WHO 2005; WHO 2006; WHO 2007). Task shifting is not a new concept; however, it has been given particular prominence and urgency in the face of the demands placed on health systems in a number of settings by the increased need for treatment of HIV/AIDS (Hermann 2009; Lehmann 2009; Schneider 2008; Zachariah 2009). Within this context, it is thought that LHWs may be able to play an important role in helping to achieve the Millennium Development Goals for health, particularly for child survival and treatment of tuberculosis (TB) and HIV/AIDS (Chen 2004; Filippi 2006; Haines 2007; Lewin 2008). For example, LHWs may be one route to expanding the coverage of effective neonatal and child health interventions, such as exclusive breastfeeding and community-based case management of pneumonia, which remains under 50% in many LMICs (Darmstadt 2005).
In contrast to earlier initiatives that tended to focus on generalist LHWs delivering a range of services within communities, more recent programmes have often been vertical in their approach. In these programmes LHWs deliver a single or a small number of focused interventions addressing a particular health issue, such as promotion of vaccination; or one aspect of treatment care, such as supporting treatment adherence for people with tuberculosis (TB) (Lehmann 2007; Schneider 2008).
Why it is important to do this review
The Cochrane review on the effectiveness of lay health worker programmes for maternal and child health and infectious diseases (Lewin 2010) identified a total of 82 randomised trials, representing a substantial body of evidence regarding the effectiveness of these types of programmes. In these trials, lay health workers received a small amount of training to perform a range of health services, often targeting common causes of childhood mortality and morbidity. The review concluded that these types of programmes can effectively deliver key maternal and child health interventions in primary and community healthcare, including interventions to increase childhood immunisation rates and breastfeeding rates.
While the review concluded that this approach is promising, the results of these trials were heterogeneous, which, given the complexity of these types of interventions, was not unexpected. In addition, the level of organisation and support used on these interventions may have been higher than in real-life settings. If these types of interventions are to be successfully implemented and scaled up, we need a fuller understanding of the factors that may influence their success and sustainability. These may include values and preferences of stakeholders and the feasibility and applicability of the intervention for particular settings and health care systems. While Cochrane reviews of effectiveness are not designed to answer these types of questions, there is growing acknowledgement that syntheses of qualitative research can address questions like those raised here.
It is also increasingly recognised that bringing together qualitative studies in one systematic review can add value by allowing us to see both similarities and differences that exist across various contexts. As with systematic reviews of effectiveness, reviews of qualitative data should be carried out in a systematic and transparent way. The last few years have seen strong development in systematic review methodology for summarising data from multiple qualitative studies, including within The Cochrane Collaboration (Noyes 2009), and the Cochrane Qualitative Research Methods Group has identified around 500 such reviews.
While high-quality systematic reviews of qualitative evidence can, on their own, prove valuable to researchers and policymakers, pairing qualitative reviews with systematic reviews of (quantitative) effectiveness data allows for even more comprehensive insights into single topic areas. At least one Cochrane review has previously prompted a “matching” review of qualitative data. The Cochrane review of directly observed therapy (DOT) versus self-administered treatment for adherence to TB treatment showed that DOT, despite its widespread use, does not achieve better outcomes (Volmink 2007). Two parallel reviews, both co-authored by members of the current research team (Munro 2007; Noyes 2007), searched for qualitative studies on factors explaining non-adherence to TB treatment. Together, these qualitative reviews not only provided supporting evidence regarding the intervention’s lack of effect but also helped explain this lack of effect and inform policy and the design of more appropriate interventions (Garner 2007). Qualitative evidence also helped to clarify the many, often context-specific barriers and facilitators to accessing and complying with complex interventions to promote medicines management and treatment.
Pairing reviews of effect with reviews of qualitative studies is equally relevant in the field of health workforce interventions and a large body of relevant qualitative research exists. This research has described barriers and facilitators to the success of interventions targeting different aspects of human resources for health. These factors include the attitudes and experience of the health workers themselves and also those of other stakeholders, such as the health professionals they work with or whose tasks they have taken over and the communities they serve. On the one hand, health workers taking on new tasks may appreciate the opportunity to be more useful as well as gaining increased salaries and public recognition (De Brouwere 2009). On the other hand, task shifting may not be accompanied by sufficient supervision or compensation and can create confusion, role conflicts and competition between health worker groups (De Brouwere 2009; Yakan 2009).
Previously, we had attempted to identify all qualitative studies that were carried out alongside the 82 trials included in the review of lay health worker programme effectiveness. Here, we contacted authors of all the included trials, checked papers for references to qualitative research, searched Pubmed for related studies, and carried out citation searches. However, we were only able to find qualitative research that had been done during or after the trial for only 14 (17%) of the trials (Glenton 2011). In addition, descriptions of qualitative methods and results were often sparse. Therefore, we decided to look for qualitative studies that explored lay health worker programmes in any context, either alongside or outside a trial context.
The current review is one of a series of reviews of qualitative research that aim to inform the World Health Organization's "Recommendations for Optimizing Health Worker Roles to Improve Access to key Maternal and Newborn Health Interventions through Task Shifting" (OPTIMIZEMNH) (WHO 2012).
To explore factors affecting the implementation of lay health worker programmes for maternal and child health.
The review has the following specific objectives:
- to identify, appraise and synthesise qualitative research evidence on barriers and facilitators to the implementation of lay health worker programmes for maternal and child health;
- to integrate the findings of this review of qualitative research evidence with those of the update of the relevant Cochrane review of effectiveness (Lewin 2012) so as to enhance and extend our understanding of how these complex interventions work and how context impacts on implementation;
- to identify hypotheses for subgroup analyses of future updates of the Cochrane review of the effectiveness of lay health worker programmes (Lewin 2012).
Criteria for considering studies for this review
Types of studies
This is a systematic review of primary qualitative studies. We will employ a broad definition of qualitative studies and include all studies that use qualitative methods for data collection (including focus group and individual interviews, observation, and document analysis) and that use qualitative methods for data analysis. We will exclude studies that collect data using qualitative methods but do not analyse those data qualitatively.
Types of participants
The review will include studies that focus on the experiences and attitudes of stakeholders about lay health worker programmes. Relevant stakeholders include the lay health workers themselves, patients and their families/carers, the general public, policy makers, programme managers, other health workers, and any others directly involved in or affected by the programme.
Types of interventions
We will include studies focusing on programmes that intend to improve maternal or child health and that use any type of lay health worker (paid or voluntary) including community health workers, village health workers, birth attendants, peer counsellors, nutrition workers and home visitors.
For the purpose of this review, we have defined "lay health worker" as any health worker who:
- performs functions related to healthcare delivery,
- is trained in some way in the context of the intervention, but
- has received no formal professional or paraprofessional certificate or tertiary education degree (Lewin 2005).
We have also adopted the same definitions of maternal and child health care that were used in the Cochrane review of lay health worker programme effectiveness (Lewin 2010):
- child health: health care aimed at improving the health of children aged less than five years;
- maternal health: health care aimed at improving reproductive health, ensuring safe motherhood, or directed at women in their role as carers for children aged less than five years.
While the Cochrane intervention review also evaluated the effectiveness of lay health worker programmes on infectious diseases, we have decided not to include this topic in the current review. We need to limit our scope in order to make the review of qualitative evidence manageable, and anticipate that studies of lay health worker infectious disease interventions will be substantially different from those in the field of maternal and child health.
Types of outcome measures
Type of phenomena of interest: The review will include studies where the phenomenon of interest is a description and interpretation of the experiences and attitudes of stakeholders towards lay health worker programmes.
Search methods for identification of studies
We will search the following electronic databases for eligible studies:
- MEDLINE, Ovid In-Process & Other Non-Indexed Citations
- MEDLINE, Ovid
- British Nursing Index and Archive, Ovid
- CINAHL, Ebsco
A search strategy has previously been developed for the Cochrane review of lay health worker programme effectiveness (Lewin 2010), including a comprehensive list of terms used in the literature to describe lay health worker interventions. We will use these terms but will remove the methods filter that was used to identify randomised trials. When searching MEDLINE ( Table 1) and CINAHL ( Table 2), we will instead make use of their filter for qualitative studies, choosing the “specificity” alternative for MEDLINE and the “Qualitative – Best balance” alternative for CINAHL. When searching the British Nursing Index ( Table 3), we will use terms based on the MEDLINE methods filter.
Searches will be limited to English for feasibility reasons, given that it is extremely time-consuming and costly to undertake full text translation into English of qualitative papers for inclusion in the review. There will be no geographic restrictions.
In addition to the electronic searches described above, we will contact experts in the field and will include studies that were carried out alongside the trials from the lay health worker programme effectiveness review (Lewin 2010), and those we have previously identified through database searches and contact with trial authors (Glenton 2011). We will also search reference lists of all papers and relevant reviews identified.
Data collection and analysis
Selection of studies
Two review authors will independently assess the titles and abstracts of the identified records to evaluate their potential eligibility; those that are clearly irrelevant to the topic of this study will be discarded at this stage. The full text of all the papers identified as potentially relevant by one or both review authors will be retrieved. These papers will then be assessed independently by two review authors, based on the review's inclusion criteria. At all stages, disagreements between the review authors will be resolved via discussion or, if required, by seeking a third review author's view. Where appropriate, we will contact the study authors for further information.
Data extraction and management
Data extraction will be performed using a data extraction form designed specifically for this review and informed by the SURE framework for identifying factors affecting the implementation of a policy option (The SURE Collaboration 2011). This framework includes the following factors: (a) knowledge and skills; attitudes regarding programme acceptability, appropriateness and credibility; and motivation to change or adopt new behaviours among recipients of care, providers of care, and other stakeholders; (b) health system constraints (including accessibility of care, financial resources, human resources, educational system, clinical supervision, internal communication, external communication, allocation of authority, accountability, management or leadership (or both), information systems, facilities, patient flow processes, procurement and distribution systems, incentives, bureaucracy, and relationship with norms and standards); and (c) social and political constraints (including ideology, short-term thinking, contracts, legislation or regulations, donor policies, influential people, corruption, and political stability).
Additional information will be extracted concerning the first author’s name; year of publication; language; country of study; clinical area; setting of the study (primary health centre or community; rural / urban, etc). We will also make note of limitations or important gaps in reporting.
A pilot trial of the data extraction form will be conducted to check its adequacy and changes will be made if necessary. In addition, we will add categories or topics to the list derived from the SURE framework as data extraction progresses and new areas are identified.
Assessment of risk of bias in included studies
Appraisal of study quality: Our inclusion criteria specifies that included studies need to use both qualitative data collection and analysis methods. This criterion also constitutes a basic quality threshold as we will exclude studies that have used qualitative methods to collect data but not to analyse these data.
In addition, and following Cochrane Qualitative Research Methods Group guidance (Noyes 2011), two researchers will apply a quality appraisal framework to each included study. Appraisal will be performed using an adaptation of the Critical Appraisal Skills Programme (CASP) quality assessment tool for qualitative studies (CASP 2006), as in other reviews of qualitative evidence (Carlsen 2007; Munro 2007). The following questions will be used:
1) Is the study context clearly described?
2) Is there evidence of researcher reflexivity?
3) Is the sampling method clearly described and appropriate for the research question?
4) Is the method of data collection clearly described and appropriate to the research question?
5) Is the method of analysis clearly described and appropriate to the research question?
6) Are the claims made supported by sufficient evidence, i.e. did the data provide sufficient depth, detail and richness?
Since the aim of the review is to obtain a fuller understanding of the factors that may influence programme success and sustainability, we will include studies that meet our inclusion criteria regardless of study quality. We will use the quality assessment when judging the relative contribution of each study to the development of explanations and relationships, as described in more detail below. In addition, it has been noted that poorer quality studies tend to contribute less to the synthesis. Therefore, the synthesis becomes ‘‘weighted’’ towards the findings of the better quality studies. Also, there is currently no consensus among qualitative researchers on the role of quality criteria and how they should be applied, and there is ongoing debate about how study quality should be assessed for the purposes of systematic reviews (Atkins 2008).
Appraisal of certainty of review findings: Few methods for assessing the certainty of findings drawn from syntheses of qualitative evidence have been developed. To assess how much certainty can be placed in the qualitative evidence for each review finding, we have therefore chosen to apply a novel approach, which we refer to as the CerQual (certainty of the qualitative evidence) approach (Figure 1). By certainty we mean how likely it is that the review finding happened in the contexts of the included studies and could happen elsewhere.
|Figure 1. Assessing the certainty of findings from syntheses of qualitative evidence: the CerQual approach|
In this approach our assessments of certainty are based on two factors: the methodological quality of the individual studies contributing to a review finding and the plausibility of each review finding.
Findings that are drawn from well-conducted studies can be regarded as more dependable (Lincoln 1985). We will therefore appraise how well the individual studies which contributed to the evidence of a review finding were conducted (methodological quality), using an adaptation of the Critical Appraisal Skills Programme (CASP) quality-assessment tool for qualitative studies (CASP 2006).
In addition to appraising the methodological quality of the individual studies that contribute to a review finding, we will also assess the plausibility of each review finding. We will assess plausibility by looking at the extent to which we are able to identify a clear pattern across the individual study data. This pattern could include, for example, circumstances where the review finding is consistent across multiple contexts or where the review finding incorporates explanations for any variations across individual studies. The plausibility of the review findings may be further strengthened if the individual studies contributing to the finding are drawn from a wide range of settings.
We will use three levels to indicate the certainty of the qualitative evidence – high, moderate and low. We will rate findings drawn from generally well-conducted studies – and showing high levels of plausibility – to be of ‘high’ certainty. Findings will be assessed as ‘moderate’ certainty where there are concerns regarding either the methodological quality of the studies or the plausibility of the review finding. Where there are concerns regarding both the methodological quality of the studies and the plausibility of the review finding, the finding will be assessed as being of ‘low’ certainty.
The CerQual approach is similar to the GRADE approach (Guyatt 2011) in the sense that both approaches aim to assess the certainty of (or confidence in) the evidence, and both also rate this certainty for each finding across studies. The GRADE approach also bases its judgement of certainty on an assessment of the quality of the evidence and other factors, including consistency across studies. However, GRADE is designed to assess the certainty of evidence regarding the effectiveness of an intervention, and is therefore not suitable for use when appraising the certainty of evidence regarding other types of questions and data, including questions about people’s perceptions and experiences that are assessed using qualitative methods. CerQual provides an approach that may be used for findings derived from syntheses of qualitative evidence.
The CerQual approach is also similar to one used by Goldsmith et al (Goldsmith 2007). In their synthesis of qualitative research, they assess the overall quality of the evidence for each individual finding by evaluating the quality, consistency and directness of the evidence. We have chosen not to refer to the directness of the evidence as it can be argued that, in the context of qualitative evidence syntheses, this dimension needs to be assessed by the user/s of the evidence.
As a final step, we will prepare summary tables of the findings of the qualitative evidence synthesis. These “Summary of qualitative findings” tables will be similar to “Summary of Findings” tables used in Cochrane reviews of effectiveness and will summarise the key findings, the certainty of evidence for each finding, and also provide an explanation of the assessment of the certainty of the qualitative evidence.
The CerQual approach is also being used in another Cochrane Review of qualitative evidence (Rashidian 2013).
Assessment of heterogeneity
Differences across the studies with regard to the study setting and the nature of the tasks being delivered will be recorded and will inform the analyses (see Subgroup analysis and investigation of heterogeneity).
Four review authors will analyse and synthesise the qualitative evidence using a thematic analysis approach (Dixon-Woods 2005). This is one of several approaches recommended by the Cochrane Qualitative Review Methods Group (Noyes 2011) and may be particularly appropriate where evidence is likely to offer only thin description and is likely to be largely descriptive as opposed to highly theorised or conceptual.
When identifying themes and categories, the authors will be guided by the SURE Framework, a framework of factors that may influence the implementation of health system interventions (The SURE Collaboration 2011). Our first step will be to develop a preliminary synthesis of the findings. Four review authors will independently read and re-read the selected studies and identify key themes and categories. The authors will search for themes until all the studies have been reviewed. The definitions and boundaries of each of the emerging themes will be discussed among the authors. Finally, one author will refine the themes and categories and, as far as possible, allocate them within the SURE Framework. The SURE framework may also be revised in line with the ideas and categories emerging.
The authors will use the SURE Framework to guide their analysis for two reasons. First of all, it provides us with a comprehensive list of possible factors that could influence intervention implementation. Secondly, the current review is one of four reviews of qualitative research that aim to inform the World Health Organization's OPTIMIZEMNH Guidelines (WHO 2012). The use of the SURE Framework across these reviews makes it possible to carry out an overarching analysis of factors influencing optimisation among different health worker groups.
Parallel synthesis of the qualitative evidence and the intervention review: The authors will bring together the results of the current review and the Cochrane review on LHW programme effectiveness (Lewin 2012). Through this parallel synthesis, we will explore how the qualitative evidence can shed light on processes, contextual factors, or intervention characteristics that may have influenced trial outcomes, and that can help explain heterogeneous results across trials. The intervention review includes a number of topics, e.g. breastfeeding and treatment support for tuberculosis, where there is substantial variation in the size of effect across studies. We plan to explore whether the data from the qualitative review helps generate hypotheses as to why this variation might have occurred. When doing so, we will take into consideration issues including the settings and time periods in which the qualitative studies were carried out in relation to the effectiveness evidence.
In addition, the qualitative evidence will offer information about stakeholders' views about the interventions described in the intervention review.
Subgroup analysis and investigation of heterogeneity
We will explore whether certain factors tied to the intervention and the context of the intervention are associated with differences in the type of facilitators and barriers to successful implementation that we identify. Specifically, we will explore whether there were differences between high, middle and low income countries in the barriers and facilitators we identify, and whether there were differences between lay health worker programmes delivering simple tasks and programmes delivering more complex tasks.
We thank Marit Johansen and Andrew Booth for their valuable support in developing the search strategies for this review. The section of the protocol entitled "Description of the intervention" is drawn largely from Lewin 2010, with small adaptations. We thank Heather Munthe-Kaas for her contribution to the development the CerQual approach.
Contributions of authors
CG, SL and CC conceptualised the review. CG, CC, BC, AS, SL, JN and AR prepared the protocol. Marit Johansen developed the search strategy. CG, CC, BC and AS will actively participate in all stages of the review (conduct search, obtain data, data extraction, synthesise data, prepare review, keep the review up to date). SL, JN and AR will help edit the review.
Declarations of interest
Simon Lewin is an editor for the Effective Practice and Organisation of Care Review Group. Claire Glenton and Simon Lewin are editors for the Cochrane Consumers and Communication Review Group. Jane Noyes is co-convener of the Cochrane Qualitative Methods Review Group. The other review authors have no conflicts of interest.
Sources of support
- No sources of support supplied
- Alliance for Health Policy and Systems Research, Implementation Research Platform, Switzerland.We received funding from the Alliance for Health Policy and Systems Research, Implementation Research Platform: WHO-AHPSR grant 2011/138613-2