The effectiveness of rural community health workers in improving health outcomes during the COVID-19 pandemic: a systematic review

Figures & data

Table 1. Definitions of terms.

Term	Definition
Community Health Workers	Refer to health workers working in communities. Depending on the country and the health system, they may be referred to as village health workers, volunteer health workers, lay health workers, and accredited social health activists [ASHAs] [27]
Rural areas	Refer to regions with population densities of fewer than 150 per square kilometer according to the OECD definition [28]
Health outcomes	A change in the health of an individual, group of people or population which is attributable to an intervention or series of interventions [29]
Low-and middle-income countries	Low income economies: Gross national income [GNI] per capita: $1,135 or less Lower middle income economies: GNI per capita: $1,136 to $4,465 Upper-Middle-Income: GNI per capita: $4,466 to $13,845 [30]

Figure 1. Conceptual framework [1,22–26,31,32]].

Figure 2. MRC complex interventions framework.

Table

	Author/Year	Country	Study design	Objective	Intervention	Phases of community health worker interventions according to the MRC complex intervention framework: development, feasibility, implementation, and evaluation phases [33].	Outcome measures	Main results	Risk of bias (L= low, H= high)	Comparative component in the study design (Y=there is a comparative component in the research design; N= there is no comparative component in the research design)
35	Reddy KP, 2021	South Africa	Cost effective analysis	To develop a dynamic COVID-19 microsimulation model to assess clinical and economic outcomes and cost-effectiveness of epidemic control strategies in KwaZulu-Natal province, South Africa.	Modeling interventions included community health worker-led mass symptom screening	Development phase	Incremental cost-effectiveness ratio (ICER)	Incremental cost-effectiveness ratio = $340 per year of life saved	L	Y
36	Hernandez S, 2020	Guatemala	Pilot interventional study	To train community health workers in mitigating infection risk using a low literacy checklist while providing essential healthcare, such as prenatal care, during the COVID‐19 pandemic.	Community health workers used a low literacy checklist to provide essential healthcare, such as prenatal care, during the COVID‐19 pandemic	Feasibility phase	Number of traditional birth attendants trained, and the number of training sessions	8 traditional birth attendants were trained during 5 training sessions	H	N
37	Reinders S, 2020	Peru	Mixed methods evaluation of a community health worker maternal and neonatal health program in Peru.	To explore indigenous communities’ responses to the COVID-19 pandemic and its consequences for maternal and neonatal health (MNH) care in the Peruvian Amazon	Community-based maternal and neonatal program with comprehensive supervision covering monthly meetings with community health workers (CHW), community leaders, and health facilities.	Implementation phase	Clusters of suspected COVID-19 cases; availability of COVID-19 test kits, training, and medical face masks; suspension of routine antenatal and postnatal services; and community health worker home visits.	There were no COVID-19 testing kits or medical face masks; antenatal and postnatal were suspended; and 2 out of 3 community health workers resumed their household visits.	H	N
38	Kaweenuttayanon N, 2021	Thailand	Interventional study	To form, train, and deploy COVID-19 surveillance teams, including village health workers to identify returnees from high-risk areas, encourage self-quarantine for 14 days, and monitor and report the development of any relevant COVID-19 symptoms	Training and deploying rural village health workers to identify and monitor returnees from high risk COVID-19 areas	Feasibility phase	Village health worker household visits; referrals of suspected cases of COVID-19, and the national incidence of COVID-19 cases.	Village health volunteers visited more than 14 million households during March and April 2020. Volunteers identified and monitored 809 911 returnees, and referred a total of 3346 symptomatic patients to hospitals by 13 July 2020. The countrywide number of new cases steadily declined from the peak on 22 March 2020 to reach less than 10 new cases per day by 27 April 2020	H	N
39	Isaac R, 2021	India	Interventional study with time series analysis of COVID-19 seroprevalence	To establish and evaluate a COVID-19 PCR-testing programme and conduct two COVID-19 seroprevalence surveys in the same community.	Establishing a COVID-19 PCR testing programme and conducting community based COVID-19 testing.	Feasibility phase	COVID-19 seroprevalence	The two seroprevalence surveys showed COVID-19 positivity rates of 2.2% in July/August 2020 and 22.0% in November 2020.	H	Y
40	Shaikh I, 2021	Pakistan	Pilot interventional study	Connecting women via lady health workers to access abortion, contraception, and other gynecological services during the COVID-19 pandemic.	A novel hybrid telemedicine-community accompaniment pilot to provide abortion services, contraception, and other gynecological consultations.	Feasibility phase	Number of women referred by lady health workers; and complete uterine evacuation and reports of adverse events following abortion services.	176 women were referred by lady health workers. 90% of the women accessing abortion services reported complete uterine evacuation. No serious adverse events were reported following abortion services.	H	N
41	Joshi U, 2022	India	Community health worker training program development including costs	To assess the costs of developing a digital program for training community health workers to deliver a psychological treatment for depression in a rural district of Madhya Pradesh, India.	No intervention.	Development phase	Cost of developing a digital community health worker program	The total cost of developing a digital community health worker program was 208,814 USD	H	N
42	Sivakumar T, 2023	India	Prospective interventional study	To examine the impact of incentivizing Accredited Social Health Activists on the outcome of persons with severe mental illness (SMI) during the COVID-19 pandemic.	Training Accredited Social Health Activists to identify persons with severe mental illness from their villages and refer them for treatment	Feasibility phase	Mental health disability and illness severity; work functioning, and self stigma	At one year follow-up, there were significant reductions in disability, illness severity, and self-stigma, and there was improved work performance.	H	Y
43	Singh SS, 2022	India	Interventional study	To implement a 1-day COVID-19 training programme for rural, unaccredited community health workers who had recently completed a community health education course from the National Institute of Open Schooling.	A one day COVID-19 training programme for rural, unaccredited community health workers	Feasibility phase	The number of community health workers completing the COVID-19 training program and the proportion of community health workers satisfied with the training program.	15 000 community health workers completed the COVID-19 training programme and 80% (81/102) were satisfied with the training.	H	N
44	Garg S, 2022	India	Program evaluation of a community health worker intervention	To assess the time use and payments of multipurpose community health workers for the various roles they play.	A well-established community health worker programme in India’s Chhattisgarh state with 71,000 multipurpose community health workers.	Implementation and evaluation phases	Time spent doing community health worker tasks; type of work done; and community health worker payments in relation to minimum wage.	Rural community health workers spent 25.3 hours per week on their community health worker tasks. Time-use was well balanced between roles of service-linkage, providing health education and curative care, COVID-19 related work and action on social determinants of health. The average payment earned was less than 60% of legal minimum wage.	H	N
45	Kharel R, 2022	Nepal	Pilot interventional study	To train female community health workers on the COVID-19 response.	Innovative training programme to rapidly equip female community health workers with knowledge on the COVID-19 response	Feasibility phase	The number of community health workers trained; and the mean pre and post intervention community health worker knowledge scores	300 community health workers were trained. The mean knowledge scores increased from 4.1 to 6.3 (t (105) = 7.8, p < 0.001)	H	Y
46	Akter F, 2022	Bangladesh	Mixed-methods interventional study	To assess the fidelity and explore the barriers and facilitators of the implementation of a community-based comprehensive social behavior communication intervention to increase community resilience through prevention, protection, and care for COVID-19.	A community-based comprehensive social behavior communication intervention to increase community resilience through prevention, protection, and care for COVID-19	Feasibility phase	Community support team knowledge	Knowledge about wearing mask, keeping social distance, washing hands and COVID-19 symptoms were high (on average more than 70%) among community support team members.	H	N
47	Gore M, 2022	India	Qualitative study of accredited social health activists in India	To describe accredited social health activists’ (ASHAs) work roles before and during the COVID-19 pandemic, explore the tasks ASHAs performed throughout the pandemic, and understand its effects on the evolving role of ASHAs.	ASHAs were trained online and in-person to respond to the COVID-19 pandemic.	Feasibility phase	Perspectives of accredited social health activists	COVID-19 activities increased the workload and health risks of accredited social health activists leading to increased stress levels experienced by accredited social health activists.	H	N
48	Kok MO, 2023	Uganda	Mixed-methods interventional study	To assess the functioning of a telehealth intervention that was set up to support community health workers during the COVID-19 pandemic.	3,500 Community Health Workers (CHW) were trained to identify, refer and care for potential COVID-19 cases. A call center staffed by health professionals supported CHWs in diagnosing and managing patients with COVID-19.	Feasibility phase	Number of community health worker calls to the call center and stakeholder perspectives	There were 35,553 community health worker calls to the call center. According to community health workers, there were no signs that people in their communities were suffering from severe health problems due to COVID-19. After experiencing Ebola outbreaks, they were skeptical about thedangers of COVID-19 infections.	H	N
49	Gebremeskel AT, 2023	Ethiopia	Qualitative study of a community health worker program in Ethiopia	To critically examine the multifaceted fragmentation challenges of Ethiopia’s Community Health Workers (CHWs) program to deliver optimal maternal newborn and child health services.	A community health worker program delivering maternal newborn and child health services in rural Ethiopia	Evaluation phase	Perspectives of stakeholders	Stakeholder perspectives highlighted significant fragmentation of different components of the community health worker intervention including financing, supplies, community health worker empowerment and coordination, and stakeholder engagement	H	N

Figure 3. The PRISMA flow chart.

Figure 4. The effectiveness of rural CHWs in LMICs during the COVID-19 pandemic as shown by increased access to health services and improved COVID-19 and non COVID-19 health outcomes.

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