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Feyssa MD, Gebru SK. Liberalizing abortion to reduce maternal mortality: expanding access to all Ethiopians. Reprod Health 2022; 19:151. [PMID: 35761348 PMCID: PMC9237962 DOI: 10.1186/s12978-022-01457-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mekdes Daba Feyssa
- St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. .,Center for International Reproductive Health Training, Addis Ababa, Ethiopia.
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Tran NT, Greer A, Dah T, Malilo B, Kakule B, Morisho TF, Asifiwe DK, Musa H, Simon J, Meyers J, Noznesky E, Neusy S, Vranovci B, Powell B. Strengthening healthcare providers' capacity for safe abortion and post-abortion care services in humanitarian settings: lessons learned from the clinical outreach refresher training model (S-CORT) in Uganda, Nigeria, and the Democratic Republic of Congo. Confl Health 2021; 15:20. [PMID: 33823880 PMCID: PMC8022315 DOI: 10.1186/s13031-021-00344-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/11/2021] [Indexed: 11/30/2022] Open
Abstract
Background Fragile and crisis-affected countries account for most maternal deaths worldwide, with unsafe abortion being one of its leading causes. This case study aims to describe the Clinical Outreach Refresher Training strategy for sexual and reproductive health (S-CORT) designed to update health providers’ competencies on uterine evacuation using both medications and manual vacuum aspiration. The paper also explores stakeholders’ experiences, recommendations for improvement, and lessons learned. Methods Using mixed methods, we evaluated three training workshops that piloted the uterine evacuation module in 2019 in humanitarian contexts of Uganda, Nigeria, and the Democratic Republic of Congo. Results Results from the workshops converged to suggest that the module contributed to increasing participants’ theoretical knowledge and possibly technical and counseling skills. Equally noteworthy were their confidence building and positive attitudinal changes promoting a rights-based, fearless, non-judgmental, and non-discriminatory approach toward clients. Participants valued the hands-on, humanistic, and competency-based training methodology, although most regretted the short training duration and lack of practice on real clients. Recommendations to improve the capacity development continuum of uterine evacuation included recruiting the appropriate health cadres for the training; sharing printed pre-reading materials to all participants; sustaining the availability of medication and supplies to offer services to clients after the training; and helping staff through supportive supervision visits to accelerate skills transfer from training to clinic settings. Conclusions When the lack of skilled human resources is a barrier to lifesaving uterine evacuation services in humanitarian settings, the S-CORT strategy could offer a rapid hands-on refresher training opportunity for service providers needing an update in knowledge and skills. Such a capacity-building approach could be useful in humanitarian and fragile settings as well as in development settings with limited resources as part of an overall effort to strengthen other building blocks of the health system.
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Affiliation(s)
- Nguyen Toan Tran
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia. .,Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1206, Genève, Switzerland. .,Training Partnership Initiative of the Inter-Agency Working Group on Reproductive Health in Crises, Women's Refugee Commission, 15 West 37th Street, New York, NY, 10018, USA.
| | - Alison Greer
- Training Partnership Initiative of the Inter-Agency Working Group on Reproductive Health in Crises, Women's Refugee Commission, 15 West 37th Street, New York, NY, 10018, USA
| | - Talemoh Dah
- Federal Medical Centre, Keffi, Nasarawa State, PMB 1004, Nigeria
| | - Bibiche Malilo
- Save the Children International DRC, 16 Avenue Avenue des Ecoles, Quartier les Volcans, Commune de Goma, North Kivu, Democratic Republic of the Congo
| | - Bergson Kakule
- CARE International DRC, Kinshasa, Democratic Republic of the Congo
| | | | | | - Happiness Musa
- CARE International Nigeria, 289 Amolai Road, GRA, Maiduguri, Nigeria
| | - Japheth Simon
- CARE International Nigeria, 289 Amolai Road, GRA, Maiduguri, Nigeria
| | - Janet Meyers
- Save the Children, 899 N Capitol Street, NE, Washington, DC, 20002, USA
| | | | - Sarah Neusy
- Doctors of The World/Médecins du Monde, France Headquarters, 62 rue Marcadet, 75018, Paris, France
| | - Burim Vranovci
- Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1206, Genève, Switzerland
| | - Bill Powell
- Ipas, P.O. Box 9990, Chapel Hill, NC, 27515, USA
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Scott K, George AS, Ved RR. Taking stock of 10 years of published research on the ASHA programme: examining India's national community health worker programme from a health systems perspective. Health Res Policy Syst 2019; 17:29. [PMID: 30909926 PMCID: PMC6434894 DOI: 10.1186/s12961-019-0427-0] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As India's accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale. METHODS We systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW-health systems interface framework. RESULTS A total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results. CONCLUSION Published work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.
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Affiliation(s)
| | - Asha S. George
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town, 7535 South Africa
| | - Rajani R. Ved
- National Health Systems Resource Centre, New Delhi, India
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Determination of medical abortion success by women and community health volunteers in Nepal using a symptom checklist. BMC Pregnancy Childbirth 2018; 18:161. [PMID: 29751788 PMCID: PMC5948871 DOI: 10.1186/s12884-018-1804-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 04/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background We sought to determine if female community health volunteers (FCHVs) and literate women in Nepal can accurately determine success of medical abortion (MA) using a symptom checklist, compared to experienced abortion providers. Methods Women undergoing MA, and FCHVs, independently assessed the success of each woman’s abortion using an 8-question symptom checklist. Any answers in a red-shaded box indicated that the abortion may not have been successful. Women’s/FCHVs’ assessments were compared to experienced abortion providers using standard of care. Results Women’s (n = 1153) self-assessment of MA success agreed with abortion providers’ determinations 85% of the time (positive predictive value = 90, 95% CI 88, 92); agreement between FCHVs and providers was 82% (positive predictive value = 90, 95% CI 88, 92). Of the 92 women (8%) requiring uterine evacuation with manual vacuum aspiration (n = 84, 7%) or medications (n = 8, 0.7%), 64% self-identified as needing additional care; FCHVs identified 61%. However, both women and FCHVs had difficulty recognizing that an answer in a red-shaded box indicated that the abortion may not have been successful. Of the 453 women with a red-shaded box marked, only 35% of women and 41% of FCHVs identified the need for additional care. Conclusion Use of a checklist to determine MA success is a promising strategy, however further refinement of such a tool, particularly for low-literacy settings, is needed before widespread use.
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Iyengar K, Iyengar SD, Danielsson KG. Can India transition from informal abortion provision to safe and formal services? LANCET GLOBAL HEALTH 2018; 4:e357-8. [PMID: 27198832 DOI: 10.1016/s2214-109x(16)30047-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/16/2016] [Accepted: 03/23/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Kirti Iyengar
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet/Karolinska University Hospital, WHO Collaborating Centre, Stockholm, Sweden; Action Research & Training for Health, Satyam, Ramgiri, Badgaon, 313011, Udaipur, Rajasthan, India.
| | - Sharad D Iyengar
- Action Research & Training for Health, Satyam, Ramgiri, Badgaon, 313011, Udaipur, Rajasthan, India
| | - Kristina Gemzell Danielsson
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet/Karolinska University Hospital, WHO Collaborating Centre, Stockholm, Sweden
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Determination of medical abortion eligibility by women and community health volunteers in Nepal: A toolkit evaluation. PLoS One 2017; 12:e0178248. [PMID: 28880926 PMCID: PMC5589081 DOI: 10.1371/journal.pone.0178248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/10/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To determine if pregnant, literate women and female community health volunteers (FCHVs) in Nepal can accurately determine a woman’s eligibility for medical abortion (MA) using a toolkit, compared to comprehensive abortion care (CAC) trained providers. Study design We conducted a prospective diagnostic accuracy study in which women presenting for first trimester abortion, and FCHVs, independently assessed each woman’s eligibility for MA using a modified gestational dating wheel to determine gestational age and a nine-point checklist of MA contraindications or cautions. Ability to determine MA eligibility was compared to experienced CAC-providers using Nepali standard of care. Results Both women (n = 3131) and FCHVs (n = 165) accurately interpreted the wheel 96% of the time, and the eligibility checklist 72% and 95% of the time, respectively. Of the 649 women who reported potential contraindications or cautions on the checklist, 88% misidentified as eligible. Positive predictive value (PPV) of women’s assessment of eligibility based on gestational age was 93% (95% CI 92, 94) compared to CAC-providers’ (n = 47); PPV of the medical contraindications checklist and overall (90% [95% CI 88, 91] and 93% [95% CI 92, 94] respectively) must be interpreted with caution given women’s difficulty using the checklist. PPV of FCHVs’ determinations were 93% (95% CI 92, 94), 90% (95% CI 89,91), and 93% (95% CI 91, 94) respectively. Conclusion Although a promising strategy to assist women and FCHVs to assess MA eligibility, further refinement of the eligibility tools, particularly the checklist, is needed before their widespread use.
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Constant D, Harries J, Moodley J, Myer L. Accuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study. Reprod Health 2017; 14:100. [PMID: 28830534 PMCID: PMC5568056 DOI: 10.1186/s12978-017-0365-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 08/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The requirement for ultrasound to establish gestational age among women seeking abortion can be a barrier to access. Last menstrual period dating without clinical examination should be a reasonable alternative among selected women, and if reliable, can be task-shared with non-clinicians. This study determines the accuracy of gestational age estimation using last menstrual period (LMP) assessed by community health care workers (CHWs), and explores providers' and CHWs' perspectives on task sharing this activity. The study purpose is to expand access to early medical abortion services. METHODS We conducted a multi-center cross-sectional study at four urban non-governmental reproductive health clinics in South Africa. CHWs interviewed women seeking abortion, recorded their LMP and gestational age from a pregnancy wheel if within 63 days. Thereafter, providers performed a standard examination including ultrasound to determine gestational age. Lastly, investigators calculated gestational age for all LMP dates recorded by CHWs. We compared mean gestational age from LMP dates to mean gestational age by ultrasound using t-tests and calculated proportions for those incorrectly assessed as eligible for medical abortion from LMP. In addition, in-depth interviews were conducted with six providers and seven CHWs. RESULTS Mean gestational age was 5 days (by pregnancy wheel) and 9 days (by LMP calculation) less than ultrasound gestational age. Twelve percent of women were eligible for medical abortion by LMP calculation but ineligible by ultrasound. Uncertainty of LMP date was associated with incorrect assessment of gestational age eligibility for medical abortion (p = 0.015). For women certain their LMP date was within 56 days, 3% had ultrasound gestational ages >70 days. In general, providers and CHWs were in favour of task sharing screening and referral for abortion, but were doubtful that women reported accurate LMP dates. Different perspectives emerged on how to implement task sharing gestational age eligibility for medical abortion. CONCLUSIONS If LMP recall is within 56 days, most women will be eligible for early medical abortion and LMP can substitute for ultrasound dating. Task sharing gestational age estimation is feasible in South Africa, but its implementation should meet women's privacy needs and address healthcare workers' concerns on managing any procedural risk.
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Affiliation(s)
- Deborah Constant
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. .,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jennifer Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Gupta P, Iyengar SD, Ganatra B, Johnston HB, Iyengar K. Can community health workers play a greater role in increasing access to medical abortion services? A qualitative study. BMC WOMENS HEALTH 2017; 17:37. [PMID: 28545584 PMCID: PMC5445398 DOI: 10.1186/s12905-017-0391-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 05/11/2017] [Indexed: 11/23/2022]
Abstract
Background Despite being legally available in India since 1971, barriers to safe and legal abortion remain, and unsafe and/or illegal abortion continues to be a problem. Community health workers have been involved in improving access to health information and care for maternal and child health in resource poor settings, but their role in facilitating accurate information about and access to safe abortion has been relatively unexplored. A qualitative study was conducted in Rajasthan, India to study acceptability, perspectives and preferences of women and community health workers, regarding the involvement of community health workers in medical abortion referrals. Methods In-depth interviews were conducted with 24 women seeking early medical abortion at legal abortion facilities or presenting at these facilities for a follow-up assessment after medical abortion. Ten community health workers who were trained to assess eligibility for early medical abortion and/or to assess whether women needed a follow-up visit after early medical abortion were also interviewed. The transcripts were coded using ATLAS-ti 7 (version 7.1.4) in the local language and reports were generated for all the codes, emerging themes were identified and the findings were analysed. Results Community health workers (CHWs) were willing to play a role in assessing eligibility for medical abortion and in identifying women who are in need of follow-up care after early medical abortion, when provided with appropriate training, regular supplies and job aids. Women however had apprehensions about contacting CHWs in relation to abortions. Important barriers that prevented women from seeking information and assistance from community health workers were fear of breach of confidentiality and a perception that they would be pressurised to undergo sterilisation. Conclusions Our findings support a potential for greater role of CHWs in making safe abortion information and services accessible to women, while highlighting the need to address women’s concerns about approaching CHWs in case of unwanted pregnancy. Further intervention research would be needed to shed light on the effectiveness of role of CHWs in facilitating access to safe abortion and to outline specific components in a programme setting. Trial registration Not applicable.
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Affiliation(s)
- Pallavi Gupta
- Action Research & Training for Health (ARTH), Satyam, Ramgiri, Badgaon, Udaipur, Rajasthan, 313011, India
| | - Sharad D Iyengar
- Action Research & Training for Health (ARTH), Satyam, Ramgiri, Badgaon, Udaipur, Rajasthan, 313011, India
| | - Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, 20 Avenue Appia, 1211, Geneva-27, Switzerland
| | - Heidi Bart Johnston
- Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box 4002, Basel, Switzerland
| | - Kirti Iyengar
- Action Research & Training for Health (ARTH), Satyam, Ramgiri, Badgaon, Udaipur, Rajasthan, 313011, India. .,Department of Women's and Children's Health, Karolinska Institutet, WHO collaborating Centre, Karolinska University Hospital, SE-17176, Stockholm, Sweden.
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Dibaba Y, Dijkerman S, Fetters T, Moore A, Gebreselassie H, Gebrehiwot Y, Benson J. A decade of progress providing safe abortion services in Ethiopia: results of national assessments in 2008 and 2014. BMC Pregnancy Childbirth 2017; 17:76. [PMID: 28257646 PMCID: PMC5336611 DOI: 10.1186/s12884-017-1266-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 02/28/2017] [Indexed: 12/02/2022] Open
Abstract
Background Ethiopia has one of the highest maternal mortality ratios in the world (420 per 100,000 live births in 2013), and unsafe abortion continues to be one of the major causes. To reduce deaths and disabilities from unsafe abortion, Ethiopia liberalized its abortion law in 2005 to allow safe abortion under certain conditions. This study aimed to measure how availability and utilization of safe abortion services has changed in the last decade in Ethiopia. Methods This paper draws on results from nationally representative health facility studies conducted in Ethiopia in 2008 and 2014. The data come from three sources at two points in time: 1) interviews with 335 health providers in 2008 and 822 health care providers in 2014, 2) review of facility logbooks, and 3) prospective data on 3092 women in 2008 and 5604 women in 2014 seeking treatment for abortion complications or induced abortion over a one month period. The Safe Abortion Care Model was used as a framework of analysis. Results There has been a rapid expansion of health facilities eligible to provide legal abortion services in Ethiopia since 2008. Between 2008 and 2014, the number of facilities reporting basic and comprehensive signal functions for abortion care increased. In 2014, access to basic abortion care services exceeded the recommended level of available facilities providing the service, increasing from 25 to 117%, with more than half of regions meeting the recommended level. Comprehensive abortion services increased from 20% of the recommended level in 2008 to 38% in 2014. Smaller regions and city administrations achieved or exceeded the recommended level of comprehensive service facilities, yet larger regions fall short. Between 2008 and 2014, the use of appropriate technology for conducting first and second trimester abortion and the provision of post abortion family planning has increased at the same time that abortion-related obstetric complications have decreased. Conclusion Ten years after the change in abortion law, service availability and quality has increased, but access to lifesaving comprehensive care still falls short of recommended levels.
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Affiliation(s)
- Yohannes Dibaba
- Research and Evaluation Unit, Ipas Ethiopia, Addis Ababa, Ethiopia.
| | - Sally Dijkerman
- Research and Evaluation Unit, Ipas Ethiopia, Addis Ababa, Ethiopia
| | - Tamara Fetters
- Research and Evaluation Unit, Ipas Ethiopia, Addis Ababa, Ethiopia
| | | | | | - Yirgu Gebrehiwot
- Faculty of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Janie Benson
- Research and Evaluation Unit, Ipas Ethiopia, Addis Ababa, Ethiopia
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Olaniran A, Smith H, Unkels R, Bar-Zeev S, van den Broek N. Who is a community health worker? - a systematic review of definitions. Glob Health Action 2017; 10:1272223. [PMID: 28222653 PMCID: PMC5328349 DOI: 10.1080/16549716.2017.1272223] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/22/2016] [Accepted: 12/08/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) can play vital roles in increasing coverage of basic health services. However, there is a need for a systematic categorisation of CHWs that will aid common understanding among policy makers, programme planners, and researchers. OBJECTIVE To identify the common themes in the definitions and descriptions of CHWs that will aid delineation within this cadre and distinguish CHWs from other healthcare providers. DESIGN A systematic review of peer-reviewed papers and grey literature. RESULTS We identified 119 papers that provided definitions of CHWs in 25 countries across 7 regions. The review shows CHWs as paraprofessionals or lay individuals with an in-depth understanding of the community culture and language, have received standardised job-related training of a shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community. CHWs can be categorised into three groups by education and pre-service training. These are lay health workers (individuals with little or no formal education who undergo a few days to a few weeks of informal training), level 1 paraprofessionals (individuals with some form of secondary education and subsequent informal training), and level 2 paraprofessionals (individuals with some form of secondary education and subsequent formal training lasting a few months to more than a year). Lay health workers tend to provide basic health services as unpaid volunteers while level 1 paraprofessionals often receive an allowance and level 2 paraprofessionals tend to be salaried. CONCLUSIONS This review provides a categorisation of CHWs that may be useful for health policy formulation, programme planning, and research.
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Affiliation(s)
- Abimbola Olaniran
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Smith
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Regine Unkels
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sarah Bar-Zeev
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
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