This review was carried out by researchers in The Cochrane Collaboration. It summarises the findings of 53 studies that explore factors influencing the success of lay health worker (LHW) programmes for mothers and child health. This review was carried out alongside the Cochrane review assessing the effectiveness of LHW programmes on maternal and child health.
What is a lay health worker?
A LHW is a lay person who has received some training to deliver healthcare services but is not a health professional. In most of the studies in this review, LHWs offered health care to people who were on low incomes living in wealthy countries or to people living in poor countries. The LHWs in wealthy countries offered health promotion, counselling and support. The LHWs in poor countries offered similar services but they sometimes also distributed food supplements, contraceptives and other products, treated children with common childhood diseases, or managed women in uncomplicated labour.
What the research says
The studies described the experiences of LHWs, mothers, programme managers, and other health workers with LHW programmes. Many of our findings were based on studies from different settings and had some methodological problems. We judged these findings to have moderate certainty. Some findings were only based on one or two studies that had some methodological problems and were judged to be of low certainty.
Mothers were generally positive about the programmes. They appreciated the LHWs’ skills and the similarities they saw between themselves and the LHWs. However, some mothers were concerned about confidentiality when receiving home visits. Others saw LHW services as not relevant or not sufficient, particularly when LHWs only offered promotional services. LHWs and mothers emphasised the importance of trust, respect, kindness and empathy. However, LHWs sometimes found it difficult to manage emotional relationships and boundaries with mothers. Some LHWs feared blame if health care was not successful. Others felt demotivated when their services were not appreciated. Support from health systems and community leaders could give LHWs credibility if these health systems and community leaders had authority and respect. Active support from family members was also important.
Health professionals often appreciated the LHWs' contributions to reducing their workload, and their communication skills and commitment. However, some health professionals thought that LHWs added to their own workloads and feared a loss of authority.
LHWs were motivated by altruism, social recognition, knowledge gain and career development. Some unsalaried LHWs wanted regular payment. Others were concerned that payment might threaten their social status or lead people to question their motives. Some salaried LHWs were dissatisfied with their pay levels. Others were frustrated when other LHWs had higher salaries. Some LHWs said that they had few opportunities to voice complaints.
Some LHWs described insufficient, poor quality and irrelevant training programmes. They called for more training in counselling and communication and in topics outside their current role, including common health problems and domestic problems. LHWs and supervisors complained about supervisors’ lack of skills, time and transportation. Some LHWs appreciated the opportunity to share experiences with other LHWs.
Some LHWs were traditional birth attendants who had received additional training. Some health professionals were concerned that these LHWs were over-confident about their ability to manage danger signs. LHWs and mothers identified women’s reluctance to be referred after bad experiences with health professionals, fear of caesarean sections, lack of transport, and costs. Some LHWs were also reluctant to refer women on because of poor co-operation with health professionals.
We organized these findings into chains of events where we have proposed how certain LHW programme elements might lead to greater programme success.
Rather than being seen as a lesser trained health worker, LHWs represent a different and sometimes preferred type of health worker. The often close relationship between LHWs and their recipients is a strength of such programmes. However, programme planners must consider how to achieve the benefits of closeness while avoiding the problems. It may also be important to offer services that recipients perceive as relevant; to ensure regular and visible support from other health workers and community leaders; and to offer appropriate training, supervision and incentives.