Background: This thesis presents an empirical investigation into the efficacy, types, and performance of community health workers (CHWs)-trained lay people to whom simple medical procedures can be "task shifted" from doctors. It has three objectives: (1) assess the effects of CHW delivered interventions for primary health outcomes in low-and middle-income countries (LMICs), (2) develop a comprehensive taxonomy of CHW characteristics and programme design features, and (3) assess the relative efficacy of different types of CHW programme designs and how they can be used to optimise CHW performance. Structure and Methods: Following the logic of early stage intervention development, this thesis has an iterative and developmental structure in which each section flows out of and builds on the previous section. Objective one is addressed in Chapters 2-4: scoping review, systematic review, and meta-analytic methods are applied to establish the efficacy and effectiveness of CHW-led interventions in LMICs. Objective two is addressed in Chapter 5: inductive, thematic analysis of systematically identified trials, influential papers, and existing information classification systems is used to develop a formal CHW taxonomy for intervention reporting and coding. Objective three is addressed in Chapter 6: systematic review methods are employed to identify interventions for improving the performance of community health workers in LMICs. Results: Objective one: a systematic review of 155 papers reporting 86 trials found high quality evidence that CHW delivered interventions reduce perinatal mortality, improve child nutritional status, and improve tuberculosis completion rates versus facility-based care. There is also moderate quality evidence that CHW delivered interventions improve certain mental, infectious disease, paediatric, and maternal health outcomes. In undertaking this process, an additional, methodological contribution was made in the form of a tool to reduce risk of bias in overviews of reviews. This tool may facilitate early stage intervention development in the future. Objective two: 253 records were used to establish, in a faceted taxonomy, the definitional clarity required for theory building and knowledge accumulation. Two categories (CHW Characteristics and CHW Programme Features) and six dimensions (Integration, Recruitment, Training, Supervision, Incentives, and Equipment) emerged. Objective three: a systematic review of 14 trials identified moderate quality evidence of the efficacy of CHW performance interventions in improving certain behavioural outcomes for patients, utilisation of services, and CHW quality of care. There was no effect on the biological outcomes of interest. Conclusion: In bringing the tools of evidence based practice to bear on community health worker interventions, this dissertation has contributed to the theoretical, methodological, and empirical evidence base from which the field can continue to advance.
| Identifer | oai:union.ndltd.org:bl.uk/oai:ethos.bl.uk:722552 |
| Date | January 2016 |
| Creators | Ballard, Madeleine |
| Contributors | Montgomery, Paul |
| Publisher | University of Oxford |
| Source Sets | Ethos UK |
| Detected Language | English |
| Type | Electronic Thesis or Dissertation |
| Source | https://ora.ox.ac.uk/objects/uuid:0958a784-e5a1-432f-8980-6f65d93e698f |
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