Lay health workers (LHWs) are widely used to provide care for a broad range of health
issues. Little is known, however, about the effectiveness of LHW interventions.
To assess the effects of LHW interventions in primary and community health care on
maternal and child health and the management of infectious diseases.
For the current version of this review we searched The Cochrane Central Register of
Controlled Trials (including citations uploaded from the EPOC and the CCRG registers)
(The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE,
Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process
& Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009);
EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985
to February 2009) (searched 19 February 2009); British Nursing Index and Archive,
Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present
(searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched
16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web
of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also
searched the reference lists of all included papers and relevant reviews, and contacted
study authors and researchers in the field for additional papers.
Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary)
in primary or community health care and intended to improve maternal or child health
or the management of infectious diseases. A 'lay health worker' was defined as any
health worker carrying out functions related to healthcare delivery, trained in some
way in the context of the intervention, and having no formal professional or paraprofessional
certificate or tertiary education degree. There were no restrictions on care recipients.
Two review authors independently extracted data using a standard form and assessed
risk of bias. Studies that compared broadly similar types of interventions were grouped
together. Where feasible, the study results were combined and an overall estimate
of effect obtained.
Eighty-two studies met the inclusion criteria. These showed considerable diversity
in the targeted health issue and the aims, content, and outcomes of interventions.
The majority were conducted in high income countries (n = 55) but many of these focused
on low income and minority populations. The diversity of included studies limited
meta-analysis to outcomes for four study groups. These analyses found evidence of
moderate quality of the effectiveness of LHWs in promoting immunisation childhood
uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding
(RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI
1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44;
P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P
<0.0001), when compared to usual care. There was moderate quality evidence that LHW
support had little or no effect on TB preventive treatment completion (RR 1.00, 95%
CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce
child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI
0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality,
and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI
0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to
draw conclusions regarding effectiveness, or to enable the identification of specific
LHW training or intervention strategies likely to be most effective.
LHWs provide promising benefits in promoting immunisation uptake and breastfeeding,
improving TB treatment outcomes, and reducing child morbidity and mortality when compared
to usual care. For other health issues, evidence is insufficient to draw conclusions
about the effects of LHWs.