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      Expanded roles of community health workers beyond malaria in the Asia-Pacific: A systematic review

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          Abstract

          In the Greater Mekong Subregion (GMS), community health workers (CHWs) are a key component of malaria elimination strategies. As malaria declines, support for, and uptake of, malaria services may also subsequently decrease. Expanding their roles beyond malaria has been proposed to sustain the services. A systematic review was conducted to identify and characterize programmes with CHWs providing services in addition to those for malaria in the Asia Pacific. This review describes the expanded roles, identifies evidence of impact or success of the programmes, and explores strategies to ensure sustainability and factors for effective implementation to inform the design of malaria CHW programmes. Searches were conducted in 6 databases, for grey literature, and in bibliographies of retrieved articles. Data were extracted from 38 published articles, 12 programme reports, and 4 programme briefs and analysed using thematic coding and descriptive analysis. Twenty-nine programmes were identified with CHWs performing both malaria and non-malaria roles in the Asia Pacific. There was evidence of impact on malaria incidence in 4 of these, none on malaria mortality, and 4 on other diseases. Monitoring and evaluation mechanisms, multi-sectoral stakeholder collaborations, and adequate training and consistent supervision of CHWs were key to effective programme implementation. Integration of programmes into broader health services, ongoing political and funding support, and engagement with local communities were found to contribute to sustaining provision of health services by CHWs. Expanding CHW roles depends on programme management and strengthening linkages with local health systems. To sustain malaria CHW services, countries need adequate policies and financing, and sufficiently strong health systems to deliver basic health services that are adapted to the health needs of the community which means transitioning away from vertical disease programs. Further research should explore programmes that have not been captured in this review and address gaps in measuring malaria outcomes.

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          Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups

          Background Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK Methods This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis. Results Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research. Discussion By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.
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            Improving the content validity of the mixed methods appraisal tool: a modified e-Delphi study

            The mixed methods appraisal tool (MMAT) was developed for critically appraising different study designs. This study aimed to improve the content validity of three of the five categories of studies in the MMAT by identifying relevant methodological criteria for appraising the quality of qualitative, survey, and mixed methods studies.
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              Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review

              Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review. A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: MethodologyRole: ResourcesRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLOS Glob Public Health
                PLOS Glob Public Health
                plos
                PLOS Global Public Health
                Public Library of Science (San Francisco, CA USA )
                2767-3375
                16 October 2024
                2024
                : 4
                : 10
                : e0003113
                Affiliations
                [1 ] Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
                [2 ] Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
                [3 ] Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
                [4 ] Harvard TH Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
                [5 ] The Open University, Milton Keynes, United Kingdom
                UP Manila: University of the Philippines Manila, PHILIPPINES
                Author notes

                The authors have declared that no competing interests exist.

                ‡ MJ and PK share co-first authorship on this work.

                Author information
                https://orcid.org/0000-0003-4635-8959
                https://orcid.org/0000-0002-5355-0562
                Article
                PGPH-D-24-00614
                10.1371/journal.pgph.0003113
                11482702
                39413107
                7f66e513-61d1-4e97-9cf9-5b548a5bfa1b
                © 2024 Jongdeepaisal et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 21 March 2024
                : 9 September 2024
                Page count
                Figures: 4, Tables: 4, Pages: 34
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100010269, Wellcome Trust;
                Award ID: 220211/Z/20/Z
                Funded by: funder-id http://dx.doi.org/10.13039/100004417, Global Fund to Fight AIDS, Tuberculosis and Malaria;
                Award ID: 20864-007-42
                Award Recipient :
                This study was funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria, Grant Number: 20864-007-42 (RJM). This research was funded in whole, or in part, by the Wellcome Trust [220211]. For the purpose of Open Access, the author has applied a CC BY public copyright license to any Author Accepted Manuscript version arising from this submission. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Medical Conditions
                Parasitic Diseases
                Malaria
                Medicine and Health Sciences
                Medical Conditions
                Tropical Diseases
                Malaria
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Health Systems Strengthening
                Medicine and Health Sciences
                Health Care
                Health Services Administration and Management
                Medicine and Health Sciences
                Public and Occupational Health
                Global Health
                People and Places
                Geographical Locations
                Asia
                Myanmar
                Medicine and Health Sciences
                Health Care
                Health Education and Awareness
                Research and Analysis Methods
                Database and Informatics Methods
                Database Searching
                Medicine and Health Sciences
                Epidemiology
                Custom metadata
                All data generated or analysed in this study are included in this article and supplementary documents.

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