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Simon Lewin - One of the best experts on this subject based on the ideXlab platform.

  • multiple and mixed methods in formative evaluation is more better reflections from a south african study
    BMC Medical Research Methodology, 2016
    Co-Authors: Willem Odendaal, Simon Lewin, Salla Atkins
    Abstract:

    Formative programme evaluations assess intervention implementation processes, and are seen widely as a way of unlocking the ‘black box’ of any programme in order to explore and understand why a programme functions as it does. However, few critical assessments of the methods used in such evaluations are available, and there are especially few that reflect on how well the evaluation achieved its objectives. This paper describes a formative evaluation of a community-based Lay Health Worker programme for TB and HIV/AIDS clients across three low-income communities in South Africa. It assesses each of the methods used in relation to the evaluation objectives, and offers suggestions on ways of optimising the use of multiple, mixed-methods within formative evaluations of complex Health system interventions. The evaluation’s qualitative methods comprised interviews, focus groups, observations and diary keeping. Quantitative methods included a time-and-motion study of the Lay Health Workers’ scope of practice and a client survey. The authors conceptualised and conducted the evaluation, and through iterative discussions, assessed the methods used and their results. Overall, the evaluation highlighted programme issues and insights beyond the reach of traditional single methods evaluations. The strengths of the multiple, mixed-methods in this evaluation included a detailed description and nuanced understanding of the programme and its implementation, and triangulation of the perspectives and experiences of clients, Lay Health Workers, and programme managers. However, the use of multiple methods needs to be carefully planned and implemented as this approach can overstretch the logistic and analytic resources of an evaluation. For complex interventions, formative evaluation designs including multiple qualitative and quantitative methods hold distinct advantages over single method evaluations. However, their value is not in the number of methods used, but in how each method matches the evaluation questions and the scientific integrity with which the methods are selected and implemented.

  • Multiple and mixed methods in formative evaluation: Is more better? Reflections from a South African study
    BMC, 2016
    Co-Authors: Willem Odendaal, Salla Atkins, Simon Lewin
    Abstract:

    Abstract Background Formative programme evaluations assess intervention implementation processes, and are seen widely as a way of unlocking the ‘black box’ of any programme in order to explore and understand why a programme functions as it does. However, few critical assessments of the methods used in such evaluations are available, and there are especially few that reflect on how well the evaluation achieved its objectives. This paper describes a formative evaluation of a community-based Lay Health Worker programme for TB and HIV/AIDS clients across three low-income communities in South Africa. It assesses each of the methods used in relation to the evaluation objectives, and offers suggestions on ways of optimising the use of multiple, mixed-methods within formative evaluations of complex Health system interventions. Methods The evaluation’s qualitative methods comprised interviews, focus groups, observations and diary keeping. Quantitative methods included a time-and-motion study of the Lay Health Workers’ scope of practice and a client survey. The authors conceptualised and conducted the evaluation, and through iterative discussions, assessed the methods used and their results. Results Overall, the evaluation highlighted programme issues and insights beyond the reach of traditional single methods evaluations. The strengths of the multiple, mixed-methods in this evaluation included a detailed description and nuanced understanding of the programme and its implementation, and triangulation of the perspectives and experiences of clients, Lay Health Workers, and programme managers. However, the use of multiple methods needs to be carefully planned and implemented as this approach can overstretch the logistic and analytic resources of an evaluation. Conclusions For complex interventions, formative evaluation designs including multiple qualitative and quantitative methods hold distinct advantages over single method evaluations. However, their value is not in the number of methods used, but in how each method matches the evaluation questions and the scientific integrity with which the methods are selected and implemented

  • non specialist Health Worker interventions for the care of mental neurological and substance abuse disorders in low and middle income countries
    Cochrane Database of Systematic Reviews, 2013
    Co-Authors: Nadja Van Ginneken, Simon Lewin, Prathap Tharyan, Girish N Rao, S M Meera, Jessica Pian, Sudha Chandrashekar, Vikram Patel
    Abstract:

    Background: In developing countries, most people with mental, neurological and substance-abuse (MNS) disorders do not receive adequate care mainly because of a lack of mental Health professionals. Non-specialist Health Workers, but also other professionals with Health roles, such as teachers, may therefore have an important role to pLay in delivering MNS Health care. Researchers in The Cochrane Collaboration carried out a review of the effects of using non-specialist Health Workers or other professionals with Health roles to help people with MNS disorders in developing countries. After searching for all relevant studies in scientific databases, they found 38 studies published before October 2012. Their findings are summarised below. What is a non-specialist Health Worker? Any type of Health Worker (like a doctor, nurse or Lay Health Worker) who is not a specialist in mental Health or neurology but who may have had some training in these fields. We also looked at teachers, as they can be particularly important in the care of children and youths. What the research says: The studies in this review were from 22 developing countries. In most studies, Lay Health Workers delivered the mental Health care, and addressed depression or anxiety (or both), or post-traumatic stress disorder. The review shows that the use of non-specialist Health Workers, compared with usual Healthcare services: · may increase the number of adults who recover from depression or anxiety (or both) two to six months after treatment; · may slightly reduce symptoms formothers with depression; · may slightly reduce the symptoms of adults with post-traumatic stress disorder (non-specialists and teachers were used in one study); · probably slightly improves the symptoms of people with dementia; · probably improves/slightly improves the mental well-being, burden and distress of carers of people with dementia; · may decrease the quantity of alcohol consumed by problem drinkers. It is uncertain whether Lay Health Workers or teachers reducepost-traumatic stress disorder symptoms among children. There were too few studies to draw any conclusions about the cost-effectiveness of using non-specialist Health Workers or teachers, or about their impact on people with other MNS conditions such as epilepsy, schizophrenia, and alcohol and drug abuse problems. In addition, very few studies measured unintended consequences of non-specialist Health Worker-led care - such effects could impact on the appropriateness and quality of care. Quality of the evidence: Overall, non-specialist Health Workers and teachers have some promising benefits in improving people's outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol-use disorders, and patient and carer outcomes for dementia. However, this evidence is of low or very low quality in some areas, and for some issues no evidence is available. Therefore, we cannot make conclusions about which specific interventions using non-specialist Health Workers to help people with MNS disorders are more effective.

  • barriers and facilitators to the implementation of Lay Health Worker programmes to improve access to maternal and child Health qualitative evidence synthesis
    Cochrane Database of Systematic Reviews, 2013
    Co-Authors: Claire Glenton, Christopher J Colvin, Benedicte Carlsen, Alison Swartz, Simon Lewin, Jane Noyes, Arash Rashidian
    Abstract:

    Background Lay Health Workers (LHWs) perform functions related to Healthcare delivery, receive some level of training, but have no formal professional or paraprofessional certificate or tertiary education degree. They provide care for a range of issues, including maternal and child Health. For LHW programmes to be effective, we need a better understanding of the factors that influence their success and sustainability. This review addresses these issues through a synthesis of qualitative evidence and was carried out alongside the Cochrane review of the effectiveness of LHWs for maternal and child Health. Objectives The overall aim of the review is to explore factors affecting the implementation of LHW programmes for maternal and child Health. Search methods We searched MEDLINE, OvidSP (searched 21 December 2011); MEDLINE Ovid In-Process & Other Non-Indexed Citations, OvidSP (searched 21 December 2011); CINAHL, EBSCO (searched 21 December 2011); British Nursing Index and Archive, OvidSP (searched 13 May 2011). We searched reference lists of included studies, contacted experts in the field, and included studies that were carried out alongside the trials from the LHW effectiveness review. Selection criteria Studies that used qualitative methods for data collection and analysis and that focused on the experiences and attitudes of stakeholders regarding LHW programmes for maternal or child Health in a primary or community Healthcare setting. Data collection and analysis We identified barriers and facilitators to LHW programme implementation using the framework thematic synthesis approach. Two review authors independently assessed study quality using a standard tool. We assessed the certainty of the review findings using the CerQual approach, an approach that we developed alongside this and related qualitative syntheses. We integrated our findings with the outcome measures included in the review of LHW programme effectiveness in a logic model. Finally, we identified hypotheses for subgroup analyses in future updates of the review of effectiveness. Main results We included 53 studies primarily describing the experiences of LHWs, programme recipients, and other Health Workers. LHWs in high income countries mainly offered promotion, counselling and support. In low and middle income countries, LHWs offered similar services but sometimes also distributed supplements, contraceptives and other products, and diagnosed and treated children with common childhood diseases. Some LHWs were trained to manage uncomplicated labour and to refer women with pregnancy or labour complications. Many of the findings were based on studies from multiple settings, but with some methodological limitations. These findings were assessed as being of moderate certainty. Some findings were based on one or two studies and had some methodological limitations. These were assessed have low certainty. Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and Health system constraints. Programme recipients were generally positive to the programmes, appreciating the LHWs’ skills and the similarities they saw between themselves and the LHWs. However, some recipients 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 recipients emphasised the importance of trust, respect, kindness and empathy. However, LHWs sometimes found it difficult to manage emotional relationships and boundaries with recipients. Some LHWs feared blame if care was not successful. Others felt demotivated when their services were not appreciated. Support from Health systems and community leaders could give LHWs credibility, at least if the Health systems and community leaders had authority and respect. Active support from family members was also important. Health professionals often appreciated the LHWs’ contributions in reducing their workload and for their communication skills and commitment. However, some Health professionals thought that LHWs added to their workload and feared a loss of authority. LHWs were motivated by factors including altruism, social recognition, knowledge gain and career development. Some unsalaried LHWs wanted regular payment, while others were concerned that payment might threaten their social status or lead recipients to question their motives. Some salaried LHWs were dissatisfied with their pay levels. Others were frustrated when payment differed across regions or institutions. Some LHWs stated that they had few opportunities to voice complaints. LHWs described insufficient, poor quality, irrelevant and inflexible training programmes, calling 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 fellow LHWs. In some studies, 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 recipients pointed to other problems, including women’s reluctance to be referred after bad experiences with Health professionals, fear of caesarean sections, lack of transport, and cost. Some LHWs were reluctant to refer women on because of poor co-operation with Health professionals. We organised these findings and the outcome measures included in the review of LHW programme effectiveness in a logic model. Here we proposed six chains of events where specific programme components lead to specific intermediate or long-term outcomes, and where specific moderators positively or negatively affect this process. We suggest how future updates of the LHW effectiveness review could explore whether the presence of these components influences programme success. Authors' conclusions Rather than being seen as a lesser trained Health Worker, LHWs may represent a different and sometimes preferred type of Health Worker. The close relationship between LHWs and recipients is a programme strength. However, programme planners must consider how to achieve the benefits of closeness while minimizing the potential drawbacks. Other important facilitators may include the development of services that recipients perceive as relevant; regular and visible support from the Health system and the community; and appropriate training, supervision and incentives.

  • still too little qualitative research to shed light on results from reviews of effectiveness trials a case study of a cochrane review on the use of Lay Health Workers
    Implementation Science, 2011
    Co-Authors: Claire Glenton, Simon Lewin, Inger B Scheel
    Abstract:

    Background: Qualitative research is used increasingly alongside trials of complex interventions to explore processes, contextual factors, or intervention characteristics that may have influenced trial outcomes. Qualitative research conducted alongside trials can also be used to shed light on the results of systematic reviews of effectiveness by looking for factors that can help explain heterogeneous results across trials. In a Cochrane review on the effects of using Lay Health Workers on maternal and child Health and infectious disease control, we identified 82 trials. These trials showed promising benefits but results were heterogeneous. Objective: To use qualitative studies conducted alongside these trials to explore factors and processes that might have influenced intervention outcomes. Methods: We attempted to identify qualitative research carried out alongside the trials by contacting trial authors, checking papers for references to qualitative research, searching Pubmed for related studies, and carrying out citation searches. For those qualitative studies that we included, we extracted information regarding study objective, data collection and analysis methods, and key themes and categories. Results: For 52 (63%) of the trials, we found no qualitative research that had been conducted alongside the trials. For 16 (20%) trials, some form of qualitative data collection had been done but was unavailable or had been done before the trial. For 14 (17%) trials, qualitative research had been done during or shortly after the trial, although descriptions of qualitative methods and results were often sparse. Most of these 14 studies aimed to elicit trial participants’ perspectives and experiences of the intervention. A common theme was participants’ appreciation of the Lay Health Workers’ shared circumstances, for instance with regard to social background or experience of the Health condition. In six studies, researchers explored the experiences of the Lay Health Workers themselves. Issues included the importance of regular supervision and Health professionals’ support or lack of support. Conclusions: Qualitative studies carried out alongside trials of complex interventions could offer opportunities to authors of systematic reviews of effectiveness wishing to understand the heterogeneity of trial results. For interventions of Lay Health Worker programmes at least, too few such studies exist at present for these opportunities to be realised.

Steven M Asch - One of the best experts on this subject based on the ideXlab platform.

  • effect of a Lay Health Worker intervention on goals of care documentation and on Health care use costs and satisfaction among patients with cancer a randomized clinical trial
    JAMA Oncology, 2018
    Co-Authors: Manali I Patel, Vandana Sundaram, Manisha Desai, Vyjeyanthi S Periyakoil, James G Kahn, Jay Bhattacharya, Steven M Asch
    Abstract:

    Importance Although Lay Health Workers (LHWs) improve cancer screening and treatment adherence, evidence on whether they can enhance other aspects of care is limited. Objective To determine whether an LHW program can increase documentation of patients’ care preferences after cancer diagnosis. Design, Setting, and Participants Randomized clinical trial conducted from August 13, 2013, through February 2, 2015, among 213 patients with stage 3 or 4 or recurrent cancer at the Veterans Affairs Palo Alto Health Care System. Data analysis was by intention to treat and performed from January 15 to August 18, 2017. Interventions Six-month program with an LHW trained to assist patients with establishing end-of-life care preferences vs usual care. Main Outcomes and Measures The primary outcome was documentation of goals of care. Secondary outcomes were patient satisfaction on the Consumer Assessment of Health Care Providers and Systems “satisfaction with provider” item (on a scale of 0 [worst] to 10 [best possible]), Health care use, and costs. Results Among the 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years, 211 (99.1%) were male, and 165 (77.5%) were of non-Hispanic white race/ethnicity. Within 6 months of enrollment, patients randomized to the intervention had greater documentation of goals of care than the control group (97 [92.4%] vs 19 [17.5%.];P  Conclusions and Relevance Incorporating an LHW into cancer care increases goals-of-care documentation and patient satisfaction and reduces Health care use and costs at the end of life. Trial Registration ClinicalTrials.gov Identifier:NCT02966509

Merrick Zwarenstein - One of the best experts on this subject based on the ideXlab platform.

  • Lay Health Workers in primary and community Health care for maternal and child Health and the management of infectious diseases
    Cochrane Database of Systematic Reviews, 2010
    Co-Authors: Simon Lewin, Karen Daniels, Claire Glenton, Godwin N Aja, B Van Wyk, Xavier Boschcapblanch, Susan Munabibabigumira, Jan Odgaardjensen, Marit Johansen, Merrick Zwarenstein
    Abstract:

    Background 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. Objectives To assess the effects of LHW interventions in primary and community Health care on maternal and child Health and the management of infectious diseases. Search methods 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. Selection criteria 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. Data collection and analysis 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. Main results 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. Authors' conclusions 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.

  • Lay Health Worker intervention with choice of dot superior to standard tb care for farm dwellers in south africa a cluster randomised control trial
    International Journal of Tuberculosis and Lung Disease, 2005
    Co-Authors: M Clarke, J Dick, Merrick Zwarenstein, Carl Lombard, V K Diwan
    Abstract:

    Setting: Farms in the Boland Health district Western Cape Province South Africa. Objective: To evaluate the effect of Lay Health Workers (LHWs) on tuberculosis (TB) control among permanent farm Workers and farm dwellers in an area with particularly high TB prevalence. Design: Pragmatic unblended cluster randomised control trial. Methods: This trial measured successful treatment completion rates among new smear-positive (NSP) adult TB patients on 106 intervention farms and compared them with outcomes in patients on 105 control farms. Farms were the unit of randomization and analysis was by intention to treat. Results: A total of 164 adult TB patients were recruited into the study 89 of whom were NSP. The successful treatment completion rate in NSP adult TB patients was 18.7% higher (P = 0.042 95% CI 0.9-36.4) on farms in the intervention group than on farms in the control group. Case finding for adult NSP TB cases was 8% higher (P = 0.2671) on farms in the intervention group compared to the control group. Conclusion: Trained LHWs were able to improve the successful TB treatment rate among adult NSP TB patients in a well-established Health service despite reduction of services. (authors)

  • Lay Health Workers in primary and community Health care
    Cochrane Database of Systematic Reviews, 2005
    Co-Authors: Simon Lewin, Merrick Zwarenstein, Judy Dick, P Pond, Godwin N Aja, B Van Wyk, Xavier Boschcapblanch, M Patrick
    Abstract:

    Background Lay Health Workers (LHWs) are widely used to provide care for a broad range of Health issues. However, little is known about the effectiveness of LHW interventions. Objectives To assess the effects of LHW interventions in primary and community Health care on Health care behaviours, patients' Health and wellbeing, and patients' satisfaction with care. Search methods We searched the Cochrane Effective Practice and Organisation of Care and Consumers and Communication specialised registers (to August 2001); the Cochrane Central Register of Controlled Trials (to August 2001); MEDLINE (1966- August 2001); EMBASE (1966-August 2001); Science Citations (to August 2001); CINAHL (1966-June 2001); Healthstar (1975-2000); AMED (1966-August 2001); the Leeds Health Education Effectiveness Database and the reference lists of articles. Selection criteria Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community Health care and intended to promote Health, manage illness or provide support to patients. A 'Lay Health Worker' was defined as any Health Worker carrying out functions related to Health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education. There were no restrictions on the types of consumers. Data collection and analysis Two reviewers independently extracted data onto a standard form and assessed study quality. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the results of included studies were combined and an estimate of effect obtained. Main results Forty three studies met the inclusion criteria, involving more than 210,110 consumers. These showed considerable diversity in the targeted Health issue and the aims, content and outcomes of interventions. Most were conducted in high income countries (n=35), but nearly half of these focused on low income and minority populations (n=15). Study diversity limited meta-analysis to outcomes for five subgroups (n=15 studies) (LHW interventions to promote the uptake of breast cancer screening, immunisation and breastfeeding promotion [before two weeks and between two weeks and six months post partum] and to improve diagnosis and treatment for selected infectious diseases). Promising benefits in comparison with usual care were shown for LHW interventions to promote immunisation uptake in children and adults (RR=1.30 [95% CI 1.14, 1.48] p=0.0001) and LHW interventions to improve outcomes for selected infectious diseases (RR=0.74 [95% CI 0.58, 0.93) p=0.01). LHWs also appear promising for breastfeeding promotion. They appear to have a small effect in promoting breast cancer screening uptake when compared with usual care. For the remaining subgroups (n=29 studies), the outcomes were too diverse to allow statistical pooling. We can therefore draw no general conclusions on the effectiveness of these subgroups of interventions. Authors' conclusions LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other Health issues, evidence is insufficient to justify recommendations for policy and practice. There is also insufficient evidence to assess which LHW training or intervention strategies are likely to be most effective. Further research is needed in these areas.

Claire Glenton - One of the best experts on this subject based on the ideXlab platform.

  • barriers and facilitators to the implementation of Lay Health Worker programmes to improve access to maternal and child Health qualitative evidence synthesis
    Cochrane Database of Systematic Reviews, 2013
    Co-Authors: Claire Glenton, Christopher J Colvin, Benedicte Carlsen, Alison Swartz, Simon Lewin, Jane Noyes, Arash Rashidian
    Abstract:

    Background Lay Health Workers (LHWs) perform functions related to Healthcare delivery, receive some level of training, but have no formal professional or paraprofessional certificate or tertiary education degree. They provide care for a range of issues, including maternal and child Health. For LHW programmes to be effective, we need a better understanding of the factors that influence their success and sustainability. This review addresses these issues through a synthesis of qualitative evidence and was carried out alongside the Cochrane review of the effectiveness of LHWs for maternal and child Health. Objectives The overall aim of the review is to explore factors affecting the implementation of LHW programmes for maternal and child Health. Search methods We searched MEDLINE, OvidSP (searched 21 December 2011); MEDLINE Ovid In-Process & Other Non-Indexed Citations, OvidSP (searched 21 December 2011); CINAHL, EBSCO (searched 21 December 2011); British Nursing Index and Archive, OvidSP (searched 13 May 2011). We searched reference lists of included studies, contacted experts in the field, and included studies that were carried out alongside the trials from the LHW effectiveness review. Selection criteria Studies that used qualitative methods for data collection and analysis and that focused on the experiences and attitudes of stakeholders regarding LHW programmes for maternal or child Health in a primary or community Healthcare setting. Data collection and analysis We identified barriers and facilitators to LHW programme implementation using the framework thematic synthesis approach. Two review authors independently assessed study quality using a standard tool. We assessed the certainty of the review findings using the CerQual approach, an approach that we developed alongside this and related qualitative syntheses. We integrated our findings with the outcome measures included in the review of LHW programme effectiveness in a logic model. Finally, we identified hypotheses for subgroup analyses in future updates of the review of effectiveness. Main results We included 53 studies primarily describing the experiences of LHWs, programme recipients, and other Health Workers. LHWs in high income countries mainly offered promotion, counselling and support. In low and middle income countries, LHWs offered similar services but sometimes also distributed supplements, contraceptives and other products, and diagnosed and treated children with common childhood diseases. Some LHWs were trained to manage uncomplicated labour and to refer women with pregnancy or labour complications. Many of the findings were based on studies from multiple settings, but with some methodological limitations. These findings were assessed as being of moderate certainty. Some findings were based on one or two studies and had some methodological limitations. These were assessed have low certainty. Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and Health system constraints. Programme recipients were generally positive to the programmes, appreciating the LHWs’ skills and the similarities they saw between themselves and the LHWs. However, some recipients 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 recipients emphasised the importance of trust, respect, kindness and empathy. However, LHWs sometimes found it difficult to manage emotional relationships and boundaries with recipients. Some LHWs feared blame if care was not successful. Others felt demotivated when their services were not appreciated. Support from Health systems and community leaders could give LHWs credibility, at least if the Health systems and community leaders had authority and respect. Active support from family members was also important. Health professionals often appreciated the LHWs’ contributions in reducing their workload and for their communication skills and commitment. However, some Health professionals thought that LHWs added to their workload and feared a loss of authority. LHWs were motivated by factors including altruism, social recognition, knowledge gain and career development. Some unsalaried LHWs wanted regular payment, while others were concerned that payment might threaten their social status or lead recipients to question their motives. Some salaried LHWs were dissatisfied with their pay levels. Others were frustrated when payment differed across regions or institutions. Some LHWs stated that they had few opportunities to voice complaints. LHWs described insufficient, poor quality, irrelevant and inflexible training programmes, calling 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 fellow LHWs. In some studies, 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 recipients pointed to other problems, including women’s reluctance to be referred after bad experiences with Health professionals, fear of caesarean sections, lack of transport, and cost. Some LHWs were reluctant to refer women on because of poor co-operation with Health professionals. We organised these findings and the outcome measures included in the review of LHW programme effectiveness in a logic model. Here we proposed six chains of events where specific programme components lead to specific intermediate or long-term outcomes, and where specific moderators positively or negatively affect this process. We suggest how future updates of the LHW effectiveness review could explore whether the presence of these components influences programme success. Authors' conclusions Rather than being seen as a lesser trained Health Worker, LHWs may represent a different and sometimes preferred type of Health Worker. The close relationship between LHWs and recipients is a programme strength. However, programme planners must consider how to achieve the benefits of closeness while minimizing the potential drawbacks. Other important facilitators may include the development of services that recipients perceive as relevant; regular and visible support from the Health system and the community; and appropriate training, supervision and incentives.

  • still too little qualitative research to shed light on results from reviews of effectiveness trials a case study of a cochrane review on the use of Lay Health Workers
    Implementation Science, 2011
    Co-Authors: Claire Glenton, Simon Lewin, Inger B Scheel
    Abstract:

    Background: Qualitative research is used increasingly alongside trials of complex interventions to explore processes, contextual factors, or intervention characteristics that may have influenced trial outcomes. Qualitative research conducted alongside trials can also be used to shed light on the results of systematic reviews of effectiveness by looking for factors that can help explain heterogeneous results across trials. In a Cochrane review on the effects of using Lay Health Workers on maternal and child Health and infectious disease control, we identified 82 trials. These trials showed promising benefits but results were heterogeneous. Objective: To use qualitative studies conducted alongside these trials to explore factors and processes that might have influenced intervention outcomes. Methods: We attempted to identify qualitative research carried out alongside the trials by contacting trial authors, checking papers for references to qualitative research, searching Pubmed for related studies, and carrying out citation searches. For those qualitative studies that we included, we extracted information regarding study objective, data collection and analysis methods, and key themes and categories. Results: For 52 (63%) of the trials, we found no qualitative research that had been conducted alongside the trials. For 16 (20%) trials, some form of qualitative data collection had been done but was unavailable or had been done before the trial. For 14 (17%) trials, qualitative research had been done during or shortly after the trial, although descriptions of qualitative methods and results were often sparse. Most of these 14 studies aimed to elicit trial participants’ perspectives and experiences of the intervention. A common theme was participants’ appreciation of the Lay Health Workers’ shared circumstances, for instance with regard to social background or experience of the Health condition. In six studies, researchers explored the experiences of the Lay Health Workers themselves. Issues included the importance of regular supervision and Health professionals’ support or lack of support. Conclusions: Qualitative studies carried out alongside trials of complex interventions could offer opportunities to authors of systematic reviews of effectiveness wishing to understand the heterogeneity of trial results. For interventions of Lay Health Worker programmes at least, too few such studies exist at present for these opportunities to be realised.

  • Lay Health Workers in primary and community Health care for maternal and child Health and the management of infectious diseases
    Cochrane Database of Systematic Reviews, 2010
    Co-Authors: Simon Lewin, Karen Daniels, Claire Glenton, Godwin N Aja, B Van Wyk, Xavier Boschcapblanch, Susan Munabibabigumira, Jan Odgaardjensen, Marit Johansen, Merrick Zwarenstein
    Abstract:

    Background 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. Objectives To assess the effects of LHW interventions in primary and community Health care on maternal and child Health and the management of infectious diseases. Search methods 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. Selection criteria 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. Data collection and analysis 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. Main results 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. Authors' conclusions 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.

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  • a randomized trial of a multi level intervention to improve advance care planning and symptom management among low income and minority employees diagnosed with cancer in outpatient community settings
    Contemporary Clinical Trials, 2020
    Co-Authors: Manali I Patel, Sana Khateeb, Tumaini R. Coker
    Abstract:

    Abstract Introduction Equitable delivery of advance care planning and symptom management among patients is crucial to improving cancer care. Existing interventions to improve the uptake of these services have predominantly occurred in clinic settings and are limited in their effectiveness, particularly among low-income and minority populations. Methods The “Lay Health Worker Educates Engages and Activates Patients to Share (LEAPS)” intervention was developed to improve advance care planning and symptom management among low-income and minority hourly-wage Workers with cancer, in two community settings. The intervention provides a Lay Health Worker to all patients newly diagnosed with cancer and aims to educate and activate patients to engage in advance care planning and symptom management with their oncology providers. In this randomized clinical trial, we will evaluate the effect on quality of life (primary outcome) using the validated Functional Assessment of Cancer Therapy – General Survey, at enrollment, 4- and 12- months post-enrollment. We will examine between-group differences on our secondary outcomes of patient activation, patient satisfaction with Healthcare decision-making, and symptom burden (at enrollment, 4- and 12-months post-enrollment), and total Healthcare use and Healthcare costs (at 12-months post-enrollment). Discussion Multilevel approaches are urgently needed to improve cancer care delivery among low-income and minority patients diagnosed with cancer in community settings. The current study describes the LEAPS intervention, the study design, and baseline characteristics of the community centers participating in the study. ClinicalTrials.gov Registration # NCT03699748 .

  • Supplemental Material, Appendix_2._Interview_Guide - End-of-Life Cancer Care Redesign: Patient and Caregiver Experiences in a Lay Health Worker–Led Intervention
    2019
    Co-Authors: Manali I Patel, David Moore, Tumaini R. Coker
    Abstract:

    Supplemental Material, Appendix_2._Interview_Guide for End-of-Life Cancer Care Redesign: Patient and Caregiver Experiences in a Lay Health Worker–Led Intervention by Manali I. Patel, David Moore and Tumaini R. Coker in American Journal of Hospice and Palliative Medicine®

  • effect of a Lay Health Worker intervention on goals of care documentation and on Health care use costs and satisfaction among patients with cancer a randomized clinical trial
    JAMA Oncology, 2018
    Co-Authors: Manali I Patel, Vandana Sundaram, Manisha Desai, Vyjeyanthi S Periyakoil, James G Kahn, Jay Bhattacharya, Steven M Asch
    Abstract:

    Importance Although Lay Health Workers (LHWs) improve cancer screening and treatment adherence, evidence on whether they can enhance other aspects of care is limited. Objective To determine whether an LHW program can increase documentation of patients’ care preferences after cancer diagnosis. Design, Setting, and Participants Randomized clinical trial conducted from August 13, 2013, through February 2, 2015, among 213 patients with stage 3 or 4 or recurrent cancer at the Veterans Affairs Palo Alto Health Care System. Data analysis was by intention to treat and performed from January 15 to August 18, 2017. Interventions Six-month program with an LHW trained to assist patients with establishing end-of-life care preferences vs usual care. Main Outcomes and Measures The primary outcome was documentation of goals of care. Secondary outcomes were patient satisfaction on the Consumer Assessment of Health Care Providers and Systems “satisfaction with provider” item (on a scale of 0 [worst] to 10 [best possible]), Health care use, and costs. Results Among the 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years, 211 (99.1%) were male, and 165 (77.5%) were of non-Hispanic white race/ethnicity. Within 6 months of enrollment, patients randomized to the intervention had greater documentation of goals of care than the control group (97 [92.4%] vs 19 [17.5%.];P  Conclusions and Relevance Incorporating an LHW into cancer care increases goals-of-care documentation and patient satisfaction and reduces Health care use and costs at the end of life. Trial Registration ClinicalTrials.gov Identifier:NCT02966509