Who is a community health worker? - a systematic review of definitions. — TEI-tagged view

Abimbola OlaniranpersName, Helen SmithpersName, Regine UnkelspersName, Sarah Bar-ZeevpersName, Nynke van den BroekpersName (2017date). “Who is a community health worker? - a systematic review of definitions..” Global Health Actiontitle·j.

Object of study — definitions and descriptions of community health workersterm·dom

Research question — what themes the definitions of community health workersterm·dom share, and how the term should be used

Contribution — a methodical, competency-based definition and categorisation of community health workersterm·dom

Full text — tagged

Who is a community health workerterm·key? - a systematic reviewterm·key of definitions.

Abstract Background: Community health workersterm·dom (CHWsterm·dom) can play vital roles in increasing coverage of basic health services. However, there is a need for a systematic categorisation of CHWsterm·dom that will aid common understanding among policy makers, programme planners, and researchers.

Objective: To identify the common themes in the definitions and descriptions of CHWsterm·dom that will aid delineation within this cadre and distinguish CHWsterm·dom from other healthcare providers.

Design: A systematic reviewterm·key of peer-reviewed papers and grey literature.

Results: We identified 119 papers that provided definitions of CHWsterm·dom in 25 countries across 7 regions. The review shows CHWsterm·dom as paraprofessionalsterm·key or lay individuals with an in-depth understanding of the community culture and language, have received standardised job-related training of a shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community. CHWsterm·dom can be categorised into three groups by education and pre-service training. These are lay health workersterm·dom (individuals with little or no formal education who undergo a few days to a few weeks of informal training), level 1 paraprofessionalsterm·dom (individuals with some form of secondary education and subsequent informal training), and level 2 paraprofessionalsterm·dom (individuals with some form of secondary education and subsequent formal training lasting a few months to more than a year). Lay health workersterm·dom tend to provide basic health services as unpaid volunteers while level 1 paraprofessionalsterm·dom often receive an allowance and level 2 paraprofessionalsterm·dom tend to be salaried.

Conclusions: This review provides a categorisation of CHWsterm·dom that may be useful for health policy formulation, programme planning, and research.

KEYWORDS: Lay health workerterm·key, health workforceterm·key, role, scope of practice Background To achieve the health-related Sustainable Development Goals (SDGs) and universal health coverage (UHC) in the post-2015 period, adequate numbers of competent health workers are required to provide services in an enabling environment [ 1 ]. A decade ago, the World Health Organization (WHO) declared a crisis in the global health workforceterm·key, characterised by severe shortages, inappropriate skill mixes, and gaps in service coverage [ 2 ]. The magnitude of the health workforceterm·key shortage varies across contexts with rural regions and low- and middle-income countries being the worst affected, and with critical shortages greatest in sub-Saharan Africa [ 3 ].

Evidence suggests that the presence of community health workersterm·dom (CHWsterm·dom) can complement an overstretched health workforceterm·key and may be key to increasing the availability of, and access to, basic health services especially in hard-to-reach areas, thereby bridging the health equity gap [ 4 , 5 ]. However, the diversity of roles and inconsistent nomenclature of CHWsterm·dom make it difficult for policy makers, programme planners, and researchers working with CHWsterm·dom in different settings to have a common understanding of ‘who is a CHWterm·dom?’ [ 6 ]. Furthermore, in contrast to professional health workers, there is remarkable diversity in the content and duration of CHWsterm·dom’ training. Some CHWsterm·dom undergo informal training, with varied training content and durations, taking place outside recognised training institutions. Other CHWsterm·dom undergo formal training in nationally recognised training institutions with structured training content and duration [ 7 , 8 ].

There have been different attempts to define and categorise CHWsterm·dom based on their roles, educational level, and remunerationterm·dom [ 5 , 9 ]. However, there is a need to build on these approaches by using a methodical approach that accommodates the diversities in CHWterm·dom definitions to identify the spectrum of CHWterm·dom categories that will aid comparison with other groups of health workers. Health worker categories that are comparable across disciplines may be crucial to designing CHWterm·dom roles and positions within multidisciplinary health teams [ 10 ].

We conducted a systematic reviewterm·key of the global literature in order to: (1) identify definitions of CHWsterm·dom reported in the literature; (2) determine key themes in how definitions are reported; and (3) clarify use of the term CHWterm·dom for policy makers.

Methods Selection criteria We included any type of paper that described CHWsterm·dom, their roles, and ways of working; this included published peer-reviewed primary research as well as commentaries, editorials, and review papers. For primary research, we included studies from any discipline using any study design and methods. We also included grey literature (unpublished reports and evaluations) if it included descriptions of CHWsterm·dom or explanations of their roles. We included literature that described CHWsterm·dom working in any aspect of primary or community healthcare and any disease or health issue. Overall, we included published and unpublished papers reported in English. In contrast, we excluded papers not focused on CHWsterm·dom or papers that focused on CHWsterm·dom but lacked a definition or description of CHWsterm·dom. Furthermore, we excluded papers that are not reported in the English language.

Search strategy We searched eight databases for peer-reviewed literature (CHWterm·dom Central, CINAHL Plus, ERIC, Global Health, LILACS, MEDLINE, Popline, and Web of Science); two of these databases also contained grey literature (CHWterm·dom Central and Popline). Keywords for the search included terms for CHWterm·dom (e.g. ‘community health workerterm·key*’ and alternate terms for ‘CHWsterm·dom’) and a term for definition (e.g. ‘defin*’). We identified a total of 66 alternate terms for CHWsterm·dom through a preliminary literature search and database subject headings (see Supplemental File 1 for an example of the search conducted in MEDLINE). We excluded terms which can be classified as ‘health professional’ as defined by the WHO’s mapping of occupations [ 11 ]. We limited the database searches to literature published in English between January 2004 and March 2016. The first global report on the global health workforceterm·key crisis was published in 2004; this emphasised the inclusion of CHWsterm·dom in country health plans and resulted in a renewed interest in CHWsterm·dom and subsequently additional research and publications on the topic [ 12 ].

We also hand-searched the references of all identified papers to find further relevant literature containing definitions or descriptions of CHWsterm·dom. When the full text was not available online (n = 2 papers), we contacted the primary authors by email to request a copy. Both primary authors provided electronic copies of the papers that were not available online.

Study selection Titles and abstracts (or executive summaries) of 7,653 sources identified in the various databases were reviewed independently by two of the authors (AO and RU) to identify potentially relevant papers. The same authors obtained and independently reviewed the full text of 783 potentially relevant papers. When there was no consensus on inclusion or exclusion of a paper (n = 1), they sought the opinion of a third reviewer (NvdB).

Data synthesis We used narrative synthesis [ 13 ] to summarise definitions and other information contained in the included papers in a structured way. We extracted information on the characteristics of the study and definitions of CHWsterm·dom using standard tables which were then used to make comparisons across included papers. Using an inductive approach, we reviewed the definitions for reoccurring patterns of items that relate to our study objectives; these formed our codes (Supplemental File 3). We reviewed these codes for concepts that are related in meaning, thereby constituting sub-themes, and subsequently we grouped sub-themes with similar connotations into themes: (1) selection criteria, (2) roles and/or tasks, (3) training, and (4) remunerationterm·dom. Finally, we compared the themes, sub-themes, and codes for congruency in meaning and developed narratives to describe the various themes and sub-themes.

Results Description of included papers Figure 1 illustrates the process of study selection. The database searches identified 7,653 references; from these, we removed 1,332 duplicates. From the remaining 6,321 titles and abstracts, we excluded 5,537 as they were not in English or did not focus on CHWsterm·dom. Of the 783 full text papers reviewed, we excluded 664 as they did not provide a definition or description of CHWsterm·dom, leaving 119 included papers ( Figure 1 ). Of the 119 included papers, 110 are peer-reviewed publications and 9 are grey reports or non-peer-reviewed papers. Table 1 summarises the characteristics of the 119 included papers; a full detailed list of the included papers and their characteristics is provided in Supplemental File 2.

PRISMA flow diagram.

Key characteristics of included papers (n = 119).

The majority (n = 100) of the papers documenting definitions of CHWsterm·dom were published in the latter half of the review period (2010–2016) ( Table 1 ). The included papers described CHWsterm·dom in 25 countries across 7 regions and all income groups as defined by the World Bank [ 14 ]. Sixty-two (52%) of the included papers described CHWsterm·dom in high-income countries, 10 (8%) in upper middle-income countries, 15 in (13%) lower middle-income countries, and 16 (13%) in low-income countries. Sixteen papers described CHWsterm·dom in more than one country.

Description of findings Common themes identified in definitions or descriptions of CHWsterm·dom are outlined in Supplemental Table 3 . The common themes in definitions of CHWsterm·dom include (1) selection criteria, (2) roles and/or tasks, (3) training, and (4) remunerationterm·dom.

Pattern of educational qualificationterm·dom, pre-service training, and remunerationterm·dom of CHWterm·dom categories.

Selection of CHWsterm·dom Overall, more than half (n = 82) of the included papers described CHWsterm·dom in relation to how they are selected from the community. Papers generally reported the selection criteria and the organisations or institutions involved in CHWsterm·dom’ selection. Overall, CHWsterm·dom are selected based on community membership, knowledge of the community culture and languages spoken, personality traits that encourage trust and respect, gender, previous experience providing healthcare, and educational qualificationterm·dom ( Table 2 ).

Variation in the selection criteria used by stakeholders.

Many of the included papers noted that CHWsterm·dom are selected because they are community residents, who may not be indigenes of the community [ 15 , 22 , 28 – 37 ], or they are indigenous members residing in the community [ 16 – 20 , 25 , 26 , 38 – 72 ]. CHWsterm·dom are also expected to have a close understanding or share the ethnicity, language [ 23 , 39 , 41 – 44 , 50 , 59 , 61 , 73 – 85 ], socioeconomic status [ 6 , 39 , 53 , 76 , 78 ], and life experiences [ 6 , 39 , 53 , 76 , 78 , 84 ] of the community. It is anticipated that these characteristics will ensure that CHWsterm·dom can better mobilise and increase community members’ acceptance of the health services provided [ 61 , 64 ]. Some papers specified that CHWsterm·dom should be trusted and respected community members [ 41 , 59 , 61 , 63 , 65 , 75 , 84 , 86 , 87 ], while in some contexts, CHWsterm·dom are expected to possess leadership qualities [ 21 , 57 , 88 ].

In addition to these attributes, CHWsterm·dom are expected to have other characteristics to better suit them for the role. In general, CHWsterm·dom providing health services to women and children tend to be female [ 15 , 16 , 18 , 21 , 27 , 37 , 39 , 43 , 52 , 89 – 92 ] and those providing services in a health facility may be required to have some form of healthcare experience [ 23 , 24 ]. Previous primary or secondary education is sometimes considered in the selection of CHWsterm·dom [ 24 , 28 , 29 , 46 ].

There are various organisations or institutions involved in the selection of CHWsterm·dom. The included papers suggest that CHWsterm·dom are either selected by the community members and leaders [ 15 – 21 , 28 ], the relevant department in the Ministry of Health on behalf of the government [ 29 , 39 , 47 ], non-governmental organisations (NGOs) [ 22 ], or by the health facility management [ 23 , 24 ]. The selection criteria, however, tend to vary across these stakeholder groups ( Table 2 ). Being a resident of the community and having personality traits that engender trust and respect are often considered by the community and NGOs when selecting CHWsterm·dom [ 15 – 22 , 38 ]. The CHWsterm·dom selected by the government (or in collaboration with the community) are often selected on the basis of residence in the community and having some form of secondary education [ 25 – 27 , 29 , 39 , 93 ]. Health facility management often select CHWsterm·dom on the basis of their level of education and having previous work experience in providing healthcare [ 23 , 24 ].

The roles and tasks of CHWsterm·dom More than three-quarters (n = 90) of the included papers described the roles and/or tasks of CHWsterm·dom in the community or within the health facility (Supplemental File 3). The roles of CHWsterm·dom include health promotion and disease prevention, treatment of basic medical conditions, and collection of health data.

In relation to health promotion and disease prevention, CHWsterm·dom are involved in activities both within the community and linked to the health facilities they are connected to. In the community, CHWsterm·dom provide services to promote a healthy lifestyle and prevent disease [ 17 , 19 , 26 , 28 , 33 , 38 , 40 , 43 , 45 , 56 , 57 , 66 , 67 , 70 , 71 , 73 , 79 , 89 , 90 , 93 – 104 ], mobilise and encourage community members to utilise available health services [ 15 , 18 , 95 , 103 , 104 ], and facilitate access to facility-based healthcare by helping community members understand where to access care when needed [ 6 , 15 , 17 , 25 , 26 , 36 , 40 , 43 , 47 , 52 , 56 , 59 , 61 , 63 – 65 , 70 , 72 , 82 , 91 , 104 – 108 ]. Acting as ‘Patient Navigatorsterm·dom’ [ 23 , 24 , 40 , 77 , 80 , 109 – 119 ], CHWsterm·dom interpret health information and provide logistical support to patients accessing healthcare within a complex healthcare system. They also communicate health messages to community members [ 6 , 16 , 19 , 33 , 49 , 56 , 60 , 62 , 70 , 73 , 74 , 82 – 86 , 88 , 102 , 104 , 114 , 117 , 119 – 123 ], help patients to cope better with clinical conditions by providing psychosocial support [ 24 , 41 , 43 , 47 , 49 , 58 , 60 , 73 , 82 , 86 , 96 , 106 , 107 ], and serve as community representatives, providing a link between the community and health system [ 47 , 59 , 74 , 81 , 82 , 84 , 89 , 95 , 96 , 98 , 120 ]. Their role as a community representative entails conveying policy-related health messages to the community members and, in turn, reporting on community health needs and priorities to the health facilities they are linked to.

Some CHWsterm·dom have additional roles of providing treatment for basic clinical conditions and minor ailments such as malaria and diarrhoea [ 15 , 38 , 39 , 44 , 55 , 95 , 99 , 122 ]. Other CHWsterm·dom provide basic obstetric case management but the CHWsterm·dom providing this have completed post-secondary formal training in order to provide these services [ 28 , 30 , 32 , 52 ]. Treatment of basic clinical conditions and management of basic obstetric cases appear to be part of a CHWterm·dom’s role in low- and middle-income countries only; we did not find any evidence of CHWsterm·dom providing these services in the papers from high-income countries.

The included papers suggest that CHWsterm·dom also have a role in helping to collect and report, via existing mechanisms, information on the health status of the community members [ 30 , 59 , 93 , 97 ].

Educational qualificationterm·dom and pre-service training of CHWsterm·dom Less than 20% (n = 21) of the included papers documented the educational qualificationsterm·dom or pre-service training of CHWsterm·dom in the definitions used (Supplemental File 2). We identified three main patterns in the educational qualificationterm·dom and pre-service training of CHWsterm·dom: Individuals with little or no formal education who have undergone a few days to a few weeks of job-related pre-service training outside a recognised training institution (e.g. training provided in a health facility by NGOs) [ 4 , 19 , 21 , 43 , 50 , 53 , 91 , 99 , 123 , 124 ].

Individuals with some form of secondary education and subsequent job-related pre-service training outside a recognised training institution lasting any time from a few days to a few weeks [ 35 , 92 ].

Individuals with some form of secondary education and subsequent pre-service training in a recognised training institution lasting a few months to more than a year [ 18 , 26 , 27 , 32 , 39 , 46 , 52 , 68 , 125 – 127 ].

Remunerationterm·dom of CHWsterm·dom Some CHWsterm·dom perform their tasks as unpaid volunteers [ 18 , 22 , 89 , 90 , 97 , 103 , 108 , 116 , 128 ]. Other CHWsterm·dom are paid an allowance [ 19 , 21 , 49 , 94 , 99 ], performance-based incentives [ 35 , 92 ], or a formal salary [ 27 , 29 , 39 , 46 , 93 , 126 ] ( Table 3 ). The form of remunerationterm·dom is often influenced by the level of educational qualificationterm·dom and form of CHWsterm·dom’ pre-service training ( Table 3 ). CHWsterm·dom with minimal or no education and subsequent informal pre-service training are likely to be unpaid or receive an allowance while CHWsterm·dom with some form of secondary education with subsequent informal pre-service training are likely to receive some allowance or monetary incentive [ 35 , 92 ]. Conversely, CHWsterm·dom with some secondary education and subsequent formal pre-service training are often salaried and paid by the government [ 27 , 46 , 126 ].

CHWsterm·dom’ service recipients The service recipients of CHWsterm·dom tend to vary with country income status (Supplemental File 3). In high-income countries, CHWsterm·dom provide health services to ethnic minority and low-income populations within these countries [ 21 , 23 , 33 , 41 , 42 , 45 , 47 – 50 , 56 – 60 , 62 , 63 , 74 – 80 , 84 – 86 , 97 , 101 , 107 , 108 , 110 , 113 , 115 , 118 – 120 , 123 ]. The service recipients in these settings are usually individuals with non-communicable diseases such as cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes [ 23 , 24 , 31 , 33 , 41 , 47 – 49 , 56 , 58 , 63 , 73 , 77 , 80 , 85 , 96 , 100 , 101 , 106 , 109 , 112 , 113 , 115 – 117 , 120 ]. Only one paper from a high-income country (United States) noted that CHWsterm·dom provide health services related to communicable diseases [ 129 ] and four documented maternal and child health services to ethnic minority populations in the United States [ 42 , 43 , 88 , 114 ].

Conversely, in low- and middle-income countries, CHWsterm·dom tend to provide services related to communicable diseases [ 19 , 22 , 28 , 35 , 44 , 55 , 98 , 99 , 128 ] and maternal and child health services [ 16 – 18 , 26 – 28 , 30 , 32 , 34 , 51 , 52 , 81 , 89 – 92 , 94 , 125 , 127 , 130 , 131 ]. Only two of the included papers from upper middle-income countries (Iran and South Africa) stated that CHWsterm·dom provide services related to non-communicable diseases [ 46 , 121 ].

Discussion This review explores the various definitions and descriptions of ‘community health workersterm·dom’ and identified the common themes in these definitions to understand the essential characteristics of health workers classified as CHWsterm·dom. Our intention was to describe the various categories of CHWsterm·dom to help clarify use of the term and reach a common understanding among key stakeholders in community health programme planning, policy, and research.

Common themes in the definitions of CHWsterm·dom Our review shows that CHWsterm·dom engage in health promotion and disease prevention including basic treatment and collecting community health information. Most of the included definitions of CHWsterm·dom are based on roles and tasks of CHWsterm·dom. Role-based classification has been used by other authors including a review of global literature which classified CHWsterm·dom as specialists (have fewer health roles within a defined thematic area) and generalists (have more health roles across thematic areas) [ 5 ]. Other studies [ 132 , 133 ], however, show that many governmental organisations and NGOs continue to formally or informally add tasks to the job description of CHWsterm·dom, thereby blurring distinctions between CHWsterm·dom who are generalists or specialists. There are suggestions that the definitions and categories of health workers should be based on competency or educational qualificationterm·dom rather than on tasks or roles [ 10 ]. In general, categorisations of health workers tend to be competency-based as the level of competency usually informs the type of tasks assigned to any group of health workers and their position within the health system. This competency-based categorisation may be key to developing frameworks to aid common understanding among stakeholders irrespective of context and comparison of different groups of health workers. Furthermore, these categories may assist programme planners in designing job profiles for multidisciplinary health teams and assigning commensurate remunerationterm·dom based on competency levels [ 134 ].

In line with our review findings, the level of competency and educational qualificationterm·dom of health workers will often determine roles/tasks, selection/recruitment, and remunerationterm·dom [ 135 ].

Through this review, we found that the level of competency or qualifications used for categorising health workers varies across settings, as found in other research [ 136 ]. The International Labour Organisation (ILO) suggest that lay health workersterm·dom may or may not possess basic literacy skills while paraprofessionalsterm·key are individuals who have had some form of formal long-duration post-secondary (non-tertiary) education and professionals usually have some form of tertiary education [ 137 ]. We modified the ILO definition of paraprofessionalsterm·key to accommodate the two levels of competency of CHWsterm·dom who may be classified as paraprofessionalsterm·key. These are level 2 paraprofessionalsterm·dom, who are individuals with some level of secondary education and subsequent formal training of longer duration in a recognised training institution; and level 1 paraprofessionalsterm·dom, who are individuals with some level of secondary education who subsequently received informal, short-duration, pre-service training. The third and lowest level of competency among CHWsterm·dom includes lay health workersterm·dom with little or no formal education but who have received informal job-related training.

In addition, we noted that those CHWsterm·dom who could be classified as lay health workersterm·dom are usually unpaid volunteers or receive an allowance while those that match the definition of level 1 paraprofessionalsterm·dom often receive an allowance or incentive and the level 2 paraprofessionalsterm·dom are usually salaried. Figure 2 illustrates how the characteristics of educational qualificationterm·dom, pre-service training, and remunerationterm·dom of the different levels are linked with the different categories of CHWsterm·dom. It shows that the likelihood of having a salary increases with higher educational qualificationsterm·dom and longer duration of formal pre-service training.

Linking pre-service training and remunerationterm·dom to different levels of CHWsterm·dom.

In line with our review findings, the selection criteria and expected competencies of health workers often vary with the organisations/institutions involved in the selection [ 138 ]. These selection criteria will be crucial in identifying fit-for-purpose CHWsterm·dom, especially as key stakeholders in global health continue to emphasise the advantages of a skills mix in health teams delivering primary care in areas with a health workforceterm·key shortage [ 1 ]. A clear understanding of the various levels of competencies of CHWsterm·dom will guide programme planners in identifying and assigning roles to CHWsterm·dom within the health system. Furthermore, a clear understanding of their competency levels and roles can inform policy and planning of CHWterm·dom remunerationterm·dom and career development [ 139 ].

CHWsterm·dom’ service recipients Evidence shows that CHWsterm·dom can increase health service coverage to hard-to-reach populations irrespective of country income status [ 140 ]. Our review noted that CHWsterm·dom providing services in high-income settings mostly delivered services related to non-communicable diseases and mainly to hard-to-reach populations. Conversely, CHWsterm·dom in low- and middle-income countries focus extensively on communicable diseases and maternal and child health and have relatively insignificant roles in the prevention and control of non-communicable diseases. There are indications that with appropriate health system support, CHWsterm·dom can also contribute to the prevention and control of non-communicable disease [ 141 ] in low- and middle-income settings where about three-quarters of non-communicable disease-related deaths occur [ 142 ].

Similarities and differences with definitions of similar cadres of health workers The absence of distinct definitions for groups of health workers impairs planning and policy formulation for multidisciplinary health teams [ 143 ]. If we compare the common themes in definitions of CHWsterm·dom with definitions of similar cadres of health workers, it is possible to determine the boundaries between each and make distinctions. Other relevant cadres of health workers include mid-level health workersterm·dom [ 144 ] and Traditional Birth Attendantsterm·dom (TBAsterm·dom) [ 145 ]. Hence, distinct CHWterm·dom definition and categories may be key to assigning roles and positions to CHWsterm·dom in multidisciplinary health teams.

Mid-level health workersterm·dom are defined as frontline health workers with up to 3 years’ post-secondary school training to perform specific health-related tasks such as clinical or diagnostic functions, which are otherwise conducted by health professionals with a higher educational qualificationterm·dom [ 146 , 147 ]. This is similar to our findings which refer to CHWsterm·dom as frontline health workers providing information and performing health-related tasks. The main difference is that CHWsterm·dom receive training of fewer than 3 years. Additionally, our review shows that the primary goal of the CHWterm·dom is to provide culturally appropriate health services to the community members.

TBAsterm·dom have been described as individuals who assist mothers during childbirth and have acquired skills by conducting deliveries of babies on their own or through apprenticeship training received from other TBAsterm·dom [ 145 ]. This definition of TBAsterm·dom contrasts with our findings which suggest that CHWsterm·dom have received a standardised job-related training in the context of the role they are expected to perform. However, trained TBAsterm·dom who have received standardised job-related training in the context of an intervention could theoretically be considered as lay health workersterm·dom but not paraprofessionalsterm·key as they usually lack secondary education.

Strengths and limitations Due to resource and time limitations, we only included papers published in English and missed opportunities to review definitions of CHWsterm·dom included in papers published in other languages (e.g. studies from francophone West Africa or Latin America). We included definitions of CHWsterm·dom published from 2004–2016, excluding those pre-dating this period such as the definition proposed by the WHO Study Group in 1989: Community health workersterm·dom should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers. [ 148 ] We anticipate that we may have missed some definitions that still have contemporary relevance. However, we tried to make up for this by comparing common themes in the definitions included with those within definitions of CHWsterm·dom pre-dating 2004 and found no diverging or alternative themes.

We acknowledge that our limited literature review to identify and include all alternative terms of CHWsterm·dom may have missed some relevant terms. Overall, we used 66 alternative terms in this review and they were drawn from different contexts spanning the various socio-economic status and geographical regions; we, therefore, consider that this should be adequate to draw the needed inferences.

We did not assess the quality of papers included in this review because most were not primary research. None of the definitions contained in the included studies were based on any systematic or conceptual framework. To the best of our knowledge, our review is the first to use a methodical approach in defining ‘who is a CHWterm·dom?’

Conclusions This review provides a methodical definition of CHWsterm·dom based on common themes in CHWterm·dom definitions, thereby clarifying use of the term for health policy makers, programme planners, and researchers. We acknowledge that a single definition may not project the diversity of the group nor is a universal definition desirable given that the concept of CHWsterm·dom is highly political and has evolved to suit specific contexts, norms, and cultures. However, our review shows a link between pre-service training and remunerationterm·dom and different levels of CHWsterm·dom and this is helpful in distinguishing between CHWsterm·dom as lay health workersterm·dom or as paraprofessionalsterm·key. In order to differentiate CHWsterm·dom from other similar cadres of health workers, definitions of CHWsterm·dom should emphasise that they are individuals with an in-depth understanding of the community culture and language, have received standardised job-related training which is of shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community.

Recommendations for research and policy There is a need for further research on sustainable fit-for-purpose models of remunerating lay health workersterm·dom who are largely unpaid or receive short-term allowances from NGOs. These models may draw on existing models of remunerating levels 1 and 2 paraprofessionalterm·key CHWsterm·dom without compromising lay health workersterm·dom’ accountability and commitment to the community. We, therefore, recommend that the models should reward high performance without compromising intrinsic motivating factors, teamwork, and commitment to the community. Fit-for-purpose and sustainable remunerationterm·dom models may be key to long-term job satisfaction, commitment, and retention of CHWsterm·dom, especially considering the resources invested in selecting, training, and equipping them before they start providing services.

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Acknowledgments We are grateful to Caroline Hercod for her assistance with retrieving papers that were not available in the searched databases and for editing the final manuscript.

Biography AO, RU, and NvdB contributed to the review design. AO and RU independently screened titles and abstracts and the full text for included papers. All authors were involved in the analysis of the data. AO prepared the initial draft of the manuscript and HS, RU, SB, and NvdB provided review comments. The final draft of the manuscript was prepared by AO, HS, and NvdB. All authors approved the final draft of the manuscript.

RESPONSIBLE EDITOR John Kinsman, Umeå University, Sweden Funding Statement The authors alone are responsible for the content and writing of this article. This work is part of the lead author’s PhD and no external funding was received.

Disclosure statement No potential conflict of interest was reported by the authors.

Ethics and consent Ethical approval and patient consent were not necessary for this literature review.

Supplemental Supplemental data for this article can be accessed here Paper context Community health workerterm·key (CHWterm·dom) definitions and categories are nuanced differently within and across contexts and stakeholder groups. Our review utilised a methodical approach in identifying the common themes in the various CHWterm·dom definitions and subsequently developed a competency-based definition and categories that accommodate the peculiarities of the various contexts. This categorisation may inform a common understanding within and across stakeholder groups and also guide community health policy making, programme planning, and research across contexts.

References Associated Data Supplementary Materials Click here for additional data file.

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