Leveraging the Role of Community Health Workers with Community Groups: Evidence on Pro-equity Interventions to Improve Immunization Coverage for Zero-dose Children and Missed Communities

"CHWs [community health workers] can fill a critical gap by providing health care services and reaching groups with health education and promotion who otherwise would not receive them."

This evidence brief, published by FHI 360, presents results from a rapid review of the literature to understand the effectiveness and implementation of interventions involving community health workers (CHWs) and community group/volunteer collaboration to reach communities in vulnerable contexts with essential health services, including immunisation services.

The brief forms part of a series of rapid literature reviews (involving peer-reviewed and grey literature published between January 2010 through November 2022) conducted by FHI 360 and supported by the Vaccine Alliance (Gavi). The purpose of the reviews is to synthesise existing evidence on the effectiveness and implementation considerations for selected interventions that could help achieve more equitable immunisation coverage, specifically helping to reach zero-dose children (those who have not received a single vaccine to prevent disease) and missed communities (population groups that face multiple deprivations, such as socio-economic inequities and gender-related barriers). Results of syntheses are presented through evidence briefs (see Related Summaries below for others in this series with implications for social change communication) and an online Evidence Map. The objectives of the evidence briefs are to understand which strategies are effective, identify implementation considerations, and assess gaps in knowledge and understanding. Overall, they are meant to help programme planners assess whether an intervention, such as CHW and community group/volunteer collaborations, should be considered for reaching zero-dose children and missed communities. For this reason, the mapping and the briefs use a categorisation scheme to rate interventions as: potentially ineffective, inconclusive, promising, or proven.

As explained in the brief, "CHWs are trained health care providers who live and work in the communities they serve. CHWs typically have less formal training than other provider cadres and perform a variety of roles, including providing preventative and curative services; health promotion; counselling and psychosocial support; as well as strengthening ties between communities and the health system, and participating in data collection and record-keeping. Community groups involve community members engaged in joint efforts to improve the development, health, and well-being of their communities through organised means. Groups are generally organized on a volunteer, unpaid basis, including for their leadership. Group leaders can be considered volunteers. In some instances, CHWs and other development workers may collaborate with community groups and volunteers to expand their reach and further health promotion efforts, including those related to immunisation services. They may also train and technically support members of these groups."

The purpose of this review was to understand whether collaborations between CHWs and community groups/volunteers improve the reach of essential health services and to identify primary implementation considerations. In particular, it sought to answer the following questions:
 

• What types of pairings of CHWs and community groups have been used to inform health programmes, including immunisation programmes, within communities in vulnerable contexts to achieve health-related outcomes?
• To what extent is leveraging the role of CHWs in collaboration with community groups effective in reaching communities in vulnerable contexts, including those with high prevalence of zero-dose children, and in improving health outcomes, especially within immunisation programmes?
• What are the main implementation considerations for carrying out interventions involving pairing a CHW with a community group to improve health equity, especially regarding their use to improve immunisation outcomes among zero-dose children, missed communities, or otherwise under-immunised populations?

The following is a summary of the findings as highlighted in the brief:  

Effectiveness of CHW and community group collaborations in reaching zero-dose children and missed or vulnerable communities: Six CHW and community group collaborations were identified across 18 articles that described their effectiveness, which allowed this intervention to be categorised as a "promising" intervention. Three main initiatives involved collaborations between CHWs and community groups, including: health extension workers and the Women's Development Army (WDA) in Ethiopia, community volunteers and health extension workers in the CORE Group Polio Project, and the Care Group (CG) approach in which a CG Promoter (who may be a CHW or civil society organisation (CSO) staff member) facilitates sessions with groups of volunteer mothers (and sometimes fathers and grandmothers) who learn behaviour change methods to promote behaviour adoption/change in a specific cohort of households. These interventions were effective at improving maternal and child health outcomes, including increasing polio vaccination coverage in one instance, although many study designs involved observational and quasi-experimental designs. 

In addition, interventions occurred in rural areas and most sought to address gender-related barriers by using female volunteers to increase knowledge sharing, empowerment, and improve outcomes among these groups. There were fewer studies conducted on these approaches and models from urban and conflict affected settings.

Main facilitators and barriers to implementation:
 

• Facilitators include implementating interventions within enabling environments, such as in countries that have supportive policies, or in which communities are engaged, trusted, and enthusiastic; and providing training, support, and supervision to CHWs and community groups/volunteers.
• Barriers include: lack of coordination, planning, and/or support; general barriers to accessing or receiving healthcare services, such as healthcare-related stigma, perception of poor-quality health care services, and inaccessible health services that hinder care seeking; and lack of funding.

Key gaps: Key gaps include lack of implementation within conflict-affected and urban settings, few studies on theoretical underpinnings and intervention conceptualisation, and complications with defining CHWs and community groups involved in collaborations.

Based on findings from the review, the brief highlights several steps programmes can take to initiate or tailor CHW and community group collaborations to help achieve equity:
 

• Understand what CHW programmes are available in target areas and what community groups exist. If identified, discuss potential collaborations within communities using participatory means.
• If CHW and community group collaborations are being considered, ensure that an enabling environment is in place to support efforts, such as considering any government or policy-related efforts that could be leveraged and ensuring that communities are supportive as well.
• Consider equity and gender balance when selecting volunteers or community groups for inclusion in the collaboration, as perceptions of bias or unfair selection of volunteers could negatively impact trust and intervention acceptance.
• Before implementation, ensure the purpose of the intervention is well understood, such as using a conceptual framework or logic model. The main purpose could be to increase the reach of CHWs in communities (i.e., amplification), to mobilise communities to increase demand for rights and/or services, to help facilitate or design an intervention in a group setting, or to strengthen connections between health facilities and communities. In addition, the roles of the CHW and community volunteers/groups in the collaboration should be clearly defined prior to implementation.