Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis | Geriatrics | JAMA Network Open | JAMA Network
[Skip to Navigation]
Sign In
Figure 1.  Process for Identifying Relevant Articles
Process for Identifying Relevant Articles

Flowchart shows search terms and criteria used to identify relevant articles for analysis. CHW indicates community health worker; NCD, noncommunicable disease.

Figure 2.  Nonphysician Health Workers (NPHWs) in the Noncommunicable Disease (NCD) Care Cascade
Nonphysician Health Workers (NPHWs) in the Noncommunicable Disease (NCD) Care Cascade

Chart shows steps and NPHW role in the NCD cascade.

Table 1.  Characteristics of Key Articles Used in Review
Characteristics of Key Articles Used in Review
Table 2.  Key Barriers and Facilitators to NPHW Care for Noncommunicable Diseases
Key Barriers and Facilitators to NPHW Care for Noncommunicable Diseases
Table 3.  A Measurement Tool to Assess Systematic Reviews–2 Evaluation of Systematic Reviews
A Measurement Tool to Assess Systematic Reviews–2 Evaluation of Systematic Reviews
1.
Institute for Health Metrics and Evaluation. Global Burden of Disease (GBD) compare tool. https://vizhub.healthdata.org/gbd-compare/. Accessed December 19, 2018.
2.
Di Cesare  M, Khang  YH, Asaria  P,  et al; Lancet NCD Action Group.  Inequalities in non-communicable diseases and effective responses.  Lancet. 2013;381(9866):585-597. doi:10.1016/S0140-6736(12)61851-0PubMedGoogle ScholarCrossref
3.
Sommer  I, Griebler  U, Mahlknecht  P,  et al.  Socioeconomic inequalities in non-communicable diseases and their risk factors: an overview of systematic reviews.  BMC Public Health. 2015;15(1):914. doi:10.1186/s12889-015-2227-yPubMedGoogle ScholarCrossref
4.
Yoo  SGK, Prabhakaran  D, Huffman  MD.  Evaluating and improving cardiovascular health system management in low-and middle-income countries.  Circ Cardiovasc Qual Outcomes. 2017;10(11):e004292. doi:10.1161/CIRCOUTCOMES.117.004292PubMedGoogle Scholar
5.
World Health Organization. Global Health Observatory (GHO) data: density of physicians per 1,000 population. https://www.who.int/gho/health_workforce/physicians_density/en/. Accessed December 19, 2018.
6.
Araujo  E, Maeda  A. How to recruit and retain health workers in rural and remote areas in developing countries: a guidance note. https://openknowledge.worldbank.org/handle/10986/16104. Published 2013. Accessed June 10, 2019.
7.
Callaghan  M, Ford  N, Schneider  H.  A systematic review of task-shifting for HIV treatment and care in Africa.  Hum Resour Health. 2010;8(1):8. doi:10.1186/1478-4491-8-8PubMedGoogle ScholarCrossref
8.
Lewin  S, Munabi-Babigumira  S, Glenton  C,  et al.  Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.  Cochrane Database Syst Rev. 2010;(3):CD004015. doi:10.1002/14651858.CD004015.pub3PubMedGoogle Scholar
9.
Schneider  H, Okello  D, Lehmann  U.  The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014.  Hum Resour Health. 2016;14(1):65. doi:10.1186/s12960-016-0163-2PubMedGoogle ScholarCrossref
10.
Joshi  R, Alim  M, Kengne  AP,  et al.  Task shifting for non-communicable disease management in low and middle income countries: a systematic review.  PLoS One. 2014;9(8):e103754. doi:10.1371/journal.pone.0103754PubMedGoogle Scholar
11.
Abegunde  DO, Shengelia  B, Luyten  A,  et al.  Can non-physician health-care workers assess and manage cardiovascular risk in primary care?  Bull World Health Organ. 2007;85(6):432-440. doi:10.2471/BLT.06.032177PubMedGoogle ScholarCrossref
12.
Gaziano  TA, Abrahams-Gessel  S, Denman  CA,  et al.  An assessment of community health workers’ ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study.  Lancet Glob Health. 2015;3(9):e556-e563. doi:10.1016/S2214-109X(15)00143-6PubMedGoogle ScholarCrossref
13.
Khan  M, Lamelas  P, Musa  H,  et al.  Development, testing, and implementation of a training curriculum for nonphysician health workers to reduce cardiovascular disease.  Glob Heart. 2018;13(2):93-100. doi:10.1016/j.gheart.2017.11.002PubMedGoogle ScholarCrossref
14.
Patel  V, Weiss  HA, Chowdhary  N,  et al.  Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months.  Br J Psychiatry. 2011;199(6):459-466. doi:10.1192/bjp.bp.111.092155PubMedGoogle ScholarCrossref
15.
Weobong  B, Weiss  HA, McDaid  D,  et al.  Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme, a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial.  PLoS Med. 2017;14(9):e1002385. doi:10.1371/journal.pmed.1002385PubMedGoogle Scholar
16.
Labhardt  ND, Balo  JR, Ndam  M, Grimm  JJ, Manga  E.  Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years.  BMC Health Serv Res. 2010;10(1):339. doi:10.1186/1472-6963-10-339PubMedGoogle ScholarCrossref
17.
Gajalakshmi  CK, Krishnamurthi  S, Ananth  R, Shanta  V.  Cervical cancer screening in Tamilnadu, India: a feasibility study of training the village health nurse.  Cancer Causes Control. 1996;7(5):520-524. doi:10.1007/BF00051884PubMedGoogle ScholarCrossref
18.
Warnakulasuriya  KA, Ekanayake  AN, Sivayoham  S,  et al.  Utilization of primary health care workers for early detection of oral cancer and precancer cases in Sri Lanka.  Bull World Health Organ. 1984;62(2):243-250.PubMedGoogle Scholar
19.
Kengne  AP, Fezeu  L, Awah  PK, Sobngwi  E, Mbanya  JC.  Task shifting in the management of epilepsy in resource-poor settings.  Epilepsia. 2010;51(5):931-932. doi:10.1111/j.1528-1167.2009.02414.xPubMedGoogle ScholarCrossref
20.
Kengne  AP, Sobngwi  E, Fezeu  LL, Awak  PK, Dongmo  S, Mbanya  JC.  Nurse-led care for asthma at primary level in rural sub-Saharan Africa: the experience of Bafut in Cameroon.  J Asthma. 2008;45(6):437-443. doi:10.1080/02770900802032933PubMedGoogle ScholarCrossref
21.
World Health Organization. HEARTS: technical package for cardiovascular disease management in primary health care. https://apps.who.int/iris/bitstream/handle/10665/252661/9789241511377-eng.pdf?sequence=1. Published 2016. Accessed September 19, 2018.
22.
World Health Organization. mhGAP training manuals for the mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: version 2.0 (for field testing). https://apps.who.int/iris/bitstream/handle/10665/259161/WHO-MSD-MER-17.6-eng.pdf?sequence=1&isAllowed=y. Published 2017. Accessed December 19, 2018.
23.
United Nations. 2011 High level meeting on prevention and control of non-communicable diseases. https://www.un.org/en/ga/ncdmeeting2011/. Published 2011. Accessed December 19, 2018.
24.
World Health Organization. Time to deliver: report of the WHO Independent High Level Commission on Noncommunicable Diseases. https://www.who.int/ncds/management/time-to-deliver/en/. Published June 1, 2018. Accessed December 19, 2018.
25.
World Health Organization. The World Health Report 2003: shaping the future. https://www.who.int/whr/2003/en/whr03_en.pdf. Published 2003. Accessed December 19, 2018.
26.
World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. https://www.who.int/healthsystems/strategy/everybodys_business.pdf. Published 2007. Accessed December 19, 2018.
27.
Stroup  DF, Berlin  JA, Morton  SC,  et al; Meta-analysis of Observational Studies in Epidemiology (MOOSE) Group.  Meta-analysis of observational studies in epidemiology: a proposal for reporting.  JAMA. 2000;283(15):2008-2012. doi:10.1001/jama.283.15.2008PubMedGoogle ScholarCrossref
28.
Moher  D, Liberati  A, Tetzlaff  J, Altman  DG; PRISMA Group.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.  Ann Intern Med. 2009;151(4):264-269. doi:10.7326/0003-4819-151-4-200908180-00135PubMedGoogle ScholarCrossref
29.
Bukhman  G, Kidder  A; Partners in Health. The PIH guide to chronic care integration for endemic non-communicable diseases. https://www.pih.org/practitioner-resource/the-pih-guide-to-chronic-care-integration-for-endemic-non-communicable-dise. Published 2011. Accessed December 19, 2018.
30.
The World Bank. Open data: country income. https://data.worldbank.org/income-level/lower-middle-income. Accessed December 19, 2018.
31.
Roda  G, Narula  N, Pinotti  R,  et al.  Systematic review with meta-analysis: proximal disease extension in limited ulcerative colitis.  Aliment Pharmacol Ther. 2017;45(12):1481-1492. doi:10.1111/apt.14063PubMedGoogle ScholarCrossref
32.
Shea  BJ, Reeves  BC, Wells  G,  et al.  AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both.  BMJ. 2017;358:j4008. doi:10.1136/bmj.j4008PubMedGoogle ScholarCrossref
33.
Green  BN, Johnson  CD, Adams  A.  Writing narrative literature reviews for peer-reviewed journals: secrets of the trade.  J Chiropr Med. 2006;5(3):101-117. doi:10.1016/S0899-3467(07)60142-6PubMedGoogle ScholarCrossref
34.
Iwelunmor  J, Plange-Rhule  J, Airhihenbuwa  CO, Ezepue  C, Ogedegbe  O.  A narrative synthesis of the health systems factors influencing optimal hypertension control in sub-Saharan Africa.  PLoS One. 2015;10(7):e0130193. doi:10.1371/journal.pone.0130193PubMedGoogle Scholar
35.
Popay  J, Roberts  H, Sowden  A,  et al. Guidance on the conduct of narrative synthesis in systematic reviews: a product from the ESRC methods Programme. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.178.3100&rep=rep1&type=pdf. Published April 1, 2006. Accessed December 19, 2018.
36.
Corbin  JM, Strauss  A.  Grounded theory research: procedures, canons, and evaluative criteria.  Qual Sociol. 1990;13(1):3-21. doi:10.1007/BF00988593Google ScholarCrossref
37.
O’Brien  BC, Harris  IB, Beckman  TJ, Reed  DA, Cook  DA.  Standards for reporting qualitative research: a synthesis of recommendations.  Acad Med. 2014;89(9):1245-1251. doi:10.1097/ACM.0000000000000388PubMedGoogle ScholarCrossref
38.
Gatuguta  A, Katusiime  B, Seeley  J, Colombini  M, Mwanzo  I, Devries  K.  Should community health workers offer support healthcare services to survivors of sexual violence? a systematic review.  BMC Int Health Hum Rights. 2017;17(1):28. doi:10.1186/s12914-017-0137-zPubMedGoogle ScholarCrossref
39.
Barnett  ML, Gonzalez  A, Miranda  J, Chavira  DA, Lau  AS.  Mobilizing community health workers to address mental health disparities for underserved populations: a systematic review.  Adm Policy Ment Health. 2018;45(2):195-211. doi:10.1007/s10488-017-0815-0PubMedGoogle ScholarCrossref
40.
Khetan  AK, Purushothaman  R, Chami  T,  et al.  The effectiveness of community health workers in CVD prevention in LMIC.  Glob Heart. 2017;12(3):233-243. doi:10.1016/j.gheart.2016.07.001PubMedGoogle ScholarCrossref
41.
Padmanathan  P, De Silva  MJ.  The acceptability and feasibility of task-sharing for mental healthcare in low and middle income countries: a systematic review.  Soc Sci Med. 2013;97:82-86. doi:10.1016/j.socscimed.2013.08.004PubMedGoogle ScholarCrossref
42.
Mutamba  BB, van Ginneken  N, Smith Paintain  L, Wandiembe  S, Schellenberg  D.  Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review.  BMC Health Serv Res. 2013;13(1):412. doi:10.1186/1472-6963-13-412PubMedGoogle ScholarCrossref
43.
Chowdhary  N, Sikander  S, Atif  N,  et al The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle income countries: a systematic review.  Best Pract Res Clin Obstet Gynecol. 2014;28(1):113-133. doi:10.1016/j.bpobgyn.2013.08.013PubMedGoogle ScholarCrossref
44.
Abdel-All  M, Putica  B, Praveen  D, Abimbola  S, Joshi  R.  Effectiveness of community health worker training programmes for cardiovascular disease management in low-income and middle-income countries: a systematic review.  BMJ Open. 2017;7(11):e015529. doi:10.1136/bmjopen-2016-015529PubMedGoogle Scholar
45.
Ogedegbe  G, Gyamfi  J, Plange-Rhule  J,  et al.  Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials.  BMJ Open. 2014;4(10):e005983. doi:10.1136/bmjopen-2014-005983PubMedGoogle Scholar
46.
Javadi  D, Feldhaus  I, Mancuso  A, Ghaffar  A.  Applying systems thinking to task shifting for mental health using lay providers: a review of the evidence.  Glob Ment Health (Camb). 2017;4:e14. doi:10.1017/gmh.2017.15PubMedGoogle Scholar
47.
Hill  J, Peer  N, Oldenburg  B, Kengne  AP.  Roles, responsibilities and characteristics of lay community health workers involved in diabetes prevention programmes: a systematic review.  PLoS One. 2017;12(12):e0189069. doi:10.1371/journal.pone.0189069PubMedGoogle Scholar
48.
Seidman  G, Atun  R.  Does task shifting yield cost savings and improve efficiency for health systems? a systematic review of evidence from low-income and middle-income countries.  Hum Resour Health. 2017;15(1):29. doi:10.1186/s12960-017-0200-9PubMedGoogle ScholarCrossref
49.
Jeet  G, Thakur  JS, Prinja  S, Singh  M.  Community health workers for non-communicable diseases prevention and control in developing countries: evidence and implications.  PLoS One. 2017;12(7):e0180640. doi:10.1371/journal.pone.0180640PubMedGoogle Scholar
50.
Alaofè  H, Asaolu  I, Ehiri  J,  et al.  Community health workers in diabetes prevention and management in developing countries.  Ann Glob Health. 2017;83(3-4):661-675. doi:10.1016/j.aogh.2017.10.009PubMedGoogle ScholarCrossref
51.
Ahluwalia  SC, Damberg  CL, Silverman  M, Motala  A, Shekelle  PG.  What defines a high-performing health care delivery system: a systematic review.  Jt Comm J Qual Patient Saf. 2017;43(9):450-459. doi:10.1016/j.jcjq.2017.03.010PubMedGoogle ScholarCrossref
52.
Pastakia  SD, Ali  SM, Kamano  JH,  et al.  Screening for diabetes and hypertension in a rural low income setting in western Kenya utilizing home-based and community-based strategies.  Global Health. 2013;9(1):21. doi:10.1186/1744-8603-9-21PubMedGoogle ScholarCrossref
53.
Balaji  M, Chatterjee  S, Koschorke  M,  et al.  The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India.  BMC Health Serv Res. 2012;12(1):42. doi:10.1186/1472-6963-12-42PubMedGoogle ScholarCrossref
54.
Chatterjee  S, Naik  S, John  S,  et al.  Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial.  Lancet. 2014;383(9926):1385-1394. doi:10.1016/S0140-6736(13)62629-XPubMedGoogle ScholarCrossref
55.
Pereira  B, Andrew  G, Pednekar  S, Kirkwood  BR, Patel  V.  The integration of the treatment for common mental disorders in primary care: experiences of health care providers in the MANAS trial in Goa, India.  Int J Ment Health Syst. 2011;5(1):26. doi:10.1186/1752-4458-5-26PubMedGoogle ScholarCrossref
56.
Nadkarni  A, Velleman  R, Dabholkar  H,  et al.  The systematic development and pilot randomized evaluation of counselling for alcohol problems, a lay counselor-delivered psychological treatment for harmful drinking in primary care in India: the PREMIUM study.  Alcohol Clin Exp Res. 2015;39(3):522-531. doi:10.1111/acer.12653PubMedGoogle ScholarCrossref
57.
Kohli  A, Makambo  MT, Ramazani  P,  et al.  A Congolese community-based health program for survivors of sexual violence.  Confl Health. 2012;6(1):6. doi:10.1186/1752-1505-6-6PubMedGoogle ScholarCrossref
58.
Mash  R, Kroukamp  R, Gaziano  T, Levitt  N.  Cost-effectiveness of a diabetes group education program delivered by health promoters with a guiding style in underserved communities in Cape Town, South Africa.  Patient Educ Couns. 2015;98(5):622-626. doi:10.1016/j.pec.2015.01.005PubMedGoogle ScholarCrossref
59.
Murray  LK, Familiar  I, Skavenski  S,  et al.  An evaluation of trauma focused cognitive behavioral therapy for children in Zambia.  Child Abuse Negl. 2013;37(12):1175-1185. doi:10.1016/j.chiabu.2013.04.017PubMedGoogle ScholarCrossref
60.
Mendenhall  E, De Silva  MJ, Hanlon  C,  et al.  Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda.  Soc Sci Med. 2014;118:33-42. doi:10.1016/j.socscimed.2014.07.057PubMedGoogle ScholarCrossref
61.
Naved  RT, Rimi  NA, Jahan  S, Lindmark  G.  Paramedic-conducted mental health counselling for abused women in rural Bangladesh: an evaluation from the perspective of participants.  J Health Popul Nutr. 2009;27(4):477-491. doi:10.3329/jhpn.v27i4.3391PubMedGoogle ScholarCrossref
62.
Haines  A, Sanders  D, Lehmann  U,  et al.  Achieving child survival goals: potential contribution of community health workers.  Lancet. 2007;369(9579):2121-2131. doi:10.1016/S0140-6736(07)60325-0PubMedGoogle ScholarCrossref
63.
Mdege  ND, Chindove  S, Ali  S.  The effectiveness and cost implications of task-shifting in the delivery of antiretroviral therapy to HIV-infected patients: a systematic review.  Health Policy Plan. 2013;28(3):223-236. doi:10.1093/heapol/czs058PubMedGoogle ScholarCrossref
64.
Abanilla  PK, Huang  KY, Shinners  D,  et al.  Cardiovascular disease prevention in Ghana: feasibility of a faith-based organizational approach.  Bull World Health Organ. 2011;89(9):648-656. doi:10.2471/BLT.11.086777PubMedGoogle ScholarCrossref
65.
Jordans  MJ, Keen  AS, Pradhan  H,  et al.  Psychosocial counselling in Nepal: perspectives of counsellors and beneficiaries.  Int J Adv Couns. 2007;29(1):57-68. doi:10.1007/s10447-006-9028-zGoogle ScholarCrossref
66.
Nishtar  S, Badar  A, Kamal  MU,  et al.  The Heartfile Lodhran CVD prevention project: end of project evaluation.  Promot Educ. 2007;14(1):17-27. doi:10.1177/175797590701400103PubMedGoogle ScholarCrossref
67.
Lorenzo  T, van Pletzen  E, Booyens  M.  Determining the competences of community based workers for disability-inclusive development in rural areas of South Africa, Botswana and Malawi.  Rural Remote Health. 2015;15(2):2919.PubMedGoogle Scholar
68.
Ali  BS, Rahbar  MH, Naeem  S, Gul  A, Mubeen  S, Iqbal  A.  The effectiveness of counseling on anxiety and depression by minimally trained counselors: a randomized controlled trial.  Am J Psychother. 2003;57(3):324-336. doi:10.1176/appi.psychotherapy.2003.57.3.324PubMedGoogle ScholarCrossref
69.
Micikas  M, Foster  J, Weis  A,  et al.  A community health worker intervention for diabetes self-management among the Tz’utujil Maya of Guatemala.  Health Promot Pract. 2015;16(4):601-608. doi:10.1177/1524839914557033PubMedGoogle ScholarCrossref
70.
Nimgaonkar  AU, Menon  SD.  A task shifting mental health program for an impoverished rural Indian community.  Asian J Psychiatr. 2015;16:41-47. doi:10.1016/j.ajp.2015.05.044PubMedGoogle ScholarCrossref
71.
Ndou  T, van Zyl  G, Hlahane  S, Goudge  J.  A rapid assessment of a community health worker pilot programme to improve the management of hypertension and diabetes in Emfuleni sub-district of Gauteng Province, South Africa.  Glob Health Action. 2013;6(1):19228. doi:10.3402/gha.v6i0.19228PubMedGoogle ScholarCrossref
72.
Abrahams-Gessel  S, Denman  CA, Montano  CM,  et al.  The training and fieldwork experiences of community health workers conducting population-based, noninvasive screening for CVD in LMIC.  Glob Heart. 2015;10(1):45-54. doi:10.1016/j.gheart.2014.12.008PubMedGoogle ScholarCrossref
73.
Chibanda  D, Mesu  P, Kajawu  L, Cowan  F, Araya  R, Abas  MA.  Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV.  BMC Public Health. 2011;11(1):828. doi:10.1186/1471-2458-11-828PubMedGoogle ScholarCrossref
74.
Mendis  S, Johnston  SC, Fan  W, Oladapo  O, Cameron  A, Faramawi  MF.  Cardiovascular risk management and its impact on hypertension control in primary care in low-resource settings: a cluster-randomized trial.  Bull World Health Organ. 2010;88(6):412-419. doi:10.2471/BLT.08.062364PubMedGoogle ScholarCrossref
75.
Zhong  X, Wang  Z, Fisher  EB, Tanasugarn  C.  Peer support for diabetes management in primary care and community settings in Anhui Province, China.  Ann Fam Med. 2015;13(1)(suppl):S50-S58. doi:10.1370/afm.1799PubMedGoogle ScholarCrossref
76.
Petersen  I, Ssebunnya  J, Bhana  A, Baillie  K; MhaPP Research Programme Consortium.  Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda.  Int J Ment Health Syst. 2011;5(1):8. doi:10.1186/1752-4458-5-8PubMedGoogle ScholarCrossref
77.
Feksi  AT, Kaamugisha  J, Sander  JW, Gatiti  S, Shorvon  SD; ICBERG (International Community-Based Epilepsy Research Group).  Comprehensive primary health care antiepileptic drug treatment programme in rural and semi-urban Kenya.  Lancet. 1991;337(8738):406-409. doi:10.1016/0140-6736(91)91176-UPubMedGoogle ScholarCrossref
78.
Joshi  R, Jan  S, Wu  Y, MacMahon  S.  Global inequalities in access to cardiovascular health care: our greatest challenge.  J Am Coll Cardiol. 2008;52(23):1817-1825. doi:10.1016/j.jacc.2008.08.049PubMedGoogle ScholarCrossref
79.
Magidson  JF, Lejuez  CW, Kamal  T,  et al.  Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq.  Glob Ment Health (Camb). 2015;2(Jan):e24. doi:10.1017/gmh.2015.22PubMedGoogle Scholar
80.
Bolton  P, Bass  JK, Zangana  GA,  et al.  A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq.  BMC Psychiatry. 2014;14(1):360. doi:10.1186/s12888-014-0360-2PubMedGoogle ScholarCrossref
81.
Balagopal  P, Kamalamma  N, Patel  TG, Misra  R.  A community-based participatory diabetes prevention and management intervention in rural India using community health workers.  Diabetes Educ. 2012;38(6):822-834. doi:10.1177/0145721712459890PubMedGoogle ScholarCrossref
82.
Abas  M, Bowers  T, Manda  E,  et al.  “Opening up the mind”: problem-solving therapy delivered by female lay health workers to improve access to evidence-based care for depression and other common mental disorders through the Friendship Bench Project in Zimbabwe.  Int J Ment Health Syst. 2016;10(1):39. doi:10.1186/s13033-016-0071-9PubMedGoogle ScholarCrossref
83.
Pisani  P, Parkin  DM, Ngelangel  C,  et al.  Outcome of screening by clinical examination of the breast in a trial in the Philippines.  Int J Cancer. 2006;118(1):149-154. doi:10.1002/ijc.21343PubMedGoogle ScholarCrossref
84.
Tsolekile  LP, Puoane  T, Schneider  H, Levitt  NS, Steyn  K.  The roles of community health workers in management of non-communicable diseases in an urban township.  Afr J Prim Health Care Fam Med. 2014;6(1):E1-E8. doi:10.4102/phcfm.v6i1.693PubMedGoogle ScholarCrossref
85.
Murray  LK, Dorsey  S, Haroz  E,  et al.  A common elements treatment approach for adult mental health problems in low-and middle-income countries.  Cogn Behav Pract. 2014;21(2):111-123. doi:10.1016/j.cbpra.2013.06.005PubMedGoogle ScholarCrossref
86.
Agyapong  VI, Osei  A, Farren  CK, McAuliffe  E.  Factors influencing the career choice and retention of community mental health workers in Ghana.  Hum Resour Health. 2015;13(1):56. doi:10.1186/s12960-015-0050-2PubMedGoogle ScholarCrossref
87.
Agyapong  VI, Osei  A, Farren  CK, Mcauliffe  E.  Task shifting of mental health care services in Ghana: ease of referral, perception and concerns of stakeholders about quality of care.  Int J Qual Health Care. 2015;27(5):377-383. doi:10.1093/intqhc/mzv058PubMedGoogle ScholarCrossref
88.
Murray  LK, Skavenski  S, Kane  JC,  et al.  Effectiveness of trauma-focused cognitive behavioral therapy among trauma-affected children in Lusaka, Zambia: a randomized clinical trial.  JAMA Pediatr. 2015;169(8):761-769. doi:10.1001/jamapediatrics.2015.0580PubMedGoogle ScholarCrossref
89.
Rahman  A, Malik  A, Sikander  S, Roberts  C, Creed  F.  Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial.  Lancet. 2008;372(9642):902-909. doi:10.1016/S0140-6736(08)61400-2PubMedGoogle ScholarCrossref
90.
Agyapong  VI, Farren  C, McAuliffe  E.  Improving Ghana’s mental healthcare through task-shifting: psychiatrists and health policy directors perceptions about government’s commitment and the role of community mental health workers.  Global Health. 2016;12(1):57. doi:10.1186/s12992-016-0199-zPubMedGoogle ScholarCrossref
91.
Jenkins  R, Kiima  D, Okonji  M, Njenga  F, Kingora  J, Lock  S.  Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability.  Ment Health Fam Med. 2010;7(1):37-47.PubMedGoogle Scholar
92.
Pallas  SW, Minhas  D, Pérez-Escamilla  R, Taylor  L, Curry  L, Bradley  EH.  Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability?  Am J Public Health. 2013;103(7):e74-e82. doi:10.2105/AJPH.2012.301102PubMedGoogle ScholarCrossref
93.
Kok  MC, Kane  SS, Tulloch  O,  et al.  How does context influence performance of community health workers in low- and middle-income countries? evidence from the literature.  Health Res Policy Syst. 2015;13(1):13. doi:10.1186/s12961-015-0001-3PubMedGoogle ScholarCrossref
94.
Farzadfar  F, Murray  CJ, Gakidou  E,  et al.  Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study.  Lancet. 2012;379(9810):47-54. doi:10.1016/S0140-6736(11)61349-4PubMedGoogle ScholarCrossref
95.
Labhardt  ND, Balo  JR, Ndam  M, Manga  E, Stoll  B.  Improved retention rates with low-cost interventions in hypertension and diabetes management in a rural African environment of nurse-led care: a cluster-randomised trial.  Trop Med Int Health. 2011;16(10):1276-1284. doi:10.1111/j.1365-3156.2011.02827.xPubMedGoogle ScholarCrossref
96.
Hung  KJ, Tomlinson  M, le Roux  IM, Dewing  S, Chopra  M, Tsai  AC.  Community-based prenatal screening for postpartum depression in a South African township.  Int J Gynaecol Obstet. 2014;126(1):74-77. doi:10.1016/j.ijgo.2014.01.011PubMedGoogle ScholarCrossref
97.
Padilla  E, Molina  J, Kamis  D,  et al.  The efficacy of targeted health agents education to reduce the duration of untreated psychosis in a rural population.  Schizophr Res. 2015;161(2-3):184-187. doi:10.1016/j.schres.2014.10.039PubMedGoogle ScholarCrossref
98.
Tomlinson  M, Doherty  T, Jackson  D,  et al.  An effectiveness study of an integrated, community-based package for maternal, newborn, child and HIV care in South Africa: study protocol for a randomized controlled trial.  Trials. 2011;12(1):236. doi:10.1186/1745-6215-12-236PubMedGoogle ScholarCrossref
99.
Adams  JL, Almond  ML, Ringo  EJ, Shangali  WH, Sikkema  KJ.  Feasibility of nurse-led antidepressant medication management of depression in an HIV clinic in Tanzania.  Int J Psychiatry Med. 2012;43(2):105-117. doi:10.2190/PM.43.2.aPubMedGoogle ScholarCrossref
100.
Wright  J, Chiwandira  C.  Building capacity for community mental health care in rural Malawi: findings from a district-wide task-sharing intervention with village-based health workers.  Int J Soc Psychiatry. 2016;62(6):589-596. doi:10.1177/0020764016657112PubMedGoogle ScholarCrossref
101.
Kengne  AP, Fezeu  L, Sobngwi  E,  et al.  Type 2 diabetes management in nurse-led primary healthcare settings in urban and rural Cameroon.  Prim Care Diabetes. 2009;3(3):181-188. doi:10.1016/j.pcd.2009.08.005PubMedGoogle ScholarCrossref
102.
Jafar  TH, Islam  M, Bux  R,  et al Cost-effectiveness of community-based strategies for blood pressure control in a low-income developing country: findings from a cluster-randomized, factorial-controlled trial.  Circulation. 2011;124(15):1615-1625. doi:10.1161/CIRCULATIONAHA.111.039990PubMedGoogle ScholarCrossref
103.
Rosenthal  EL, Rush  CH, Allen  CG. Understanding scope and competencies: a contemporary look at the United States community health worker field—progress report of the community health worker (CHW) core consensus (C3) project. building national consensus on CHW core roles, skills, and qualities. http://chrllc.net/sitebuildercontent/sitebuilderfiles/c3_report_20160810.pdf. Published July 2016. Accessed June 5, 2019.
104.
Palazuelos  D, Ellis  K, Im  DD,  et al.  5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting.  Glob Health Action. 2013;6(1):19658. doi:10.3402/gha.v6i0.19658PubMedGoogle ScholarCrossref
105.
Mounier-Jack  S, Griffiths  UK, Closser  S, Burchett  H, Marchal  B.  Measuring the health systems impact of disease control programmes: a critical reflection on the WHO building blocks framework.  BMC Public Health. 2014;14(1):278. doi:10.1186/1471-2458-14-278PubMedGoogle ScholarCrossref
106.
Huff-Rousselle  M.  Reflections on the frameworks we use to capture complex and dynamic health sector issues.  Int J Health Plann Manage. 2013;28(1):95-101. doi:10.1002/hpm.2161PubMedGoogle ScholarCrossref
107.
Sheikh  K, Gilson  L, Agyepong  IA, Hanson  K, Ssengooba  F, Bennett  S.  Building the field of health policy and systems research: framing the questions.  PLoS Med. 2011;8(8):e1001073. doi:10.1371/journal.pmed.1001073PubMedGoogle Scholar
108.
Frenk  J.  The global health system: strengthening national health systems as the next step for global progress.  PLoS Med. 2010;7(1):e1000089. doi:10.1371/journal.pmed.1000089PubMedGoogle Scholar
109.
Manzi  A, Kirk  C, Hirschhorn  LR. MESH-QI implementation guide: mentorship and enhanced supervision for healthcare and quality improvement. https://www.pih.org/sites/default/files/2017-12/MESH%20QI%20Final%20web%2012.2017.pdf. Published 2017. Accessed October 29, 2019.
110.
Anatole  M, Magge  H, Redditt  V,  et al Nurse mentorship to improve the quality of health care delivery in rural Rwanda.  Nurs Outlook. 2013;61(3):137-144. doi:10.1016/j.outlook.2012.10.003PubMedGoogle ScholarCrossref
111.
Joshi  R, Chow  CK, Raju  PK,  et al The Rural Andhra Pradesh Cardiovascular Prevention Study (RAPCAPS): a cluster randomized trial.  J Am Coll Cardiol. 2012;59(13):1188-1196. doi:10.1010/j.jacc.2011.10.901PubMedGoogle ScholarCrossref
112.
Adeyemo  A, Tayo  BO, Luke  A, Ogedegbe  O, Durazo-Arvizu  R, Cooper  RS.  The Nigerian antihypertensive adherence trial: a community-based randomized trial.  J Hypertens. 2013;31(1):201-207. doi:10.1097/HJH.0b013e32835b0842PubMedGoogle ScholarCrossref
113.
Johnson  D, Saavedra  P, Sun  E,  et al.  Community health workers and Medicaid managed care in New Mexico.  J Community Health. 2012;37(3):563-571. doi:10.1007/s10900-011-9484-1PubMedGoogle ScholarCrossref
114.
Beckham  S, Kaahaaina  D, Voloch  KA, Washburn  A.  A community-based asthma management program: effects on resource utilization and quality of life.  Hawaii Med J. 2004;63(4):121-126.PubMedGoogle Scholar
115.
Cooper  RA.  Unraveling the physician supply dilemma.  JAMA. 2013;310(18):1931-1932. doi:10.1001/jama.2013.282170PubMedGoogle ScholarCrossref
116.
Victor  RG, Lynch  K, Li  N,  et al.  A cluster-randomized trial of blood-pressure reduction in black barbershops.  N Engl J Med. 2018;378(14):1291-1301. doi:10.1056/NEJMoa1717250PubMedGoogle ScholarCrossref
117.
Schoenthaler  AM, Lancaster  KJ, Chaplin  W, Butler  M, Forsyth  J, Ogedegbe  G.  Cluster Randomized Clinical Trial of FAITH (Faith-Based Approaches in the Treatment of Hypertension) in Blacks.  Circ Cardiovasc Qual Outcomes. 2018;11(10):e004691. doi:10.1161/CIRCOUTCOMES.118.004691PubMedGoogle Scholar
118.
Arnhold Institute for Global Health. Task force on global advantage. http://icahn.mssm.edu/research/arnhold/research-development/task-force-global-advantage. Accessed December 28, 2018.
119.
WeCare Indiana. Improving maternal and infant health to reduce infant mortality. https://www.regenstrief.org/projects/wecare-indiana/. Accessed December 28, 2018.
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Global Health
    December 2, 2019

    Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis

    Author Affiliations
    • 1Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York
    • 2Department of Medicine, New York University School of Medicine, New York
    • 3Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 4The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
    • 5The George Institute for Global Health, New Delhi, India
    • 6Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
    • 7Department of Population Health, New York University School of Medicine, New York
    JAMA Netw Open. 2019;2(12):e1916545. doi:10.1001/jamanetworkopen.2019.16545
    Key Points español 中文 (chinese)

    Question  What are the health system factors that support or impair the ability of nonphysician health workers to treat noncommunicable diseases in low- and middle-income countries?

    Findings  This systematic review and qualitative analysis examined 15 systematic reviews, encompassing 71 studies. These studies consistently demonstrated 6 key lessons of successful care by nonphysician health workers: careful staff recruitment, detailed training, authorization to provide autonomous care, adequate medications and supplies, reliable data systems, and fair, performance-based compensation.

    Meaning  Effective, scalable care for noncommunicable diseases led by nonphysicians is feasible in diverse low-resource settings but requires several common, key implementation steps.

    Abstract

    Importance  Cardiovascular disease, cancer, and other noncommunicable diseases (NCDs) are the leading causes of mortality in low- and middle-income countries. Previous studies show that nonphysician health workers (NPHWs), including nurses and volunteers, can provide effective diagnosis and treatment of NCDs. However, the factors that facilitate and impair these programs are incompletely understood.

    Objective  To identify health system barriers to and facilitators of NPHW-led care for NCDs in low- and middle-income countries.

    Data Sources  All systematic reviews in PubMed published by May 1, 2018.

    Study Selection  The search terms used for this analysis included “task shifting” and “non-physician clinician.” Only reviews of NPHW care that occurred entirely or mostly in low- and middle-income countries and focused entirely or mostly on NCDs were included. All studies cited within each systematic review that cited health system barriers to and facilitators of NPHW care were reviewed.

    Data Extraction and Synthesis  Assessment of study eligibility was performed by 1 reviewer and rechecked by another. The 2 reviewers extracted all data. Reviews were performed from November 2017 to July 2018. All analyses were descriptive.

    Main Outcomes and Measures  All barriers and facilitators mentioned in all studies were tallied and sorted according to the World Health Organization’s 6 building blocks for health systems.

    Results  This systematic review and qualitative analysis identified 15 review articles, which cited 156 studies, of which 71 referenced barriers to and facilitators of care. The results suggest 6 key lessons: (1) select qualified NPHWs embedded within the community they serve; (2) provide detailed, ongoing training and supervision; (3) authorize NPHWs to prescribe medication and render autonomous care; (4) equip NPHWs with reliable systems to track patient data; (5) furnish NPHWs consistently with medications and supplies; and (6) compensate NPHWs adequately commensurate with their roles.

    Conclusions and Relevance  Although the health system barriers to NPHW screening, treatment, and control of NCDs and their risk factors are numerous and complex, a diverse set of care models has demonstrated strategies to address nearly all of these challenges. These facilitating approaches—which relate chiefly to strong, consistent NPHW training, guidance, and logistical support—generate a blueprint for the creation and scale-up of such programs adaptable across multiple chronic diseases, including in high-income countries.

    Introduction

    Noncommunicable diseases (NCDs) are the leading causes of premature death worldwide.1 Noncommunicable diseases are increasingly prevalent in low- and middle-income countries (LMICs), especially their most vulnerable communities,2,3 where human resources for health are severely limited.4 More than one-half of LMICs have fewer than 1 physician per 1000 people,5 which is the minimal threshold advised by the World Health Organization (WHO), and in many LMICs, less than one-quarter of physicians practice in rural areas where one-half of the population lives.6

    Fortunately, evidence demonstrates that nonphysician health workers (NPHWs) (ie, persons without a medical doctorate degree who render health care)7-10 can render multiple aspects of care presumed to require a physician.7,8 Models of care that employ NPHWs—including health professionals (eg, nurses) and laypeople (eg, community health workers [CHWs])—have successfully treated many causes of death and disability, especially maternal-child mortality and HIV/AIDS.7-9

    Models that successfully leverage NPHWs for NCD control also show promise.10 Pilot studies11-13 demonstrate that NPHWs can accurately perform cardiovascular risk screening to identify high-risk patients and counsel them on behavior change. In addition, NPHWs can screen for and treat risk factors associated with cardiovascular disease, such as depression,14,15 diabetes,16 and hypertension,16 including by prescribing medication, and can track and improve patients’ adherence to these therapies. Nonphysician health workers can also screen for cancers17,18 and treat epilepsy19 and asthma,20 among other chronic diseases.

    However, the rapid increase of NCDs in LMICs requires the scale-up of these programs into global initiatives,21,22 as recent United Nations summits have demanded.23,24 This demand poses a problem: understanding which elements of health systems (eg, governance and delivery structures) support or hinder NPHWs in the care cascade.10

    Methods

    We undertook a systematic review and qualitative analysis to identify and analyze health system barriers to and facilitators of NPHW-led care for NCDs, as detailed within systematic reviews of these interventions in LMICs. We defined a health system according to the WHO Health Systems Framework’s 6 building blocks25,26: service delivery, health workforce, governance, information systems, medication access, and financing. This descriptive analysis of these heterogeneous interventions did not compile quantitative outcomes, nor did it evaluate a hypothesis. We conducted and reported this review per the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline,27 and we display studies identified, screened, reviewed, and included per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline28 in Figure 1. We did not seek formal review from an institutional review board because we limited our study to published information and did not engage with any human subjects.

    Objectives of the Review

    We aimed to identify all systematic reviews of initiatives leveraging NPHWs for the treatment of NCDs in LMICs. We defined an NCD as any chronic disease independent of infection, but included long-term conditions caused by infection, such as poststreptococcal rheumatic heart disease.29 We defined LMICs according to 2016 World Bank criteria.30 We considered a study to be leveraging NPHWs if these staff engaged in clinical decision-making for patient care, regardless of physician supervision. This approach includes models for both task-shifting completely from physicians to NPHWs and task-sharing, in which NPHWs assume care under physician oversight.10

    Literature Searching

    We began our review with 6 systematic reviews already known to us that addressed all of the aforementioned subjects (ie, sentinel reviews). One reviewer (D.J.H.), a clinician-investigator trained in implementation science and public health, searched PubMed from its inception to May 1, 2018, for all systematic reviews that examined NCD care performed by NPHWs in LMICs. Our search terms, developed in consultation with a librarian specializing in advanced search techniques,31 included “non-physician health worker(s),” “task-shifting,” “task-sharing,” “community health worker,” “CHW,” or “non-physician clinician(s)” (Figure 1). We did not expressly search for terms such as “nurse” or “health system,” nor did we exclude them. We excluded all articles that did not focus on NCD care, were not conducted entirely or primarily in LMICs, or were not systematic reviews. A second reviewer (R.J.), a clinician-investigator with expertise in systematic reviews,10 repeated the first reviewer’s search independently. We did not use search software or manual searching, nor did we search databases other than PubMed. Both searches agreed completely and identified all 6 aforementioned reviews, as well as 9 others, all written in English. We quantified the rigor of these 15 reviews using the A Measurement Tool to Assess Systematic Reviews–2 tool, which is designed to evaluate systematic reviews of health care interventions.32

    Study Eligibility and Data Extraction

    Using review methods derived from Green et al,33 Iwelunmor et al,34 and Popay et al,35 2 coauthors (D.J.H. and A.K., who was then a medical student with public health expertise) reviewed each of these systematic reviews in detail. Each reviewer identified every article referenced within each document that concerned NPHW care for NCDs, referenced barriers to and facilitators of NPHW care (for NCDs or other conditions), was a systematic review, or was referenced in 2 or more systematic reviews. This approach intended to identify any barriers and facilitators of NPHW care relevant to NCD control, but also any systematic reviews that referenced the same but that we had overlooked. The reviewer then examined the abstract of each such article to determine whether it appeared to examine health system issues affecting NPHW-led NCD care. We read each article that explored these issues and identified all concepts related to health systems. We did not contact authors for further details and limited our review to articles published in English. We performed this review from November 2017 to July 2018. Each coauthor who reviewed each article classified the NPHW barriers and facilitators using the WHO’s building block framework,25,26 given its extensive prior use and validation in health systems research. The 2 coauthors (D.J.H. and A.K.) reviewed each other’s classification list for agreement. When they could not reach consensus, they consulted a third coauthor (R.J.) for a final decision.

    Categorization of Study Outcomes

    After compiling the classification list of health system concepts, we tabulated each documented barrier or facilitator in each reviewed study, as classified by D.J.H. and A.K. Because the study outcomes were heterogeneous, and because our objective was to review qualitative health system factors within these studies rather than those outcomes, we did not perform any meta-analyses or other quantitative analyses, nor did we quantify the quality of these studies apart from the A Measurement Tool to Assess Systematic Reviews calculation.32 After compiling all barriers and facilitators, D.J.H. and A.K. qualitatively reviewed the results for key themes, with feedback from R.J. and the other coauthors. Our goal was to identify actionable elements of an NPHW care intervention (eg, how staff are recruited, supervised, or compensated) that appeared to influence the success or failure of the program in delivering care. We used grounded theory—that is, the iterative review of data to code barriers and facilitators and then sort them into concepts—given that our goal was to describe data rather than test a hypothesis.36 The report follows the Standards for Reporting Qualitative Research (SRQR) reporting guideline.37

    Statistical Analysis

    We did not undertake any statistical analysis apart from the tally of barriers and facilitators.

    Results

    Our PubMed search yielded 1273 publications. The search terms are shown in the eAppendix in the Supplement. Among these results, we identified 15 systematic reviews9,10,38-50 that focused on NCDs and significantly involved LMICs (Table 1). These documents referenced a total of 156 unique articles. Of these, we identified 71 unique articles that met further review criteria defined in the Methods section (Figure 1). We summarize this content in Table 2, organizing content by key measures of health care performance: quality, access, safety, and coverage.51

    Results varied in scope and content across building blocks, and the diseases discussed in the studies were heterogeneous (Table 2; eTable and eReferences in the Supplement). There were a total of 174 barriers and 170 facilitators. Among both barriers and facilitators, service delivery (69 barriers and 54 facilitators) and health workforce (46 barriers and 62 facilitators) factors appeared most commonly, with governance (17 barriers and 23 facilitators), information systems (12 barriers and 19 facilitators), medication access (12 barriers and 7 facilitators), and financing (13 barriers and 8 facilitators) factors arising intermittently. Among the NCDs covered within these 15 articles, cardiovascular conditions and mental illness were the most common (3 studies each); there were 2 studies pertaining to multiple NCDs, 2 pertaining to diabetes, and only 1 pertaining to sexual violence. Most systematic reviews were robust, scoring between 5 and 14 on an A Measurement Tool to Assess Systematic Reviews–2 scale of 13 to 16 items (Table 3). Among the 71 cross-referenced articles, the diseases treated and delivery context were heterogeneous, with neither grossly associated with specific care barriers or facilitators (Table 2; eTable and eReferences in the Supplement).

    Service Delivery

    Three themes emerged among service delivery barriers: logistics, infrastructure, and stigma. Logistical problems included patient difficulty reaching clinics, and, conversely, health worker difficulties reaching patients’ homes.38-40,52-57 Weak care infrastructure caused crowding and lack of privacy,41,58-60 increasing the wait times for care.61 Care delivery barriers included small scale of care,42 difficulty scaling services up,43 limited curative care,62,63 lack of referral systems for care,64 and poor integration across care components.65-67 The stigma of seeking care, especially for mental illness and obesity, was a cultural barrier.39,43,44,68 Patient literacy also sometimes hampered care,53,69 as did skepticism of treatment plans56,60,70,71 and gender-related barriers.72

    Conversely, delivery facilitators involved creative solutions to logistical barriers and care sensitive to community needs. These strategies included home-based or home-adjacent care,42,43,45,73 integrated care across conditions,72,74-76 use of consistent care protocols,77,78 and programs to track and refer patients, including telemedicine.67,79 Nimgaonkar et al70 described a mental health intervention within a village health worker initiative in India and found that integrating these 2 programs facilitated reaching patients and decreased stigma. Culturally applicable health education was also helpful,40,43,45,80 as was community engagement and embeddedness.46,81 Abas et al,82 offering problem-solving therapy for depression in Zimbabwe, found that employing female health workers of the same socioeconomic status as their patients aided care delivery.46

    Health Workforce

    Workforce barriers comprised gaps between NPHWs’ capacity to perform key tasks and their supervisors’ expectations and support for them to do so. Workers’ skills and training were often insufficient.38,40,46,58,69,83-85 Furthermore, supervisors deployed NPHWs ineffectively to use these skills because of unclear job roles,60,86,87 excessive workload,38,60 and weak or adversarial relationships with other workers.10,41,62 Third, weak oversight65,72-74,86,87 hampered workers’ ability to meet expectations. Staff turnover also hampered care.8,10,88

    Workforce facilitators addressed the aforementioned gaps but also aided in the judicious selection of workers. Nonphysician health workers who were recruited from the community served, or who were aware of its languages and customs, were an asset.39,42,43,46,47,70,82 Also helpful was rigorous, locally relevant training, including care algorithms10,40,44,47,72,76,77,89 and close collaboration with other health workers.10,39,41,45,47,70,77,80,89 Gaziano et al12 evaluated CHWs’ ability to screen for cardiovascular disease risk in Guatemala, Mexico, and Bangladesh and found that careful staff selection, training in local languages, and the use of simple care records facilitated success. Programs for epilepsy care in Kenya77 and postpartum depression in Pakistan89 also praised detailed care protocols and close supervision, respectively.

    Governance

    Governance barriers pertained to the insufficient authority of NPHWs to treat NCDs resulting from the lack of political will to authorize them and the consequent inability to assume key roles. In addition to weak oversight by supervisors, NPHWs reported poor communication with clinical directors,46 policy makers,90 and other overseers.84 In the absence of implementation science data,8,72 NPHWs faced mistrust regarding new roles, limiting their scope of care.40 These problems were compounded by ambiguity regarding NPHWs’ job roles38,40 and limitations on what care nonphysicians could provide,63 especially regarding prescribing medications.10,41,45 Weak care monitoring64,91 and backup support45 also arose, as did structural political factors, such as deliberate corruption of purpose,62 lack of governmental coordination,90 or active deprioritization by the ministry of health,92 hindering the distribution of personnel and resources.62

    However, initiatives providing NPHWs a clear mandate and scope of work integrated within existing health care infrastructure93 aided care delivery,43,46 especially when policy makers and community officials actively assisted the NPHWs’ work and that of their supervisors62,76,86,90,94 and made express commitments to equitable care access.46 An evaluation of CHWs’ effectiveness in treating hypertension and diabetes in Iran94 noted that their impact was substantially greater for diabetes than hypertension because of Iran’s codification of their role in diabetes care.

    Information Systems

    Information system barriers comprised 2 categories: difficulty tracking patients and storing their data for longitudinal care. Nonphysician health workers struggled to record clinical encounters40,71,73,74; when present, information storage was inefficient.8,40,70 Contacting patients by telephone was also sometimes difficult.58 However, strategies to overcome these barriers were diverse and creative. A hypertension and diabetes program in Cameroon sent reminder letters to patients95; other programs used electronic or telephone systems for patient tracking,46,90 program eligibility and other screening,96,97 and surveillance and intervention planning.8,77,78 Some programs used telemedicine to provide NPHW oversight98 or even remote clinical encounters.79,92

    Medication Access

    Inconsistent access to medication hampered NPHW care, whereas reliable access promoted it. Many studies8,10,16,46,62,70,71,76,99 noted disruptions in medication or equipment as a challenge. Even when present, medications were sometimes expensive,55 and NPHWs were not always trained on how to use them.100 Interventions that leveraged consistent, inexpensive medication access were invaluable,8,10,46,77,78 but uncommon. Joshi et al,78 in discussing strategies to strengthen nonphysician cardiovascular disease care in rural China, noted that cost-effective drug distribution plans were helpful, as was the use of a single-tablet, multidrug polypill. A nurse-led hypertension treatment program in Cameroon101 also benefited from locally available medication.

    Financing

    Finance barriers fell into 2 categories: supply-side issues, such as lack of program funding41,46,64 and consequent poor pay for NPHWs,44,88 and mismanagement of resources, including poor performance incentives,74 lack of long-term planning,91 and overuse of out-of-pocket models for reimbursement (instead of insurance subsidies). The latter issue decreased patients’ demand for care102 and encouraged curative care in lieu of preventive medicine.62 Financial facilitators of care, conversely, included not only adequate program and salary funds8,62 but also social protection schemes to encourage patients to access care.97 One study,91 evaluating the integration of mental health care into CHW-led primary care in Kenya, noted that donor awareness of local needs optimized allocation of resources.

    Discussion

    We undertook a systematic review of health system factors that support or impair NPHW-led interventions to control NCDs in LMICs. Issues involving service delivery, the health workforce, and program governance encompassed the most diverse themes, ranging from logistical matters (eg, the distribution of workers), to structural issues of oversight, to cultural ones (eg, stigma). However, in all 6 domains, most themes pertained to either sufficient quantity of resources (eg, size of clinics or procurement of medications) or their effective stewardship (eg, authorizing NPHWs to use these medicines). Actionable lessons emerged across each block, as outlined here:

    1. Service delivery: Provide protocol-based NPHW care that is community based and culturally sensitive to the community served, with physical infrastructure to allow access and referral based on robust physician backup systems.

    2. Workforce: Select qualified NPHWs responsive to and embedded within communities, and provide rigorous training to workers and support from supervisors.

    3. Governance: Provide detailed, feasible work expectations, with explicit support from clinical leadership and policy makers. Grant authority for NPHWs to perform appropriate clinical duties, including prescribing medication.

    4. Information systems: Furnish electronic systems to allow NPHWs to remotely contact patients, follow their clinical data, and assess their eligibility for health interventions.

    5. Medications: Provide a consistent supply chain of essential drugs, an efficient system for their distribution to patients, and training on appropriate use.

    6. Financing: Provide adequate funds for essential program supplies, pay NPHWs fairly and consistently, and minimize patient out-of-pocket costs.

    These findings also inform other frameworks specific to the performance of nonphysicians. The US-based CHW Core Consensus Project,103 for example, uses a framework asking how CHWs’ roles have evolved, what roles they currently play, and what skills they need to fill these roles. We found a substantial increase in NPHW-led NCD care models in recent years in all aspects of the NCD care cascade (Figure 2); more broadly, we found that NPHWs should be selected from within the communities served, rigorously trained, and given authority and material support to do their work. Similarly, Palazuelos et al104 designed a 5-point framework to appraise the resources CHWs need in LMIC settings: supervision, partnership, incentives, choice (recruitment), and education. These concepts, too, parallel the need for NPHW oversight, role definition, remuneration, selection, and training, respectively, as described already.

    Literature Gaps

    Few studies devised or evaluated process measures that could reveal whether and why their interventions operated consistently. For example, tracking how health care workers order key medications, when the medications arrive at clinics, and how often patients actually receive them could address the problem of medications being out of stock. Cost-effectiveness data were also rare,15,58,63,102,104 despite their implications for health policy. Furthermore, studies’ use of novel technologies and governance models raised unanswered questions, such as how best to use mobile telephones for decision support or how to implement performance-based compensation. In addition, although adequate compensation and supervision were crucial to NPHWs’ day-to-day performance, strategies for workers’ retention and promotion did not arise.

    Health System Framework Challenges

    The WHO’s building block framework did not accommodate all care barriers and facilitators described105,106 because some factors operate outside the health system. For example, some patient access barriers, such as community suspicion of government and inclement weather and roads, derive from factors not directly tied to health but still speak to themes (ie, social dynamics, climate, and built environment) that are instrumental to NPHW-led care. These political and cultural factors also influence the health system proper—for example, through the power dynamics that dictate how policy makers implement a health intervention, or the social values with which communities receive it (ie, the “software” through which the system’s building-block “hardware” renders care).107 This descriptive gap underscores the need for health care frameworks to acknowledge extrasystem barriers and facilitators; integrate health system factors with social, economic, and environmental factors; and use a multidisciplinary approach to NPHW system integration.

    Also, some barriers and facilitators fit into multiple blocks.25,26 These included NPHW remuneration (workforce vs financing), NPHW team integration (workforce vs governance), and training on medication use (workforce vs medication). Although we categorized these elements by consensus, as described in the Methods section, the ambiguity highlights the interrelatedness of the building blocks. However, the relevance of the exact categorization is debatable, insofar as the blocks are interconnected,106 with cross-block innovations required to enable effective NPHW care.108

    Policy and Program Implications

    Our review suggests both practices and policy ideas to optimize NPHW-led NCD care, which some groups have begun to use. Partners in Health’s Mentorship and Enhanced Supervision for Health Care and Quality Improvement initiative,109,110 for example, stipulates that NPHW mentors continuously observe mentees every 4 to 6 weeks using a checklist to ensure quality of care. The Rural Andhra Pradesh Cardiovascular Prevention Study,111 a randomized trial of nonphysician hypertension screening and referral in India, benefited from a simple patient evaluation algorithm. The Nigerian Anti-Hypertensive Trial,112 a randomized trial of nurse-led hypertension treatment, benefited from nurses’ permission to dispense medications. Unfortunately, despite evidence that such interventions are effective12 and culturally acceptable,82 improve outcomes,48 and control costs,70,113,114 few have been scaled into national-level health systems.102

    These findings are also applicable to high-income countries such as the United States, where physician assistants, nurses, and pharmacists provide a growing fraction of care.115In addition, nonphysicians are providing care outreach in novel settings, such as high blood pressure counseling and treatment in barber shops116 and churches.117 The Robert Wood Johnson foundation recently convened a task force identifying novel examples of global nonphysician care that can be applied in underserved US communities118; similarly, an intervention in Indiana is leveraging interventions validated in LMICs to reduce infant mortality.119

    Limitations

    Our review approach had notable limitations. We did not search databases beyond PubMed to identify systematic reviews, nor did we review articles not cited within the systematic reviews we identified, introducing bias both in our selection of studies and inherent within them (Table 3). Furthermore, although 2 reviewers examined all articles, they split the initial review of these articles, with each half reviewed post hoc by the other. Given the ambiguity and overlap of the WHO’s health system building block classification, including many barriers and facilitators not covered within the 6 blocks, it is possible that we missed or incorrectly categorized pertinent findings, potentially altering the results. Although we detailed the care site and disease treated within each study, we did not quantify such trends within these heterogeneous data. Nonetheless, strengths of this work include its detailed, reproducible systematic review protocol, its review of all classifications with a third coauthor, and its codevelopment of approach with a research librarian.

    Conclusions

    Because NCDs are now the leading cause of premature death and disability in low-income regions where physicians remain scarce, we sought to understand how NPHW-led programs for the control of these diseases are aided or impaired by the health systems they inhabit. This study found a small but growing set of studies describing these health system barriers and facilitators, usually incidentally rather than by the studies’ design, but with frequent and consistent messages regarding each of the WHO’s health system building blocks.

    Beyond the training, retention, supervision, and deployment of these workers, furnishing strong support systems (supply chains for medications and equipment) and other infrastructure (telephone patient tracking or electronic patient records), as well as adequate program funding, also may facilitate success. In addition, further implementation research—in which these elements are expressly furnished, delivered, and evaluated for delivery and its care impact—will better illuminate how these elements are associated with care delivery. With these data, the effective scale-up of NPHW programs for the leading cause of morbidity and mortality in LMICs may be feasible.

    Back to top
    Article Information

    Accepted for Publication: October 9, 2019.

    Published: December 2, 2019. doi:10.1001/jamanetworkopen.2019.16545

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Heller DJ et al. JAMA Network Open.

    Corresponding Author: David J. Heller, MD, MPH, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, 1216 Fifth Ave, Ste 562, New York, NY 10029 (david.heller@mssm.edu).

    Author Contributions: Dr Heller had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Joshi and Vedanthan contributed equally as senior authors of this article.

    Concept and design: Heller, Kumar, Horowitz, Joshi, Vedanthan.

    Acquisition, analysis, or interpretation of data: Heller, Kumar, Kishore, Joshi, Vedanthan.

    Drafting of the manuscript: Heller, Kumar, Horowitz.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Heller, Kumar.

    Administrative, technical, or material support: Heller, Kumar, Kishore.

    Supervision: Horowitz, Joshi, Vedanthan.

    Conflict of Interest Disclosures: Drs Heller and Kishore reported receiving grants from Teva Pharmaceuticals during the conduct of the study. Dr Kishore also reported serving as a consultant to Resolve to Save Lives. No other conflicts were reported.

    Additional Contribution: Research librarian Rachel Pinotti, MS (Icahn School of Medicine at Mount Sinai), helped refine the review’s search methods. Ms Pinotti received no compensation for this work.

    References
    1.
    Institute for Health Metrics and Evaluation. Global Burden of Disease (GBD) compare tool. https://vizhub.healthdata.org/gbd-compare/. Accessed December 19, 2018.
    2.
    Di Cesare  M, Khang  YH, Asaria  P,  et al; Lancet NCD Action Group.  Inequalities in non-communicable diseases and effective responses.  Lancet. 2013;381(9866):585-597. doi:10.1016/S0140-6736(12)61851-0PubMedGoogle ScholarCrossref
    3.
    Sommer  I, Griebler  U, Mahlknecht  P,  et al.  Socioeconomic inequalities in non-communicable diseases and their risk factors: an overview of systematic reviews.  BMC Public Health. 2015;15(1):914. doi:10.1186/s12889-015-2227-yPubMedGoogle ScholarCrossref
    4.
    Yoo  SGK, Prabhakaran  D, Huffman  MD.  Evaluating and improving cardiovascular health system management in low-and middle-income countries.  Circ Cardiovasc Qual Outcomes. 2017;10(11):e004292. doi:10.1161/CIRCOUTCOMES.117.004292PubMedGoogle Scholar
    5.
    World Health Organization. Global Health Observatory (GHO) data: density of physicians per 1,000 population. https://www.who.int/gho/health_workforce/physicians_density/en/. Accessed December 19, 2018.
    6.
    Araujo  E, Maeda  A. How to recruit and retain health workers in rural and remote areas in developing countries: a guidance note. https://openknowledge.worldbank.org/handle/10986/16104. Published 2013. Accessed June 10, 2019.
    7.
    Callaghan  M, Ford  N, Schneider  H.  A systematic review of task-shifting for HIV treatment and care in Africa.  Hum Resour Health. 2010;8(1):8. doi:10.1186/1478-4491-8-8PubMedGoogle ScholarCrossref
    8.
    Lewin  S, Munabi-Babigumira  S, Glenton  C,  et al.  Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.  Cochrane Database Syst Rev. 2010;(3):CD004015. doi:10.1002/14651858.CD004015.pub3PubMedGoogle Scholar
    9.
    Schneider  H, Okello  D, Lehmann  U.  The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014.  Hum Resour Health. 2016;14(1):65. doi:10.1186/s12960-016-0163-2PubMedGoogle ScholarCrossref
    10.
    Joshi  R, Alim  M, Kengne  AP,  et al.  Task shifting for non-communicable disease management in low and middle income countries: a systematic review.  PLoS One. 2014;9(8):e103754. doi:10.1371/journal.pone.0103754PubMedGoogle Scholar
    11.
    Abegunde  DO, Shengelia  B, Luyten  A,  et al.  Can non-physician health-care workers assess and manage cardiovascular risk in primary care?  Bull World Health Organ. 2007;85(6):432-440. doi:10.2471/BLT.06.032177PubMedGoogle ScholarCrossref
    12.
    Gaziano  TA, Abrahams-Gessel  S, Denman  CA,  et al.  An assessment of community health workers’ ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study.  Lancet Glob Health. 2015;3(9):e556-e563. doi:10.1016/S2214-109X(15)00143-6PubMedGoogle ScholarCrossref
    13.
    Khan  M, Lamelas  P, Musa  H,  et al.  Development, testing, and implementation of a training curriculum for nonphysician health workers to reduce cardiovascular disease.  Glob Heart. 2018;13(2):93-100. doi:10.1016/j.gheart.2017.11.002PubMedGoogle ScholarCrossref
    14.
    Patel  V, Weiss  HA, Chowdhary  N,  et al.  Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months.  Br J Psychiatry. 2011;199(6):459-466. doi:10.1192/bjp.bp.111.092155PubMedGoogle ScholarCrossref
    15.
    Weobong  B, Weiss  HA, McDaid  D,  et al.  Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme, a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial.  PLoS Med. 2017;14(9):e1002385. doi:10.1371/journal.pmed.1002385PubMedGoogle Scholar
    16.
    Labhardt  ND, Balo  JR, Ndam  M, Grimm  JJ, Manga  E.  Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years.  BMC Health Serv Res. 2010;10(1):339. doi:10.1186/1472-6963-10-339PubMedGoogle ScholarCrossref
    17.
    Gajalakshmi  CK, Krishnamurthi  S, Ananth  R, Shanta  V.  Cervical cancer screening in Tamilnadu, India: a feasibility study of training the village health nurse.  Cancer Causes Control. 1996;7(5):520-524. doi:10.1007/BF00051884PubMedGoogle ScholarCrossref
    18.
    Warnakulasuriya  KA, Ekanayake  AN, Sivayoham  S,  et al.  Utilization of primary health care workers for early detection of oral cancer and precancer cases in Sri Lanka.  Bull World Health Organ. 1984;62(2):243-250.PubMedGoogle Scholar
    19.
    Kengne  AP, Fezeu  L, Awah  PK, Sobngwi  E, Mbanya  JC.  Task shifting in the management of epilepsy in resource-poor settings.  Epilepsia. 2010;51(5):931-932. doi:10.1111/j.1528-1167.2009.02414.xPubMedGoogle ScholarCrossref
    20.
    Kengne  AP, Sobngwi  E, Fezeu  LL, Awak  PK, Dongmo  S, Mbanya  JC.  Nurse-led care for asthma at primary level in rural sub-Saharan Africa: the experience of Bafut in Cameroon.  J Asthma. 2008;45(6):437-443. doi:10.1080/02770900802032933PubMedGoogle ScholarCrossref
    21.
    World Health Organization. HEARTS: technical package for cardiovascular disease management in primary health care. https://apps.who.int/iris/bitstream/handle/10665/252661/9789241511377-eng.pdf?sequence=1. Published 2016. Accessed September 19, 2018.
    22.
    World Health Organization. mhGAP training manuals for the mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: version 2.0 (for field testing). https://apps.who.int/iris/bitstream/handle/10665/259161/WHO-MSD-MER-17.6-eng.pdf?sequence=1&isAllowed=y. Published 2017. Accessed December 19, 2018.
    23.
    United Nations. 2011 High level meeting on prevention and control of non-communicable diseases. https://www.un.org/en/ga/ncdmeeting2011/. Published 2011. Accessed December 19, 2018.
    24.
    World Health Organization. Time to deliver: report of the WHO Independent High Level Commission on Noncommunicable Diseases. https://www.who.int/ncds/management/time-to-deliver/en/. Published June 1, 2018. Accessed December 19, 2018.
    25.
    World Health Organization. The World Health Report 2003: shaping the future. https://www.who.int/whr/2003/en/whr03_en.pdf. Published 2003. Accessed December 19, 2018.
    26.
    World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. https://www.who.int/healthsystems/strategy/everybodys_business.pdf. Published 2007. Accessed December 19, 2018.
    27.
    Stroup  DF, Berlin  JA, Morton  SC,  et al; Meta-analysis of Observational Studies in Epidemiology (MOOSE) Group.  Meta-analysis of observational studies in epidemiology: a proposal for reporting.  JAMA. 2000;283(15):2008-2012. doi:10.1001/jama.283.15.2008PubMedGoogle ScholarCrossref
    28.
    Moher  D, Liberati  A, Tetzlaff  J, Altman  DG; PRISMA Group.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.  Ann Intern Med. 2009;151(4):264-269. doi:10.7326/0003-4819-151-4-200908180-00135PubMedGoogle ScholarCrossref
    29.
    Bukhman  G, Kidder  A; Partners in Health. The PIH guide to chronic care integration for endemic non-communicable diseases. https://www.pih.org/practitioner-resource/the-pih-guide-to-chronic-care-integration-for-endemic-non-communicable-dise. Published 2011. Accessed December 19, 2018.
    30.
    The World Bank. Open data: country income. https://data.worldbank.org/income-level/lower-middle-income. Accessed December 19, 2018.
    31.
    Roda  G, Narula  N, Pinotti  R,  et al.  Systematic review with meta-analysis: proximal disease extension in limited ulcerative colitis.  Aliment Pharmacol Ther. 2017;45(12):1481-1492. doi:10.1111/apt.14063PubMedGoogle ScholarCrossref
    32.
    Shea  BJ, Reeves  BC, Wells  G,  et al.  AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both.  BMJ. 2017;358:j4008. doi:10.1136/bmj.j4008PubMedGoogle ScholarCrossref
    33.
    Green  BN, Johnson  CD, Adams  A.  Writing narrative literature reviews for peer-reviewed journals: secrets of the trade.  J Chiropr Med. 2006;5(3):101-117. doi:10.1016/S0899-3467(07)60142-6PubMedGoogle ScholarCrossref
    34.
    Iwelunmor  J, Plange-Rhule  J, Airhihenbuwa  CO, Ezepue  C, Ogedegbe  O.  A narrative synthesis of the health systems factors influencing optimal hypertension control in sub-Saharan Africa.  PLoS One. 2015;10(7):e0130193. doi:10.1371/journal.pone.0130193PubMedGoogle Scholar
    35.
    Popay  J, Roberts  H, Sowden  A,  et al. Guidance on the conduct of narrative synthesis in systematic reviews: a product from the ESRC methods Programme. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.178.3100&rep=rep1&type=pdf. Published April 1, 2006. Accessed December 19, 2018.
    36.
    Corbin  JM, Strauss  A.  Grounded theory research: procedures, canons, and evaluative criteria.  Qual Sociol. 1990;13(1):3-21. doi:10.1007/BF00988593Google ScholarCrossref
    37.
    O’Brien  BC, Harris  IB, Beckman  TJ, Reed  DA, Cook  DA.  Standards for reporting qualitative research: a synthesis of recommendations.  Acad Med. 2014;89(9):1245-1251. doi:10.1097/ACM.0000000000000388PubMedGoogle ScholarCrossref
    38.
    Gatuguta  A, Katusiime  B, Seeley  J, Colombini  M, Mwanzo  I, Devries  K.  Should community health workers offer support healthcare services to survivors of sexual violence? a systematic review.  BMC Int Health Hum Rights. 2017;17(1):28. doi:10.1186/s12914-017-0137-zPubMedGoogle ScholarCrossref
    39.
    Barnett  ML, Gonzalez  A, Miranda  J, Chavira  DA, Lau  AS.  Mobilizing community health workers to address mental health disparities for underserved populations: a systematic review.  Adm Policy Ment Health. 2018;45(2):195-211. doi:10.1007/s10488-017-0815-0PubMedGoogle ScholarCrossref
    40.
    Khetan  AK, Purushothaman  R, Chami  T,  et al.  The effectiveness of community health workers in CVD prevention in LMIC.  Glob Heart. 2017;12(3):233-243. doi:10.1016/j.gheart.2016.07.001PubMedGoogle ScholarCrossref
    41.
    Padmanathan  P, De Silva  MJ.  The acceptability and feasibility of task-sharing for mental healthcare in low and middle income countries: a systematic review.  Soc Sci Med. 2013;97:82-86. doi:10.1016/j.socscimed.2013.08.004PubMedGoogle ScholarCrossref
    42.
    Mutamba  BB, van Ginneken  N, Smith Paintain  L, Wandiembe  S, Schellenberg  D.  Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review.  BMC Health Serv Res. 2013;13(1):412. doi:10.1186/1472-6963-13-412PubMedGoogle ScholarCrossref
    43.
    Chowdhary  N, Sikander  S, Atif  N,  et al The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle income countries: a systematic review.  Best Pract Res Clin Obstet Gynecol. 2014;28(1):113-133. doi:10.1016/j.bpobgyn.2013.08.013PubMedGoogle ScholarCrossref
    44.
    Abdel-All  M, Putica  B, Praveen  D, Abimbola  S, Joshi  R.  Effectiveness of community health worker training programmes for cardiovascular disease management in low-income and middle-income countries: a systematic review.  BMJ Open. 2017;7(11):e015529. doi:10.1136/bmjopen-2016-015529PubMedGoogle Scholar
    45.
    Ogedegbe  G, Gyamfi  J, Plange-Rhule  J,  et al.  Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials.  BMJ Open. 2014;4(10):e005983. doi:10.1136/bmjopen-2014-005983PubMedGoogle Scholar
    46.
    Javadi  D, Feldhaus  I, Mancuso  A, Ghaffar  A.  Applying systems thinking to task shifting for mental health using lay providers: a review of the evidence.  Glob Ment Health (Camb). 2017;4:e14. doi:10.1017/gmh.2017.15PubMedGoogle Scholar
    47.
    Hill  J, Peer  N, Oldenburg  B, Kengne  AP.  Roles, responsibilities and characteristics of lay community health workers involved in diabetes prevention programmes: a systematic review.  PLoS One. 2017;12(12):e0189069. doi:10.1371/journal.pone.0189069PubMedGoogle Scholar
    48.
    Seidman  G, Atun  R.  Does task shifting yield cost savings and improve efficiency for health systems? a systematic review of evidence from low-income and middle-income countries.  Hum Resour Health. 2017;15(1):29. doi:10.1186/s12960-017-0200-9PubMedGoogle ScholarCrossref
    49.
    Jeet  G, Thakur  JS, Prinja  S, Singh  M.  Community health workers for non-communicable diseases prevention and control in developing countries: evidence and implications.  PLoS One. 2017;12(7):e0180640. doi:10.1371/journal.pone.0180640PubMedGoogle Scholar
    50.
    Alaofè  H, Asaolu  I, Ehiri  J,  et al.  Community health workers in diabetes prevention and management in developing countries.  Ann Glob Health. 2017;83(3-4):661-675. doi:10.1016/j.aogh.2017.10.009PubMedGoogle ScholarCrossref
    51.
    Ahluwalia  SC, Damberg  CL, Silverman  M, Motala  A, Shekelle  PG.  What defines a high-performing health care delivery system: a systematic review.  Jt Comm J Qual Patient Saf. 2017;43(9):450-459. doi:10.1016/j.jcjq.2017.03.010PubMedGoogle ScholarCrossref
    52.
    Pastakia  SD, Ali  SM, Kamano  JH,  et al.  Screening for diabetes and hypertension in a rural low income setting in western Kenya utilizing home-based and community-based strategies.  Global Health. 2013;9(1):21. doi:10.1186/1744-8603-9-21PubMedGoogle ScholarCrossref
    53.
    Balaji  M, Chatterjee  S, Koschorke  M,  et al.  The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India.  BMC Health Serv Res. 2012;12(1):42. doi:10.1186/1472-6963-12-42PubMedGoogle ScholarCrossref
    54.
    Chatterjee  S, Naik  S, John  S,  et al.  Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial.  Lancet. 2014;383(9926):1385-1394. doi:10.1016/S0140-6736(13)62629-XPubMedGoogle ScholarCrossref
    55.
    Pereira  B, Andrew  G, Pednekar  S, Kirkwood  BR, Patel  V.  The integration of the treatment for common mental disorders in primary care: experiences of health care providers in the MANAS trial in Goa, India.  Int J Ment Health Syst. 2011;5(1):26. doi:10.1186/1752-4458-5-26PubMedGoogle ScholarCrossref
    56.
    Nadkarni  A, Velleman  R, Dabholkar  H,  et al.  The systematic development and pilot randomized evaluation of counselling for alcohol problems, a lay counselor-delivered psychological treatment for harmful drinking in primary care in India: the PREMIUM study.  Alcohol Clin Exp Res. 2015;39(3):522-531. doi:10.1111/acer.12653PubMedGoogle ScholarCrossref
    57.
    Kohli  A, Makambo  MT, Ramazani  P,  et al.  A Congolese community-based health program for survivors of sexual violence.  Confl Health. 2012;6(1):6. doi:10.1186/1752-1505-6-6PubMedGoogle ScholarCrossref
    58.
    Mash  R, Kroukamp  R, Gaziano  T, Levitt  N.  Cost-effectiveness of a diabetes group education program delivered by health promoters with a guiding style in underserved communities in Cape Town, South Africa.  Patient Educ Couns. 2015;98(5):622-626. doi:10.1016/j.pec.2015.01.005PubMedGoogle ScholarCrossref
    59.
    Murray  LK, Familiar  I, Skavenski  S,  et al.  An evaluation of trauma focused cognitive behavioral therapy for children in Zambia.  Child Abuse Negl. 2013;37(12):1175-1185. doi:10.1016/j.chiabu.2013.04.017PubMedGoogle ScholarCrossref
    60.
    Mendenhall  E, De Silva  MJ, Hanlon  C,  et al.  Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda.  Soc Sci Med. 2014;118:33-42. doi:10.1016/j.socscimed.2014.07.057PubMedGoogle ScholarCrossref
    61.
    Naved  RT, Rimi  NA, Jahan  S, Lindmark  G.  Paramedic-conducted mental health counselling for abused women in rural Bangladesh: an evaluation from the perspective of participants.  J Health Popul Nutr. 2009;27(4):477-491. doi:10.3329/jhpn.v27i4.3391PubMedGoogle ScholarCrossref
    62.
    Haines  A, Sanders  D, Lehmann  U,  et al.  Achieving child survival goals: potential contribution of community health workers.  Lancet. 2007;369(9579):2121-2131. doi:10.1016/S0140-6736(07)60325-0PubMedGoogle ScholarCrossref
    63.
    Mdege  ND, Chindove  S, Ali  S.  The effectiveness and cost implications of task-shifting in the delivery of antiretroviral therapy to HIV-infected patients: a systematic review.  Health Policy Plan. 2013;28(3):223-236. doi:10.1093/heapol/czs058PubMedGoogle ScholarCrossref
    64.
    Abanilla  PK, Huang  KY, Shinners  D,  et al.  Cardiovascular disease prevention in Ghana: feasibility of a faith-based organizational approach.  Bull World Health Organ. 2011;89(9):648-656. doi:10.2471/BLT.11.086777PubMedGoogle ScholarCrossref
    65.
    Jordans  MJ, Keen  AS, Pradhan  H,  et al.  Psychosocial counselling in Nepal: perspectives of counsellors and beneficiaries.  Int J Adv Couns. 2007;29(1):57-68. doi:10.1007/s10447-006-9028-zGoogle ScholarCrossref
    66.
    Nishtar  S, Badar  A, Kamal  MU,  et al.  The Heartfile Lodhran CVD prevention project: end of project evaluation.  Promot Educ. 2007;14(1):17-27. doi:10.1177/175797590701400103PubMedGoogle ScholarCrossref
    67.
    Lorenzo  T, van Pletzen  E, Booyens  M.  Determining the competences of community based workers for disability-inclusive development in rural areas of South Africa, Botswana and Malawi.  Rural Remote Health. 2015;15(2):2919.PubMedGoogle Scholar
    68.
    Ali  BS, Rahbar  MH, Naeem  S, Gul  A, Mubeen  S, Iqbal  A.  The effectiveness of counseling on anxiety and depression by minimally trained counselors: a randomized controlled trial.  Am J Psychother. 2003;57(3):324-336. doi:10.1176/appi.psychotherapy.2003.57.3.324PubMedGoogle ScholarCrossref
    69.
    Micikas  M, Foster  J, Weis  A,  et al.  A community health worker intervention for diabetes self-management among the Tz’utujil Maya of Guatemala.  Health Promot Pract. 2015;16(4):601-608. doi:10.1177/1524839914557033PubMedGoogle ScholarCrossref
    70.
    Nimgaonkar  AU, Menon  SD.  A task shifting mental health program for an impoverished rural Indian community.  Asian J Psychiatr. 2015;16:41-47. doi:10.1016/j.ajp.2015.05.044PubMedGoogle ScholarCrossref
    71.
    Ndou  T, van Zyl  G, Hlahane  S, Goudge  J.  A rapid assessment of a community health worker pilot programme to improve the management of hypertension and diabetes in Emfuleni sub-district of Gauteng Province, South Africa.  Glob Health Action. 2013;6(1):19228. doi:10.3402/gha.v6i0.19228PubMedGoogle ScholarCrossref
    72.
    Abrahams-Gessel  S, Denman  CA, Montano  CM,  et al.  The training and fieldwork experiences of community health workers conducting population-based, noninvasive screening for CVD in LMIC.  Glob Heart. 2015;10(1):45-54. doi:10.1016/j.gheart.2014.12.008PubMedGoogle ScholarCrossref
    73.
    Chibanda  D, Mesu  P, Kajawu  L, Cowan  F, Araya  R, Abas  MA.  Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV.  BMC Public Health. 2011;11(1):828. doi:10.1186/1471-2458-11-828PubMedGoogle ScholarCrossref
    74.
    Mendis  S, Johnston  SC, Fan  W, Oladapo  O, Cameron  A, Faramawi  MF.  Cardiovascular risk management and its impact on hypertension control in primary care in low-resource settings: a cluster-randomized trial.  Bull World Health Organ. 2010;88(6):412-419. doi:10.2471/BLT.08.062364PubMedGoogle ScholarCrossref
    75.
    Zhong  X, Wang  Z, Fisher  EB, Tanasugarn  C.  Peer support for diabetes management in primary care and community settings in Anhui Province, China.  Ann Fam Med. 2015;13(1)(suppl):S50-S58. doi:10.1370/afm.1799PubMedGoogle ScholarCrossref
    76.
    Petersen  I, Ssebunnya  J, Bhana  A, Baillie  K; MhaPP Research Programme Consortium.  Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda.  Int J Ment Health Syst. 2011;5(1):8. doi:10.1186/1752-4458-5-8PubMedGoogle ScholarCrossref
    77.
    Feksi  AT, Kaamugisha  J, Sander  JW, Gatiti  S, Shorvon  SD; ICBERG (International Community-Based Epilepsy Research Group).  Comprehensive primary health care antiepileptic drug treatment programme in rural and semi-urban Kenya.  Lancet. 1991;337(8738):406-409. doi:10.1016/0140-6736(91)91176-UPubMedGoogle ScholarCrossref
    78.
    Joshi  R, Jan  S, Wu  Y, MacMahon  S.  Global inequalities in access to cardiovascular health care: our greatest challenge.  J Am Coll Cardiol. 2008;52(23):1817-1825. doi:10.1016/j.jacc.2008.08.049PubMedGoogle ScholarCrossref
    79.
    Magidson  JF, Lejuez  CW, Kamal  T,  et al.  Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq.  Glob Ment Health (Camb). 2015;2(Jan):e24. doi:10.1017/gmh.2015.22PubMedGoogle Scholar
    80.
    Bolton  P, Bass  JK, Zangana  GA,  et al.  A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq.  BMC Psychiatry. 2014;14(1):360. doi:10.1186/s12888-014-0360-2PubMedGoogle ScholarCrossref
    81.
    Balagopal  P, Kamalamma  N, Patel  TG, Misra  R.  A community-based participatory diabetes prevention and management intervention in rural India using community health workers.  Diabetes Educ. 2012;38(6):822-834. doi:10.1177/0145721712459890PubMedGoogle ScholarCrossref
    82.
    Abas  M, Bowers  T, Manda  E,  et al.  “Opening up the mind”: problem-solving therapy delivered by female lay health workers to improve access to evidence-based care for depression and other common mental disorders through the Friendship Bench Project in Zimbabwe.  Int J Ment Health Syst. 2016;10(1):39. doi:10.1186/s13033-016-0071-9PubMedGoogle ScholarCrossref
    83.
    Pisani  P, Parkin  DM, Ngelangel  C,  et al.  Outcome of screening by clinical examination of the breast in a trial in the Philippines.  Int J Cancer. 2006;118(1):149-154. doi:10.1002/ijc.21343PubMedGoogle ScholarCrossref
    84.
    Tsolekile  LP, Puoane  T, Schneider  H, Levitt  NS, Steyn  K.  The roles of community health workers in management of non-communicable diseases in an urban township.  Afr J Prim Health Care Fam Med. 2014;6(1):E1-E8. doi:10.4102/phcfm.v6i1.693PubMedGoogle ScholarCrossref
    85.
    Murray  LK, Dorsey  S, Haroz  E,  et al.  A common elements treatment approach for adult mental health problems in low-and middle-income countries.  Cogn Behav Pract. 2014;21(2):111-123. doi:10.1016/j.cbpra.2013.06.005PubMedGoogle ScholarCrossref
    86.
    Agyapong  VI, Osei  A, Farren  CK, McAuliffe  E.  Factors influencing the career choice and retention of community mental health workers in Ghana.  Hum Resour Health. 2015;13(1):56. doi:10.1186/s12960-015-0050-2PubMedGoogle ScholarCrossref
    87.
    Agyapong  VI, Osei  A, Farren  CK, Mcauliffe  E.  Task shifting of mental health care services in Ghana: ease of referral, perception and concerns of stakeholders about quality of care.  Int J Qual Health Care. 2015;27(5):377-383. doi:10.1093/intqhc/mzv058PubMedGoogle ScholarCrossref
    88.
    Murray  LK, Skavenski  S, Kane  JC,  et al.  Effectiveness of trauma-focused cognitive behavioral therapy among trauma-affected children in Lusaka, Zambia: a randomized clinical trial.  JAMA Pediatr. 2015;169(8):761-769. doi:10.1001/jamapediatrics.2015.0580PubMedGoogle ScholarCrossref
    89.
    Rahman  A, Malik  A, Sikander  S, Roberts  C, Creed  F.  Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial.  Lancet. 2008;372(9642):902-909. doi:10.1016/S0140-6736(08)61400-2PubMedGoogle ScholarCrossref
    90.
    Agyapong  VI, Farren  C, McAuliffe  E.  Improving Ghana’s mental healthcare through task-shifting: psychiatrists and health policy directors perceptions about government’s commitment and the role of community mental health workers.  Global Health. 2016;12(1):57. doi:10.1186/s12992-016-0199-zPubMedGoogle ScholarCrossref
    91.
    Jenkins  R, Kiima  D, Okonji  M, Njenga  F, Kingora  J, Lock  S.  Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability.  Ment Health Fam Med. 2010;7(1):37-47.PubMedGoogle Scholar
    92.
    Pallas  SW, Minhas  D, Pérez-Escamilla  R, Taylor  L, Curry  L, Bradley  EH.  Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability?  Am J Public Health. 2013;103(7):e74-e82. doi:10.2105/AJPH.2012.301102PubMedGoogle ScholarCrossref
    93.
    Kok  MC, Kane  SS, Tulloch  O,  et al.  How does context influence performance of community health workers in low- and middle-income countries? evidence from the literature.  Health Res Policy Syst. 2015;13(1):13. doi:10.1186/s12961-015-0001-3PubMedGoogle ScholarCrossref
    94.
    Farzadfar  F, Murray  CJ, Gakidou  E,  et al.  Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study.  Lancet. 2012;379(9810):47-54. doi:10.1016/S0140-6736(11)61349-4PubMedGoogle ScholarCrossref
    95.
    Labhardt  ND, Balo  JR, Ndam  M, Manga  E, Stoll  B.  Improved retention rates with low-cost interventions in hypertension and diabetes management in a rural African environment of nurse-led care: a cluster-randomised trial.  Trop Med Int Health. 2011;16(10):1276-1284. doi:10.1111/j.1365-3156.2011.02827.xPubMedGoogle ScholarCrossref
    96.
    Hung  KJ, Tomlinson  M, le Roux  IM, Dewing  S, Chopra  M, Tsai  AC.  Community-based prenatal screening for postpartum depression in a South African township.  Int J Gynaecol Obstet. 2014;126(1):74-77. doi:10.1016/j.ijgo.2014.01.011PubMedGoogle ScholarCrossref
    97.
    Padilla  E, Molina  J, Kamis  D,  et al.  The efficacy of targeted health agents education to reduce the duration of untreated psychosis in a rural population.  Schizophr Res. 2015;161(2-3):184-187. doi:10.1016/j.schres.2014.10.039PubMedGoogle ScholarCrossref
    98.
    Tomlinson  M, Doherty  T, Jackson  D,  et al.  An effectiveness study of an integrated, community-based package for maternal, newborn, child and HIV care in South Africa: study protocol for a randomized controlled trial.  Trials. 2011;12(1):236. doi:10.1186/1745-6215-12-236PubMedGoogle ScholarCrossref
    99.
    Adams  JL, Almond  ML, Ringo  EJ, Shangali  WH, Sikkema  KJ.  Feasibility of nurse-led antidepressant medication management of depression in an HIV clinic in Tanzania.  Int J Psychiatry Med. 2012;43(2):105-117. doi:10.2190/PM.43.2.aPubMedGoogle ScholarCrossref
    100.
    Wright  J, Chiwandira  C.  Building capacity for community mental health care in rural Malawi: findings from a district-wide task-sharing intervention with village-based health workers.  Int J Soc Psychiatry. 2016;62(6):589-596. doi:10.1177/0020764016657112PubMedGoogle ScholarCrossref
    101.
    Kengne  AP, Fezeu  L, Sobngwi  E,  et al.  Type 2 diabetes management in nurse-led primary healthcare settings in urban and rural Cameroon.  Prim Care Diabetes. 2009;3(3):181-188. doi:10.1016/j.pcd.2009.08.005PubMedGoogle ScholarCrossref
    102.
    Jafar  TH, Islam  M, Bux  R,  et al Cost-effectiveness of community-based strategies for blood pressure control in a low-income developing country: findings from a cluster-randomized, factorial-controlled trial.  Circulation. 2011;124(15):1615-1625. doi:10.1161/CIRCULATIONAHA.111.039990PubMedGoogle ScholarCrossref
    103.
    Rosenthal  EL, Rush  CH, Allen  CG. Understanding scope and competencies: a contemporary look at the United States community health worker field—progress report of the community health worker (CHW) core consensus (C3) project. building national consensus on CHW core roles, skills, and qualities. http://chrllc.net/sitebuildercontent/sitebuilderfiles/c3_report_20160810.pdf. Published July 2016. Accessed June 5, 2019.
    104.
    Palazuelos  D, Ellis  K, Im  DD,  et al.  5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting.  Glob Health Action. 2013;6(1):19658. doi:10.3402/gha.v6i0.19658PubMedGoogle ScholarCrossref
    105.
    Mounier-Jack  S, Griffiths  UK, Closser  S, Burchett  H, Marchal  B.  Measuring the health systems impact of disease control programmes: a critical reflection on the WHO building blocks framework.  BMC Public Health. 2014;14(1):278. doi:10.1186/1471-2458-14-278PubMedGoogle ScholarCrossref
    106.
    Huff-Rousselle  M.  Reflections on the frameworks we use to capture complex and dynamic health sector issues.  Int J Health Plann Manage. 2013;28(1):95-101. doi:10.1002/hpm.2161PubMedGoogle ScholarCrossref
    107.
    Sheikh  K, Gilson  L, Agyepong  IA, Hanson  K, Ssengooba  F, Bennett  S.  Building the field of health policy and systems research: framing the questions.  PLoS Med. 2011;8(8):e1001073. doi:10.1371/journal.pmed.1001073PubMedGoogle Scholar
    108.
    Frenk  J.  The global health system: strengthening national health systems as the next step for global progress.  PLoS Med. 2010;7(1):e1000089. doi:10.1371/journal.pmed.1000089PubMedGoogle Scholar
    109.
    Manzi  A, Kirk  C, Hirschhorn  LR. MESH-QI implementation guide: mentorship and enhanced supervision for healthcare and quality improvement. https://www.pih.org/sites/default/files/2017-12/MESH%20QI%20Final%20web%2012.2017.pdf. Published 2017. Accessed October 29, 2019.
    110.
    Anatole  M, Magge  H, Redditt  V,  et al Nurse mentorship to improve the quality of health care delivery in rural Rwanda.  Nurs Outlook. 2013;61(3):137-144. doi:10.1016/j.outlook.2012.10.003PubMedGoogle ScholarCrossref
    111.
    Joshi  R, Chow  CK, Raju  PK,  et al The Rural Andhra Pradesh Cardiovascular Prevention Study (RAPCAPS): a cluster randomized trial.  J Am Coll Cardiol. 2012;59(13):1188-1196. doi:10.1010/j.jacc.2011.10.901PubMedGoogle ScholarCrossref
    112.
    Adeyemo  A, Tayo  BO, Luke  A, Ogedegbe  O, Durazo-Arvizu  R, Cooper  RS.  The Nigerian antihypertensive adherence trial: a community-based randomized trial.  J Hypertens. 2013;31(1):201-207. doi:10.1097/HJH.0b013e32835b0842PubMedGoogle ScholarCrossref
    113.
    Johnson  D, Saavedra  P, Sun  E,  et al.  Community health workers and Medicaid managed care in New Mexico.  J Community Health. 2012;37(3):563-571. doi:10.1007/s10900-011-9484-1PubMedGoogle ScholarCrossref
    114.
    Beckham  S, Kaahaaina  D, Voloch  KA, Washburn  A.  A community-based asthma management program: effects on resource utilization and quality of life.  Hawaii Med J. 2004;63(4):121-126.PubMedGoogle Scholar
    115.
    Cooper  RA.  Unraveling the physician supply dilemma.  JAMA. 2013;310(18):1931-1932. doi:10.1001/jama.2013.282170PubMedGoogle ScholarCrossref
    116.
    Victor  RG, Lynch  K, Li  N,  et al.  A cluster-randomized trial of blood-pressure reduction in black barbershops.  N Engl J Med. 2018;378(14):1291-1301. doi:10.1056/NEJMoa1717250PubMedGoogle ScholarCrossref
    117.
    Schoenthaler  AM, Lancaster  KJ, Chaplin  W, Butler  M, Forsyth  J, Ogedegbe  G.  Cluster Randomized Clinical Trial of FAITH (Faith-Based Approaches in the Treatment of Hypertension) in Blacks.  Circ Cardiovasc Qual Outcomes. 2018;11(10):e004691. doi:10.1161/CIRCOUTCOMES.118.004691PubMedGoogle Scholar
    118.
    Arnhold Institute for Global Health. Task force on global advantage. http://icahn.mssm.edu/research/arnhold/research-development/task-force-global-advantage. Accessed December 28, 2018.
    119.
    WeCare Indiana. Improving maternal and infant health to reduce infant mortality. https://www.regenstrief.org/projects/wecare-indiana/. Accessed December 28, 2018.
    ×