Lay Health Worker Self-Management Interventions: A Systematic Review

The primary aim of this systematic review was to comprehensively examine lay health worker (LHW)-led self-management interventions for adults managing long-term conditions (LTCs). The researchers sought to understand how these interventions were implemented and synthesize findings, focusing on the intervention components used. To achieve this, they conducted a thorough search across five databases: Cochrane, MEDLINE, CINAHL, PsycINFO, and Web of Science, focusing on articles published between January 2010 and December 2015. The inclusion criteria were stringent, limiting the analysis to studies involving adult participants with non-communicable or somatic diseases (or their prevention), utilizing LHW-led self-management interventions organized through primary health care or similar settings, and employing RCTs or quantitative trials. Importantly, studies focusing on LHWs' self-management, interventions led by untrained peer supporters, family interventions, or those targeting specific conditions like cancer, HIV, asthma, or mental health were excluded. This rigorous approach ensured a focused analysis on the core research question.

A systematic search was undertaken across the five databases mentioned above between December 2015 and January 2016. The search strategy was designed to identify relevant articles reported in English only, due to limitations in translation resources. The keywords employed combined broad terms encompassing various roles of LHWs (e.g., Community Health Worker, Lay health worker, Lay supporter, Peer counselor, Peer educator, Health trainer) with terms related to self-management and self-care. This approach incorporated both MeSH terms and free-text keywords to maximize the retrieval of relevant studies. The researchers utilized a comprehensive approach, combining various synonyms and related terms to ensure that studies utilizing different terminology for LHWs and self-management interventions were still included within the search results. The complete search strategy was made available upon request, allowing for full transparency and reproducibility of the methodology.

The search yielded 40 original studies that fulfilled the pre-defined inclusion criteria. These studies encompassed self-management interventions for diabetes (n=29), cardiovascular diseases (n=8), and individuals at risk of cardiovascular diseases (n=3). The selected studies comprised 22 randomized controlled trials (RCTs) and 18 other trials, with intervention durations ranging from a single day to 24 months. Data extraction was performed independently by one author and subsequently discussed with other researchers involved in study selection. Any disagreements among reviewers were resolved through consensus, guaranteeing the reliability of the data selection process. This ensured consistency in the interpretation and application of the inclusion and exclusion criteria, minimizing bias and maximizing the validity of the subsequent analysis. The study's extensive range of intervention durations and the significant number of participants provided a robust dataset for analysis.

The 40 included studies originated from seven countries, with the majority (n=31) from the United States. The study population comprised 10,065 participants at baseline (55% female), with 7,970 participants completing follow-up assessments. A total attrition rate of 21% was observed. Methodological quality of the studies varied, ranging from 9 to 25 points (out of a possible 28 points) on the MQSQ scale. Differences in the methodological quality were mainly due to variations in the application of randomization and blinding methods. The variation in methodological quality among the included studies underscores the heterogeneity of research methodologies employed in the field of LHW-led self-management interventions. This variability needed to be considered during the synthesis of findings. The duration of self-management interventions in the selected studies varied considerably, ranging from one day to 24 months, demonstrating diversity in intervention approaches.

The review identified diverse roles for Lay Health Workers (LHWs) within self-management interventions. LHWs acted as peer supporters, educators, role models, and community capacity builders, bridging the gap between communities, healthcare professionals, and clients. Their ability to share values, socioeconomic backgrounds, and sometimes even lived experiences of long-term conditions (LTCs) with participants was highlighted as a significant advantage. This shared understanding fostered trust and improved rapport, contributing to the overall effectiveness of the intervention. Studies showed that LHWs had varied levels of training, with durations and methods differing significantly across the reviewed studies. The effectiveness of LHWs depended on their ability to build rapport with clients, understand their unique needs, and provide appropriate support. The flexible and adaptable nature of LHWs and their understanding of clients' contexts allow for tailored intervention that might be difficult for other health care providers to implement. The analysis also explored the support structures available to LHWs, including supervision from program coordinators, nurse care managers, and university professionals, which helped to ensure consistency and quality of intervention delivery.

The implementation of LHW-led self-management interventions showed considerable variation across the studies. Intervention formats included group sessions, individual appointments, telephone consultations, and home visits. Elements such as lectures and physical activity (PA) classes were frequently incorporated. Behavior change techniques (BCTs) employed included self-monitoring, goal setting, information providing, action planning, and social support. The duration and frequency of interventions also varied widely, ranging from one day to 24 months. Despite this heterogeneity, many interventions shared similar formats and BCTs, regardless of their ultimate effectiveness. The use of different methods of intervention shows the adaptability and flexibility of LHWs. The variety of intervention methods also underscores the diverse approaches used in addressing self-management needs across different long-term conditions and patient populations.

The review systematically classified intervention components based on their formats (group, individual, etc.), elements (lectures, PA classes), and the specific behavior change techniques (BCTs) employed. A total of thirty-five distinct BCTs were identified across the studies. Common BCTs included self-monitoring, goal setting, and social support, which are well-established behavior change strategies. Interventions often incorporated empowerment, social support, and tailoring-oriented principles, reflecting a person-centered approach to self-management. Recruitment strategies for intervention participants were also diverse, ranging from approaches at hospitals and community centers to the use of media and online resources. The use of multiple BCTs within some interventions was noted, however the results did not establish a consistent relationship between the number of BCTs and the effectiveness of the intervention. The diversity of methods employed in recruiting participants indicates that successful interventions can employ multiple approaches to meet the needs of the patient population.

The analysis of intervention effectiveness focused on changes in physical activity (PA) and nutrition behavior (NB). Eight interventions demonstrated a positive impact on PA, and another eight showed improvements in NB. Interestingly, similar intervention components and behavior change techniques (BCTs) were applied in both effective and ineffective interventions, highlighting the complexity of predicting outcomes based solely on intervention components. Group meetings were identified as a potentially effective format, particularly for enhancing PA. This suggests that social interaction and support may play a crucial role in behavior change, but further research is needed to confirm this finding. Self-monitoring emerged as a promising behavior change technique, possibly contributing to improvements in both PA and NB. However, the study cautions against drawing definitive conclusions due to the high variability in intervention components and outcomes across the reviewed studies. Further investigation is required to establish stronger causal links between specific intervention components and behavioral outcomes.

The review categorized intervention components based on format (e.g., group, individual), elements (lectures, PA classes), and BCTs, using established taxonomies. Content analysis was used to identify patterns. While some BCTs, such as self-monitoring, hands-on activities, and social support, consistently showed associations with improved PA and NB, others, such as goal setting, were linked to both successful and unsuccessful interventions. The number of BCTs used varied considerably (from 3 to 15 in PA interventions, and from 3 to 9 in NB interventions) and did not definitively correlate with outcome success. This suggests that the mere application of multiple BCTs does not guarantee intervention effectiveness. Effective interventions often involved a combination of group and individual components. The lack of consistent relationships between specific BCTs and outcomes highlights the nuanced nature of behavior change and the need for more research to understand the interplay of factors influencing intervention success. This suggests that additional components, such as the intensity and duration of the intervention, may play a significant role in determining effectiveness.

The study acknowledges limitations in establishing firm connections between specific intervention components and outcomes due to the substantial heterogeneity across studies. This included variations in study protocols, populations, behavior change techniques, and outcome measures. The high variability of BCTs and self-management outcomes made it difficult to draw robust conclusions about the effectiveness of individual techniques or intervention elements. The review prioritized a qualitative description of LHW characteristics and interventions, therefore not all studies included provided detailed information for rigorous quantitative analysis of BCT effectiveness. In particular, only a third of the studies reported on PA and/or NB outcomes. Despite these limitations, the review identified some promising trends and highlighted the need for more rigorous, standardized approaches to measuring and reporting intervention components and outcomes. This information would be beneficial to both future research and clinical practice. The study emphasized the need for future research to better identify the interaction of several factors related to the success or failure of interventions.

The review highlights the substantial potential of lay health worker (LHW) interventions to improve self-management for individuals with diabetes, cardiovascular diseases, and other chronic conditions. LHW-led programs offer a promising avenue for disease prevention and improved health outcomes. A key strength of LHW interventions is their capacity to reach vulnerable and underserved populations who may face barriers accessing traditional healthcare services. This suggests that LHW interventions are not only effective at improving health outcomes but are also effective at increasing access to health services for vulnerable populations. The study's findings underscore the importance of LHWs in promoting health equity and addressing health disparities. The integration of LHWs into healthcare systems could significantly enhance access to care and improve self-management support for a broader range of individuals. However, the success of these interventions critically depends on the quality of LHW training and the standardization of intervention approaches.

To maximize the effectiveness of LHW-led self-management interventions, the review strongly advocates for systematic training programs that equip LHW candidates with the necessary skills and knowledge. This includes comprehensive training in adopting and applying various intervention formats and behavior change techniques (BCTs). The effectiveness of these interventions is directly correlated to the quality of training received by the LHWs. The inconsistent training programs found within the study illustrate the need for standardization. A lack of consistent training could compromise the effectiveness of the interventions. The development of an evidence-based standard for LHW training and interventions is crucial for ensuring quality, consistency, and effectiveness across different contexts and settings. This would involve not only a formal curriculum but ongoing support and supervision for LHWs. The establishment of these standards requires further research to identify the optimal training models and intervention strategies.

The review emphasizes the need for continued research to refine and optimize LHW training and interventions. This includes investigating the impact of factors like intervention intensity, duration, and the quality of the LHW-participant relationship. Additional research is also needed to better define the ideal length and format of interventions, and to further explore the effectiveness of different BCTs. The current study, while valuable, could benefit from further analysis on the specific interactions among intervention elements and the variability observed among studies. Research that explicitly examines the interaction between LHW training and intervention effectiveness could further refine best practices for intervention design. It is important that future research on this topic utilizes standardized training methodologies and measures in order to fully explore the potential of LHW interventions.