Table 5.
Characteristics of included studies
| Author | Type of evaluation | Setting | Type of lay provider | Type of service provided | Sample size | Findings |
|---|---|---|---|---|---|---|
| Abas et al. (2016) | Case study: acceptability and implementation | Zimbabwe | Lay health worker (LHW) | LHWs carry out structured psychosocial assessment and a screen test, following it up with advice, discharge, problem-solving therapy (PST), or referral. Where clients are suffering from socioeconomic problems, LHWs may refer to income-generating projects also taking place in collaboration with the Friendship project | Six staff interviews; six patient interviews; five focus groups with 8–12 per group | A collaborative care intervention, including screening, PST and referral for depression and other CMDs is positively received by patients (happier, valued, less stigmatized, less lonely), rewarding for female community LHWs to deliver, and can be sustained over time at low cost. Sharing similar socioeconomic backgrounds with their clients enabled LHWs in establishing more productive relationships with their clients and improved service delivery |
| Agyapong et al. (2015b) (I) | Perceptions survey tool and qualitative analysis | Ghana | Community mental health workers (CMHWs) (includes community psychiatric nurses, community mental health officers and clinical psychiatry officers) | Different cadres of CMHWs support mental health work and refer to psychiatrists where necessary. Community Mental Health Officers (CMHOs), the least specialized cadre, are meant to detect cases and not diagnose or treat; however, due to workforce shortage, they often do both | Eleven psychiatrists, 26 health policy directors, 164 CMHWs | CMHWs are not seen as undermining the role of psychiatrists and find it easy to refer major cases; however, due to the shortage of psychiatrists and the geographic barriers, referrals do not always take place, making it necessary to both better train CMHWs for role clarity, and to increase the numbers of psychiatrist available for supervision. Over the 7-year period studied, LHWs were making fewer referrals as they had gained more confidence in the scope of their practice. CMHWs believe that patients and other healthcare workers have concerns about the quality of care they provide |
| Agyapong et al. (2015a) (II) | Perceptions survey tool and qualitative analysis | Ghana | CMHWs include community psychiatric nurses, community mental health officers and clinical psychiatry officers | CMHWs address conditions such as schizophrenia, psychosis, epilepsy, dementia, and other common mental illness. In addition, they perform health education tasks; reproductive and child health services; link to psychiatric services and patient advocacy regarding social services | 164 CMHWs | CMHWs work beyond the scope of their practice and training, they provide financial assistance to patients, and sometimes fill in at regional hospitals for general medical consultations. Less than a quarter of CMHWs work closely with a psychiatrist. CMHWs do not increase nor undermine the work of psychiatrists. Community Mental Health Officers (CMHOs), meant to detect cases, are often treating and prescribing medicines, which is beyond the scope of their practice and should be addressed by either enhancing the scope of their training or ensuring availability of other cadres of health workers to cover tasks not meant to be covered by non-specialized health workers. CMHWs are integrated in Ghana's health system; however collaboration with traditional or religious healers is minimal, even though these stakeholders are important community sources of care seeking |
| Agyapong et al. (2016) | Perceptions survey tool and qualitative analysis | Ghana | CMHWs include community psychiatric nurses, community mental health officers and clinical psychiatry officers | CMHO training programmes introduced in 2010 to address the gap in mental health services. CMHOs have shorter training than other CMHWs and are not meant to diagnose, treat or prescribe medicines, but do so regularly due to shortages | Eleven psychiatrists, 29 heath policy directors, 164 CMHWs | There is a gap in training and supervision and a disconnect between what psychiatrists and health policy directors perceive to be available to CMHWs and what is available to them in reality. Many CHMWs are working beyond the scope of their practice with inadequate training and supervision afforded to them. Further investment in supervision and training is necessary |
| Ali et al. (2003) | Randomized controlled trial | Pakistan | Women briefly trained from the same community | Supportive, problem-solving counselling was provided to women with depression in their homes for eight sessions | 124 depressed women | Based on AKUADS (Aga Khan University Anxiety and Depression Scale) score, there was a net reduction in anxiety and depression of 21% in the intervention arm |
| Ali et al. (2010) | Quasi-experimental action research | Pakistan | Women community health workers (CHWs) | CHWs would visit the home of new mothers to offer basic cognitive behavioural therapy, and provide supportive and problem-solving counselling. CHWs later discussed these with a clinical psychologist on a weekly basis. Those with more serious cases were referred for treatment. Instruction on healthy child-rearing practices was also provided | 102 postpartum women with depression | AKUADS (Aga Khan University Anxiety and Depression Scale) scores dropped more for counselled v. not counselled group; however, both groups experienced declines in depression possibly due to general support provided in parenting and child-rearing practices |
| Baker-Henningham et al. (2005) | Randomized controlled trial | Jamaica | Community health aides | Community health aides visited mothers’ homes weekly for a half-hour, demonstrating activities that engaged both parent and child and supporting parenting competence; in addition, they provided counselling and problem solving even though these were not explicitly included in the intervention | 139 mothers with undernourished children | Significant decline in depressive symptoms was reported in mothers receiving home visit with those receiving 40–50 visits benefitting the most (compared with fewer visits) |
| Bolton et al. (2014) | Randomized controlled trial | Thailand | Lay counsellors | Lay counsellors provided a Common Elements Treatment Approach (CETA) to Burmese survivors of imprisonment, torture and related trauma. Transdiagnostic interventions capitalize on commonalities across evidence-based treatments instead of having one particular focus, making them more response to cross cutting needs using decision rules and guidelines, with flexibility for contextual differences | 247 participants (intervention n = 182; wait list controlled n = 165) | CETA participants experienced improvements in all outcomes, including depression, post-traumatic stress, functional impairment, anxiety, and aggression |
| Buttorff et al. (2012) | Economic evaluation | India | Lay health worker | Collaborative stepped care for CMDs using: (1) lay health workers in primary care settings trained to provide psychosocial services, (2) physicians already in the clinic, and (3) mental health specialists making monthly visits. Intensity of care provided was matched with severity of disorder to optimize human resource allocation. Subjects were taught stress reducing strategies and provided with tailored information and access to relevant networks and support organizations. Case management and proactive monitoring formed the basis of the intervention | 1648 people with anxiety/depression | In public facilities, patient in the intervention arm showed improved health outcomes and lower time costs; health system costs were similar across intervention and control groups. |
| Chatterjee et al. (2014) | Randomized controlled trial & economic evaluation | India | CHWs | Collaborative community-based care: treatment plans, psychoeducational material to patients, adherence management, peer support, rehabilitation, health promotion for physical ailments, and network links to community agencies to address social, legal, and economic challenges. This package of services was delivered by CHWs in three phases: (1) the intensive engagement phase (0–3 months), including six to eight home visits made by CHWs; (2) the stabilization phase (4–7 months), with sessions delivered once every 15 days; and (3) the maintenance phase (8–12 months), with sessions delivered once a month | 282 schizophrenic patients | Collaborative community-based care including supervised CHWs was more effective than facility based services for people with moderate to severe schizophrenia, especially for overall disability. No effect was observed for stigma. Costs were greater in intervention with a third attributed to supervision costs |
| Hung et al. (2014) | Prospective cohort study | South Africa | CHWs | Task shifting for screening of depression among pregnant women | 361 postpartum women | The study demonstrated the feasibility of incorporating depression screening into CHWs’ routine workflow |
| Kumakech et al. (2009) | Cluster randomized controlled trial | Uganda | Peer group support with teachers as facilitators | AIDS counselling with two peer group sessions per week: share fears, worries and concerns, problem identification and problem solving | 326 children aged 10–15 years (intervention group n = 159 orphans, control n = 167 orphans) | After adjusting for baseline scores, follow-up scores for the intervention group in comparison with controls showed significant improvement in depression, anger, and anxiety, but not for self-concept. This study demonstrated that peer-group support intervention decreased psychological distress, particularly symptoms of depression, anxiety and anger |
| Larson-Stoa et al. (2015) | Programme evaluation study through routine data collection | Indonesia | Paraprofessionals | Psychosocial group and individual counselling programme lasting 3 months with follow-up for victims of torture | 178 participants | The results indicated the participants’ anxiety symptoms, depressive symptoms, somatic symptoms, and functioning improved from the intake to the follow-up. The programme appeared to have been effective in reducing participants’ symptoms and impairment in functioning |
| Lorenzo et al. (2015) | Qualitative (In-depth interviews, with an inductive and interpretative phenomenological approach used to analyse data) | South Africa, Botswana, and Malawi | Community disability worker (CDW) | Community-based rehabilitation involving: (1) integrated management of health conditions and impairments with a strong family focus, (2) negotiating disability-inclusive community development, and (3) coordinated and efficient intersectoral management systems for disability inclusion | Sixteen CDWs who had at least 5 years’ experience of disability-related work in a rural area | Three main themes with sub-categories emerged demonstrating the competencies of CDWs. First, integrated management of health conditions and impairments within a family focus comprised ‘focus on the functional abilities’ and ‘communication, information gathering and sharing’. Second, negotiating for disability-inclusive community development included four sub-categories, namely ‘mobilizing families and community leaders’, ‘finding local solutions with local resources’, ‘negotiating retention and transitions through the education system’ and ‘promoting participation in economic activities’. Third, coordinated and efficient intersectoral management systems involved ‘gaining community and professional recognition’ and the ability to coordinate efforts (‘it's not a one-man show’). The CDWs spoke of their commitment to fighting the inequities and social injustices that persons with disabilities experienced. They facilitate change and manage the multiple transitions experienced by the families at different stages of the disabled person's development |
| Magidson et al. (2015) | Implementation research / case study | Iraq | CHWs | Brief behavioural activation treatment for depression (BATD) was adapted with cultural modifications for low-literacy patient population and tailored training for non-specialist CHWs with little to no experience in behavioural therapies | Thirteen (11 CHWs, one study psychiatrist and one clinical supervisor). 107 patients received the intervention | Of the 107 patients that received the intervention, there was 72% retention, and they completed all of the nine sessions. Case 1: despite challenges the client responded well to BATD. Client noted positive changes in her personal life. Case 2: client noted positive changes in her personal life and this was noted by her family members. Intervention was found to be acceptable and effective at reducing depressive symptoms and improving functioning |
| Mendenhall et al. (2014) | Implementation research (focus group discussions, in-depth interviews) | Ethiopia, India, Nepal, South Africa, and Uganda | CHWs | Packages of care at the community level focused on early identification, awareness raising, stigma reduction, increasing demand for appropriate mental health care, and addressing continuing care and social and economic needs of people with priority mental disorders | Seventy-seven CHWs, 110 community members, 80 service users and caregivers, 113 primary health care workers, 39 specialists and policy makers (36 focus groups, 164 in-depth interviews) | Task sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: (1) increased numbers of human resources and better access to medications, (2) ongoing structured supportive supervision at the community and primary care levels, and (3) adequate training and compensation for health workers involved in task sharing |
| Murray et al. (2015b) | Randomized controlled trial | Zambia | Lay counsellors | Lay counsellor-provided trauma-focused cognitive behavioural therapy (TF-CBT) to address trauma and stress-related symptoms among orphans and vulnerable children | 257 children (intervention group n = 131, control n = 126) | TF-CBT provided by lay counsellors decreased trauma and stress-related symptoms as measured by the UCLA Posttraumatic Stress Disorder Reaction Index and improved functional impairment for high levels of trauma |
| Murray et al. (2014) | Implementation / operations research | Iraq & Thai/Burma Border | Lay counsellors | The study explored the implementation of a CETA, a transdiagnostic intervention for adults with mood or anxiety problems developed specifically for use with lay counsellors as opposed to single focus on evidence based treatments for one treatment category. CETA is a new approach to training of lay counsellors using decision rules based on evidence to guide selection and sequencing of treatment elements, allowing for flexibility in individual symptom presentation | Thirty-four counsellors; five supervisors | Lay counsellors were able to adhere to fidelity of the intervention while also using qualitative research findings and feedback into implementation design to account for cultural and contextual differences. The CETA approach allows counsellors to treat and manage clients’ symptoms while handling comorbidities and providing decision tools to help determine selection, sequencing and dosing in culturally-sensitive ways. Support through an apprenticeship model (supervision) ensured fidelity |
| Neuner et al. (2008) | Randomized controlled trial | Uganda | Lay counsellors | Lay counsellors (trained refugees) carried out manualized narrative exposure therapy and flexible trauma counselling (two treatment arms compared with a no treatment group) in a refugee settlement in Uganda, trained in a 6-week course | 277 Rwandan and Somali refugees | Over 6–9 months, refugees in the treatment arms had improved clinical and statistical scores on the post-traumatic stress diagnostic scale, also demonstrating improvements in physical health |
| Nimgaonkar & Menon (2015) | Implementation research and impact evaluation through survey, focus group, and routine data collection | India | Village health workers and health animators | Programme integrated into pre-existing comprehensive medical programme to identify and manage psychiatric disorders rapidly, comprehensively and sustainably. Village health workers and health animators followed up on activities cataloguing patients’ compliance, functionality and treatment regimen | The eligible Adivasi population was 13 345 at the beginning and 14 816 at the end of the programme | It was possible to train staff at all levels as the first step of an effort to integrate mental health into a comprehensive medical care programme that had previously focused solely on treatable acute and chronic medical disorders. The success of the programme is partly attributable to the pre-existing network of medical healthcare workers who were attuned to local cultural beliefs, the decentralization of healthcare and the mental health educational programmes. Surveys conducted before and after programme initiation also suggested improved knowledge, attitudes and acceptance of mental illness by the community. The annual per capita cost of the programme was 122.53 Indian Rupees per person per annum (USD 1.61) |
| Padilla et al. (2015) | Pre-/post-assessment | Argentina | Health agents | Annual training of health agents was instituted to better detect signs of mental illness and offer earlier treatment to reduce duration of untreated psychosis (DUP) | 672 260 population of province studied over 7 years for DUP | Consecutive years of training of health agents to improve screening and detection of mental illness, when coupled with an effective system to refer cases to specialty care, correlates with reductions in DUP in new cases detected in a rural environment |
| Patel et al. (2010b) | Randomized controlled trial | India | Lay health counsellor | Collaborative stepped care intervention with lay health counsellor | 2796 participants | Patients with ICD-10 CMDs were more likely to have recovered at 6 months of collaborative stepped care than the control. There was strong evidence of effect in public facility attenders and no evidence of effect in private facility attenders |
| Patel et al. (2011) | Randomized controlled trial | India | Lay health counsellor | Collaborative stepped care intervention with lay health counsellor | 2796 participants | Prevalence of ICD-10 CMDs and the severity of symptoms of depression and anxiety in individuals attending public primary healthcare facilities with a CMD and in the subgroup of individuals with depression, over a 12-month period, was reduced using the MANAS collaborative stepped-care intervention led by lay health counsellors. Reduction in the risk of suicidal behaviours (plans or attempts) and disability days (days of no work or reduced work) and weaker effects on overall disability scores were also seen |
| Petersen et al. (2011) | Post-intervention process evaluation | South Africa, Uganda | CHWs | A common implementation framework using a multi-sectoral community collaborative, task-shifting and self-help approach was used across both countries as part of the Mental Health and Poverty Project (MHaPP): (i) reorientation of district management towards integrated primary mental healthcare; (ii) establishment of community collaborative multi-sectoral forums; (iii) task shifting, which entailed establishing an expert consultancy liaison mental health team and training of general PHC staff and CHWs or equivalents in identification, management and referral of mental disorders; and (iv) promotion of self-help groups at the community level | Qualitative process interviews with unspecified range of key stakeholders across both countries, focus group discussions, and use of meeting notes and observational data | Sensitization efforts were successful in allocating more resources to community mental health integration into primary care. Collaborative multi-sectoral forum was successful in mobilizing some extra resources to support mental health. Mental health training provided to CHWs strengthened their capacity to respond to psychosocial problems and related CMDs they encountered in their regular home visits. Further, referral pathways were strengthened in this programme. The common implementation framework supported both countries in successfully integrating mental health services into primary care even with different foci and resource availability across countries. However, task shifting was more successful in South Africa than in Uganda where resource limitations and inadequate mental health specialization from CHWs created bottle necks in service delivery and demoralized CHWs. It is therefore important to ensure that the system has safeguards in place to support task shifting |
| Pradeep et al. (2014) | Randomized controlled trial | India | CHWs | Enhanced care by CHWs was provided to patients. CHWs visited patients immediately following the first medical consultation, educated the patient and her family members about depression and its treatment. This was followed by emphasis on adhering to treatment and medication regimen and at least four CHW visits as well as monthly physician consultation | 260 adults with depression | Seeking and adhering to treatment was higher in the intervention group; however, there was no significant difference in severity of depression or quality of life between groups or between completers and dropouts at six months. |
| Rahman et al. (2008) | Cluster randomized controlled trial | Pakistan | Lady Health Workers | Trained lady health workers held a weekly session that included cognitive behavioural therapy for 4 weeks in the last month of pregnancy, three sessions in the first postnatal month, and nine 1-monthly sessions thereafter | 1054 pregnant women | Integration of a cognitive behaviour therapy-based intervention into the routine work of CHWs more than halved the rate of depression in prenatally depressed women compared with those receiving enhanced routine care. In addition to symptomatic relief, the women receiving the intervention had less disability and better overall and social functioning, and these effects were sustained after 1 year |
| Rotheram-Borus et al. (2015) | Cluster randomized controlled trial | South Africa | Mentor Mothers (CHWs) | Building on its existing home-visiting programme: CHWs were trained for 1 month in cognitive behavioural change strategies and role-playing. They were trained to provide and apply health information about general maternal and child health, HIV/TB, alcohol use, and nutrition to low-income, urban women's lives | 1238 mothers | Despite not originally targeting reductions in maternal depression or improved maternal emotional health, the home-visiting intervention with urban South African mothers was associated with improved maternal emotional health 36 months after their children were born. CHWs encouraged and trained mothers to care for their infants, regardless of stress. Relative to standard care, intervention mothers were significantly less likely to report depressive symptoms and more positive quality of life at 36 months. Alcohol use was significantly related to use over time, but was also related to depression and HIV status at each assessment and associated with partner violence at 36 months. A more intensive and group-focused intervention is needed to address alcohol use |
| Thurman et al. (2014) | Longitudinal quasi-experimental design: pre/post-assessment | South Africa | Lay volunteers and trained paraprofessionals | Two models were tested: (1) home-visiting programmes that use a trained and compensated paraprofessional workforce and (2) programmes that rely on volunteers, who most often receive limited training and nominal incentives for their efforts. | 1487 children and 918 caregivers | No measurable reduction in psychological distress among children or caregivers served by paraprofessionals compared to volunteers was observed. Child behavioural problems, depression among boys, and family functioning were worse by follow-up, regardless of programme model |
| Tomlinson et al. (2011) | Cluster randomized controlled trial | South Africa | Local women trained as CHWs | Local women with good social skills (and mothers themselves) carried out the Philani intervention Programme, which consists of home visits with pregnant women and interventions to reduce alcohol misuse, increase adherence to perinatal HIV regimens, and boost child nutrition. CHWs were trained in: (1) cognitive-behavioural approaches to establishing healthy routines and to problem-solving around goal setting, choices, triggers, and shaping of desirable behaviours; (2) key information about general maternal and child health, techniques for framing each health issue that is a risk (nutrition, alcohol, and HIV), and strategies for applying the health information in families’ daily lives; and (3) coping with their own life challenges | 1238 pregnant women | Training CHWs as generalists appears to benefit child growth by preparing them to address the highest priority health issues, to address general maternal and child health, and to practice effective caretaking and problem solving. |
| Wright & Chiwandira (2016) | Impact evaluation of scale-up and integration | Malawi | Health surveillance assistants (HSAs) | The intervention involved four elements: (1) reducing clients’ risk of harm to self or others, (2) providing client-focused psychoeducation, (3) providing clients with psychological and emotional support, and (4) promoting psychosocial support through families and the wider community | 224 people in distress | HSAs’ approach to mental health care delivery was found to be both credible and practical in meeting the needs of the population. Sustained scale-up and integration of the delivery model was observed. Increased case detection was seen by HSAs. No changes were observed in visits to psychiatric hospitals |