Ayele 1993.

Methods	Study design: Cluster RCT Duration of study: June to December 1990 Unit of allocation: District (1 intervention, 1 control) Method of allocation: Random Unit of analysis: Community health agents (52 intervention, 52 control) Sampling: All community health agents performing at least one duty
Participants	Country: Ethiopia Income classification: Low‐income Geographical scope: Two districts in south‐western Ethiopia Rural/urban: Rural Setting: Community Supervisees: CHAs (all male farmers, 98% married) Supervisors: Health station supervisors Patients/clients: General population
Interventions	Stated purpose: Examine the effect of refresher training and monthly supervision on functional status of CHAs. Description intervention: 5‐day refresher training for CHAs and monthly supervision. Supervision was "supportive" and matched the contents of the refresher training (ascertained from personal communication with author, Charles Larson). Control: Routine supervision and no refresher training for CHAs. Supervision was more one‐sided, the supervisor's primary aim was to review clinic records and collect statistics (ascertained from personal communication with author, Charles Larson). Training: As described above Frequency of supervisory visits: Monthly supervision for intervention group. Non‐systematic and irregular supervision for control group, which on average occurred every two months (ascertained from personal communication with author, Charles Larson). Co‐interventions: All CHAs (intervention and control) provided with registration books, monthly reporting forms and stationary. Meeting held with community and community leaders to improve support of CHAs.
Outcomes	Primary outcomes: Functional status score summarising 13 criteria Secondary outcomes: Individual functional status scores including outreach, health education, environmental health, Maternal and Child Health, Expanede Programme of Immunisation, school health, registering births and deaths, home visits, referrals and epidemic control Time points when outcomes measured: 3 months and 6 months from implementation
Notes	Funding: Not stated
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"....the two districts were randomly assigned as intervention or control districts based upon a coin flip."
Allocation concealment (selection bias)	Low risk	Allocation performed at start of study
Blinding (performance bias and detection bias) All outcomes	High risk	"CHA activities were assessed monthly using a checklist completed by the CHA and his health station supervisor. These supervisors were aware of the study but not the district comparison or the study hypothesis"
Incomplete outcome data (attrition bias) All outcomes	Low risk	Number of CHAs: Baseline (102), 3 months (102), 6 months (102)
Selective reporting (reporting bias)	Low risk	All outcome variables reported
Other bias	High risk	Does not meet EPOC inclusion criteria of minimum of 2 intervention and 2 control sites Funding source not stated “The health sector support may have enhanced CHA activity for a number of reasons. One is that the community was motivated to support the CHA when they perceived support from the health sector, and this in turn enhanced community utilization of the CHA’s services. This explanation is consistent with the finding that the intervention group received more supervision from community leaders than did the control group. The peasant association executives were more involved in the administrative supervision of their respective CHAs during this follow‐up period”.
Baseline outcome measurements similar?	Low risk	"At the onset of the study there were no significant group differences in the composite or individual functional status scores."
Baseline characteristics similar?	High risk	"As can be seen from table 1, the two groups were similar with the exception of intervention CHAs being older and having served longer (P < 0.01)".
Protection against contamination?	Low risk	Control group unlikely to have received intervention