Table 2.

Summary of key findings and recommendations on CHW services for disadvantaged groups

Group	Key findings on CHW services	Strategies for improving reach and impact
Rural & remote place of residence	• CHW programmes may help to attenuate urban-rural differences in healthcare access, but there are often differences in access to CHW services within rural areas due to large catchment areas (with those living closer to CHWs/health posts advantaged) • CHW services may be less accessible to migrant, mobile, and homeless populations • CHW referrals, education and promotion may reduce, but not fully overcome place-based differences in utilisation of professional facility-based services (especially MNCH services)* • Weaknesses in the wider health system exacerbate place-based differences and may undermine trust in CHWs charged with promoting health services	• Hire CHWs who live in rural and remote communities to serve these communities • CHW catchment areas should be manageable in size and account for local transportation infrastructure and difficulty of terrain • Where access to health facilities is very limited, consider expanding CHWs’ remit (e.g. to include more direct/curative service provision)+ • Provide torch light, radio, medical kits (containing essential medicines and equipment), mobile phones, and/or mobile phone credit to CHWs • Establish linkages with free or low-cost (emergency) transportation services+ • Provide bicycles or motorcycles to CHWs • Hire male CHWs in addition to female CHWs in settings where women’s mobility is restricted • Deploy ‘mobile’ CHWs in addition to community-based CHWs to reach nomadic and homeless populations • Strengthen transfer-of-care processes to facilitate continuous care when people move or migrate • Provide financial incentives or transport stipends for clients referred to health facilities+
Poor/low-SES	• CHWs services are generally equitable with respect to SES, with a number of studies reporting greater coverage and utilisation of CHW programmes by the poor • Low-SES clients experienced more barriers to taking up CHW referrals and health advice • There is some evidence that CHW programmes reduce differences in health across socioeconomic groups, but most studies showed that significant differences persist (especially for MNCH outcomes)*	• Provide CHW and other health services at low or no cost+ • Provide free or subsidized transportation to health facilities and home-based care where possible • Establish linkages with free or low-cost transportation services+ • Provide financial incentives for CHWs to identify and serve the pooresta • Incorporate food parcels and social welfare grants within CHW services • Empower CHWs to provide ‘fee-free referral vouchers’ to low-SES clients in need of facility-based treatment • Establish CHW triaging system to flag poor, high-risk patients to facility-based professionals for immediate attention (preventing need for costly overnight stay and repeat visits)
Women & girls	• Quantitative data suggest that CHW programmes provide comparable coverage and have similar effects on health outcomes in males and females • Qualitative data revealed that many women still lack agency to make their own decisions about when and how to engage with CHW and other health services (especially for sexual and reproductive health needs)	• Provide home-based care/home visits where possible (countering women’s restricted mobility) • Use mHealth to facilitate confidential consultations for women • Embed family planning services within general medical outreach camps • Hire male CHWs to engage with men and act as ‘ambassadors’ on women’s health rights and needs • Strategic distribution of tasks between male and female CHWs • In some cases, deploy CHWs in mixed-gendered pairs for home visits
Illiterate/ less educated	• CHW services are generally equitable with respect to less educated groups in terms of coverage, utilisation, and acceptability • There was some evidence of better MNCH outcomes when women or their husbands were more educated*	• Use illustrated (rather than text-based) informational materials • Use other non-textual locally appropriate channels for behaviour change communication (e.g. radio, mobile video drama)+ • Arrange for CHWs to accompany clients to health facilities
Marginalized caste, tribal, and ethnic groups	• CHW services were generally found to provide comparable coverage, acceptability, and utilisation for marginalized and non-marginalized groups • CHW may provide lower quality services to groups they see as ‘backward’, ‘traditional’, or adhering to cultural beliefs about illness • Marginalized caste, tribal, and ethnic groups may be less likely to take up CHW referrals and health advice	• Recruit CHWs from ethnic and linguistic minority groups • Show respect for cultural traditions in CHW service provision, e.g. by involving traditional healers in care • CHWs can accompany clients to health facilities to advocate on their behalf and prevent mistreatment
Low social capital	• There is some evidence that CHWs provide more services to those with greater social capital or whom are part of their own social networks • Those with low social capital may have reduced ability take up CHW referrals to health centres	• Arrange for CHWs to accompany clients to health facilities • CHW referral slips that facilitate access to facility-based services
Un- & informally employed	• CHWs appear to serve all occupational groups equally, although there was some evidence of lower trust and utilisation among farmers and the unemployed • In families that are highly dependent on low-wage labour or subsistence farming, the opportunity cost of attending health-related appointments may be a barrier to engagement	• Schedule CHW working hours to accommodate clients’ work commitments (e.g., evenings and weekends)
Religious minorities	• Findings were inconclusive, though there is some limited evidence of persistent poorer health outcomes for religious minorities (mainly Muslims living in Christian- or Hindu-majority countries)	• None reported
Disabilities	• Limited data available	• Provide home-based care/home visits to overcome travel-related barriers • Train CHWs on physical and mental disabilities

^*Supported by findings of meta-analysis

⁺ Common element of interventions with pro-equity outcomes in quantitative data set (see Table 3)

^aSome important limitations of this approach are discussed in Section “Socioeconomic status”