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Table 1 Description of Health Intervention Program Involving Community Health Workers (CHWs) in English literature (n = 43)

From: Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996–2016)

Author Year Location Names of CHWs Program Duration The Role of CHWs Types of Training Challenges (−) Facilitating factors (+)
Reproductive Health
Levi A, Factor D, and Deutsch K [41]. 2013
Yushu, Qinghai province
Community Health Workers (CHWs) 6 years Health education (women empowerment), basic maternal care, referral, conduct prenatal visits, identify danger signs, attend births and visit newborn Basic knowledge, referral, conduct prenatal visits, identify danger signs, attend births and visit newborn 1. Program sustainability;
2. Various quality of the CHWs training
1. Strategic planning;
2. Government support;
3. Clinic support
Jiang, et al. [77] 2016
Guangxi province
Traditional Birth Attendance (TBAs); Village Maternal Health Care Workers Not reported Mobilization of pregnant women for institutional delivery, assisting with home visit for basic care and escorting pregnant women to the hospital for childbirth. Different levels of training in Maternal Child Health hospitals: emphasized identifying high-risk pregnancies and assisting with referrals; for TBAs, focused on care during childbirth and referral skills; for trained birth attendance (TrBAs), additional midwifery training and were required to conduct at least 30 independent deliveries under the supervision of an obstetrician. 1. How to deal with TBAs;
2. Logistical challenge of institution-based delivery in remote areas.
1. Sufficient and comprehensive preparation within the health system, including training of health human resources, building infrastructure, improvement of service quality, and establishment of referral channels and quality referral centers.
2. Financial support from county hospitals or township health centers.
Dickerson, et al. [76] 2010
Outreach Provider (both local healthcare worker and laypersons) 20 months Maternal-newborn education including antepartum/postpartum care seeking and nutrition; birth planning and maternal newborn
danger sign recognition; skilled attendance at birth; clean delivery practices; prevention of postpartum hemorrhage (PPH), birth asphyxia, and neonatal hypothermia and hypoglycemia; proper care of the umbilical cord; and breast-feeding and postnatal care seeking.
Training contend focus on maternal-new born health education, hands-on skills, material resources distribution. Role-playing is the most common learning method. Not reported Not reported
Tu, et al. [25] 2004
Eight Chinese sites: Shanghai and Chongqing cities and Hebei, Henan, Jiangsu, Zhejiang, Fujian, and Sichuan province
Family-planning workers, including contraceptive providers and community-based distributors. Since 1970s. Contraceptive providers are in charge of providing contraceptives to the local family-planning service units at the primary community level and managing and supervising contraceptives. Community-based distributors are in charge of distributing contraceptives and providing general counselling for clients in their service areas. Not reported 1. Family-planning providers were ambivalent about the provision of sexual and reproductive health services to unmarried young people.
2. Continued adherence to traditional norms, ambiguities and limitations in the current policy.
3. The family planning workers’ recognition of the need to protect the sexual health of unmarried young people.
1. Family-planning workers are clearly concerned for the well-being of unmarried young people 2. They agreed with the establishment of programmes that improving unmarried young people’s knowledge of sexual and reproductive health.
3. They seemed willing to empower the government to establish educational and service delivery programmes for unmarried young people.
Tang, et al. [79] 2009
Yunnan province
Village Doctor (VD), family planning workers, women’s cadres, and teachers 28 months Reproductive health knowledge education that based on Internet: family planning and safe practice, maternal and child health RTI/STI/HIV prevention and control, adolescent sexual health, gender consciousness, development of women’s identity, health promotion and health education Computer skills training workshop 1. There was no recertification mechanism to motivate village doctors to upgrade their knowledge and skills and to improve practice. 1. Using the website as one of the main strategies to improve village doctors’ knowledge, attitudes, and practices and to close the distance between urban and rural areas.
Edwards & Roelofs [42] 2006
Yunnan province
Grassroots maternal and child health worker; VD; traditional village midwives 6 years: Not reported Holistic learning methodology (skills in communication and group dynamics, critical analysis, clinical skills, and personal growth); participatory training with methods centred on cycles of reflection-action-assessment; supportive working relationships fostered among different categories of health workers at village, township, county, and provincial levels. 1. Doubts from work unit leaders;
2. Various learning needs;
3. Different literacy levels;
4. Unequal clinical competencies
1. Strong, transparent partnerships (deep engagement with local partners);
2. Official support from government;
3. Maintaining a good fit between core project elements and the existing health system;
4. Creating supporting organizational structures;
5. Designing a transition plan at the start of the project
Zeng, et al. [80] 2008
Shaanxi province
VD 3.5 years Conduct mini-survey of all women of reproductive age at the beginning; Recruit participants; obtain informed consent; visit participants every two weeks to provide more supplements and to retrieve the used blister strips and record the number of remaining capsules. has training for VD, but did not mention the content of training Not reported Not reported
Ma, et al. [27] 2010
Shen County in the central China
Village nurse 2 months Recruitment and distribution of the supplements, home visit once a week, provide counselling about the possible side effects Not reported Not reported Not reported
Sun, et al. [80] 2010
Shen County in the central China
Village nurse 2 months Home visit once a week, replenish supplements and monitor compliance by counting and recording the number of supplements that were taken Not reported Not reported Not reported
Hemminki, et al. [23] 2013
Anhui province, Shanxi province, Chongqing city
VD and family planning worker 2 years Provide health education and encourage pregnant women to seek health care; inform township health centers of pregnancies in their villages; postnatal care through phone consultation or home visits. Health education communication skills was provided to both township midwives, village doctors and village family planning workers. Lectures covered maternal health care regulations and self-care during pregnancy and recognition of risk during pregnancy. Group discussions and role-plays. 1. In the training, teachers may not have known how the midwives worked or what situation and problem they faced in their work.
2. Modern teaching methods like small-group were not feasible because of too many trainees.
3. Some VD do not want to do health education due to lack of financial compensation.
Not reported
Tao, et al. [24] 2013
Qinghai province, Hebei provinc, Henan province, Jiangsu province
VD Not reported Directly observe every dosing of smearing positive TB patients during the whole treatment period either on facility-based or home-based. A family member can be accepted as DOT provider after training for those families living in extremely remote areas. No detail information about the training content. 1. DOT allowance did not reach to the doctors;
2. Lack of a performance-based incentive approach;
3. Inconvenient transportation system;
4. Shortage of hands, time conflict between DOT and routine jobs;
5. Insufficient capacity of village doctors on home-based DOT;
6. TB stigma;
7. Low effect of training programs
8. Lack of subsidies
1. Raising both monetary and non-monetary incentives of DOT rural health workers
Gai, et al. [82] 2008
Shandong province
VD Since 1990s Education program for patients and rural residents, including distribution of pamphlets, verbal announcements, village broadcasts, and bulletins. Case detection and supervised patients. Occupational training in TB control and treatment. 1. Village doctors are recognized their current knowledge was insufficient to meet the demands of their work.
2. Some practices of village doctors were inappropriate for patient referral
Not reported
Wei, et al. [82] 2008
Guangxi province and Shandong province
VDs; family member 1 year Diagnosis, prepare TB treatment, follow up, and determine treatment outcomes. Follow up: Select a family members as their treatment supporter and train them in this role (intervention group)/observe the patient taking drugs (control group) 1) Introduction of the desk guide and how to use a guideline in practice; 2) Strengthening communication between doctors and TB patients; 3) Educating patients and choosing a treatment supporter; 4) Educating the TB supporter; 5) Reviewing patients at the county TB dispensary. 1. Economic development and road accessibility 1. Giving local policy-makers and practitioners a lead while making changes in policy and practice.
2. Systematic approach to adaptation and scale-up.
3. The adapted guideline and other materials were replicable and sustainable for scale-up.
Sun, et al. [80] 2008
Shandong Province
VD Since 1990s Monitor the patients taking their medications at the right time at the right dose. Not reported Not reported Not reported
Xiong, et al. [83] 2007
Hubei province
VD 1 year evaluation Survey, trace and refer suspects (patients with TB symptoms) to county TB dispensaries or other designated sputum examination centres. 1. Technical training (the provincial workgroup drew up a strategic plan and trained TB staff from 30 county TB dispensaries.
2. A total of 35,000 desk calendars with information about TB and control policy were printed and delivered to village doctors, patients and village leaders.
1. Main reasons of the low follow-up rate were the shortages of funds and human resources.
2. A mobile population and inaccurate information were the main causes of the low follow-up success rate.
Not reported
China Tuberculosis Control Collaboration [21] 1996
VD Started at 1991 Observing every dose of the TB drug; follow up the patient who do not come for their treatment. Not reported Not reported 1. Top-down approach;
2. Supervision of staff was facilitated by system of record-keeping that is easily understand but difficult to falsify, including separate district registers, laboratory registers, and treatment cards.
Meng, et al. [79] 2004
Shandong province
VD Started at 1992 Observing every dose of the TB drug Not reported 1. VDs were not willing to provide this kind of services because of no financial incentives;
2. TB health experts thought that drug talking without supervision by the VDs was acceptable;
3. TB patients may find it inconvenient to go to a village clinic to take the drugs
Not reported
Tobacco Control
Abdullah, et al. [62] 2015
Shanghai city
CHWs 6 months Intervention including 6 individualized counseling sessions about children second-hand smoke exposure. Practicum training, including lectures, in-class discussion, case reviews, and role-plays 1. Maintain the communication between participants and CHWs 1. The satisfaction with CHWs
Child Health and Vaccination
Jin, Sun, Jiang and Shen [61] 2005
Hefei city, Anhui Province
VD Around 6 months Early childhood development consulting Training is based on the WHO’s teaching materials about the technique of early child healthcare, using reading, videotape presenting, and practice to improve the knowledge and ability of village doctors. 1. Village doctors were unwilling to conduct the consultation because there was no additional financial reward. 1. Mothers were eager to learn more about early childhood development and willing to practice and apply it.
Wang, et al. [71] 2007
Hunan province
Village-based Health Workers 1 year Administer using auto-disable syringe and administer vaccine storage for hepatitis B. Not reported Not reported Not reported
Chen, et al. [22] 2016
Xuanhua city, Sichuan province
VD Not reported Use the app to make appointment, record, and track children’s immunization status, to remind the caregiver about immunization The use of EPI app 1. Only include younger ones, older village doctors may be limited; migrant children;
2. Caregivers changed their cell phone numbers
1. mHealth technology is helpful.
NCD related - Diabetes and/or Hypertension
Feng et al. [43] 2013
Lu’An city, An’hui province
VD 6 years (every 12 months for plasma glucose and ever month for body weight and blood pressure) Conduct glucose screening; measuring body weight and blood pressure; provide counseling on glucose screening; promote screening participation (during each biannual follow up glucose screening); referral; provide behavior change counseling for pre-diabetics Web-based training and A comprehensive ‘occupational toolkit’ consists of a workbook, a manual and a set of cue-cards, providing knowledges on diabetes and working guidance to assist the VDs’ practice. E.g., Each cue-card enlists critical steps or elements for delivering a specific type of counseling; the manual is a reference book including elementary protocols (e.g., diabetes screening performance, dietary modification counseling, etc), common problems and solution tips, and fundamentals of diabetes prevention (e.g., basic knowledge for intervention execution) 1.Most village doctors are currently unaware of and certainly not practicing in diabetes prevention;
2. Heavy workload already;
3. The project heavily relies on electronic support, the actual practice may beyond the ability of VDs’ and elder villagers’ in rural area to use computerized systems
1. Trust from the patient and communities;
2. The service itself is not complex, capable for VDs (only 15 min);
3. Well-established guidelines and manuals;
4. Village clinics provide appropriate settings for diabetes measurement and counseling;
5. Electronic support and web-based training are cost-saving and time flexible; and it allows continuous expansion of trainees;
6. Performance-based incentives;
7. Local health authorities support on resources
Lin et al. [44] 2014
Xilingol county; Inner Mongolia
VD 4 years Case management and monitoring via Electronic Health Record; follow-up via regular visits, measure blood pressure and blood sugar levels; check medication compliance Not reported 1. Lack of policy support from the health system 1. Closely connect with higher levels of the healthcare system and benefit the rural area, if implemented in large-scale
Chen et al. [36] 2014
Lu An; Anhui province
VD 6 months
(1 month per session)
Identifying high-risk patients, and follow-up counseling on lifestyle modification, health education on diabetes risk, balanced diet, and physical activity Instructions on the application method of the program, with standardized “step-by-step” navigation for VDs to follow in practice 1. Lack of electricity security (facility) in remote settings;
2. Communication difficulties: sometimes unable to engage patients in completing every listed item in the instruction.
1. Innovative;
2. Easy to follow the navigation; Professional knowledge built in the program helps in the case identification and management;
3. High acceptance rate among diabetes patient.
Zhong et al. [56] 2015
Tonglin, Hefei province, Bangbu, Anhui province
Peer Leaders; Community Health Service Center (CHSC) Staff 6 months /session Biweekly educational meetings Co-led by peer leaders (PL) and staff of Community Health Service Centers (CHSCs). Topics: diet, physical activity, medications, foot care, stress management.
PL: outreach, promotion, emotional support meeting and non-professional activity (Tai Ji, morning exercise, etc.)
Not reported 1. Lack of staff resources in some sub-communities (organizational support from hospitals) 1. Close relationship with peer leaders;
2. Knowledge;
3. High patient engagement
Li et al. [102] 2015
3 provinces in China, specific location was not mentioned
VD (cross-sectional survey among VDs) Providing hypertension and/or diabetes case management; create citizen health record Routine training programs including content like health care policy, standards, basic public health services (BPHS) quality management, and the norms, standards and service delivery paths of BPHS. 1. Limited compensation, low financial incentive, uneven geographic coverage of the New Cooperative Medical Scheme insurance contract 1. More education, more training opportunities, receiving more public health care subsidy;
2. Integrated management and supervision;
3. Being a New Cooperative Medical Scheme insurance program-contracted provide
Browning et al. [54] 2016
Fengtai District, Beijing
Health coach (health workers from the local community health station (CHS)) 1 year Conduct bi-weekly/monthly telephone and face-to-face motivational interview (MI) health coaching as psychosocial supporting and lifestyle counseling approaches to improve the outcome of glycemic control and self-care of T2DM patients. Key concepts in patient-centred communications, health psychology, epidemiology of key targeted illnesses and conditions, the framework and rationale of MI, and the application of MI core skills across the behavior change process. Review workshop of these techniques will be arranged at 1 month after the project initiate, and every 3 months after that. 1. Long-term effectiveness needs to be assessed;
2. Not generalizable to rural settings with few human resource
1. Good learning and practice capacity;
2. Well-organized training process including review workshops;
3. Pilot study - quality control
Peiris et al. [55] 2016
Beijing; Hebei province
Lay Family Health Promoters (FHP); Healthcare staff 2 years Healthcare staffs: case monitoring, provide support to FHPs via communication tools built inside the SMARTDiabetes application; FHPs: report the progress and update EHR data on behalf of the patients (i.e. Their families who have diabetes) via the SMARTDiabetes application. Co-determine action plan with the support from healthcare staffs. Experience sharing with other FHPs in the community via App-based forum. Installation and the use of the technology and management of diabetes 1. Hard to generalize for other contexts without electronic health record infrastructure, and for the population with limited access to smartphone technology 1. Cost-saving;
2. Time-saving;
3. Strong motivation of FHPs to support families with diabetes;
4. Close communication between clinical healthcare staffs and FHPs
NCD related - Cancer
Belinson et al. [45] 2014
Henan Province
Community Leaders (CLs); promoters; local health worker 3 years Joint tasks for CLs and promoters: gather personal information; label the specimens and follow the procedures; advertisement and community notification about the screening program via video, posters, workshops.
CLs: instruct sample collection; Local health workers: consulting after results generated, refer positives to visit clinics for management.
Meaning of a positive test; Management options and techniques; via video and workshops Not reported 1. Good communication skills;
2. Enthusiasm for the community-based screening model;
3. Community, institutional and government support
Chai et al. [46] 2015
An’hui province
VD 5 years 1. Provide health counseling regarding: alerting risks and harms; setting objective behaviors; discussing efficacy and benefits; anticipating barriers and problems;
2. Risk assessment promotion;
3. Providing assistance and supports on healthy lifestyle; assist and support patients’ behavioral change (reviewing behavior changes, encouraging improvement, identify and select problems, and solve problems);
4. Manage, record and post typical cases bimonthly on a web forum and share experiences with other experts and VDs (prevention and management)
Web-based tutorial on implementing the project prevention in both video and textual formats; typical case studies as references for practice; video and pictorial materials about cancer and its prevention 1.The project heavily relies on electronic support, the actual practice may beyond the ability of VDs’ in remote rural area to use computerized systems 1. Performance-based incentive and awards; 2. Well-established web-based support and supervision system are technically helpful and time-saving for VDs to practice; 3. The user-friendly education and learning assistance; 4. Self-practice, encouragement, and problem inquiring and answering allow most village doctors became confident users of the electronic support system
NCD related - Mental Health
Prince et al. [60] 2007
urban and rural catchment, no specific location mentioned
CHWs 2 years Help the researchers to detect high-risk population, being the community key informants of the research team Not reported Not reported Not reported
Gong et al. [61] 2014
Liuyang city, Hunan province
VD 1 year 1. Develop and maintain case files for every schizophrenia patient.
2. Store and distribute antipsychotics to family members on a weekly basis, or directly observe drug-taking (DOT) at the village clinic on a daily basis.
3. Accompany patients and family members on bimonthly visits to psychiatrists for drug dispensation in order to participate in assessing patients’ mental status and explain treatment plans to patients and their families.
4. Record patients’ medication-taking behavior weekly.
5. Identify signs of relapse in order to provide prompt referral services.
Mental health knowledge, case-management skills, and directly observed therapy (DOT). 1. Overload already, no time for extra work;
2. Chinese healthcare system does not compensate VDs financially for extra effort in providing mental health services;
3. Inadequate engagement from patients and patient’s family
1. Under the national “686” mental health scheme - government support;
2. Consistent collaboration with local government;
3. Training protocol met with local VDs’ competence and expectations
Chen et al. [62] 2014
Xuhui and Hongkou Districts; Shanghai
CHWs 2 years Work with community psychiatrist and nurse as a team to conduct case management: 1. assess the health condition, recovery status, daily functioning, employment status, and social activities of participants; 2. assess patients’ needs to provide references for developing personalized rehabilitation plan; 3. develop personalized rehabilitation plan and assist the patient to cope with the plan: drug adherence training, daily skills training, family psychological intervention; 4. monthly individual follow-up to refine the intervention plan; 5. participate the already established training course Not reported Not reported Not reported
Zhou and Gu. [63] 2014
CHWs 2.5 years Assist chronic schizophrenia patients with self-management. After each patient received weekly self-management skill training, CHWs reviewed patients’ self-management checklist (record their daily adherence quality of sleep, occurrence of side effects, occurrence of residual symptoms and early signs of relapse, daily activities, and general mood) every month on a group meeting to supervise the adherence and collect records Not reported Not reported Not reported
Ma et al. [63] 2015
Guangxi province
Primary health care providers 2006-now Community education, medication distribution; observe compliance and life status; report side effects or any abnormality; referral and follow-up Training provided by the national ‘686 project’: mental health disease management, education and social treatment and prevention of mental illness 1. Lack of professional knowledge;
2. Fear of patients’ attack;
3. More extra work;
4. No management approach
5. Less subsidies
1. The capacity to use communication skills with patients and their family members, have proper attitude (without discrimination);
2. Understand the professional knowledge of mental health
3. More income/subsidy
Tang et al. [52] 2015
Mianzhu, Sichuan province
VD 2 months Conduct weekly intervention with elderly depression patients using cognitive behavioral therapy techniques to: physical examination; 2. identify emotion status and negative automatic thoughts; 3. proceed psychological intervention; 4. provide problem solving method Workshop on mental disorder knowledge, counseling concepts and techniques, with specific focus on cognitive behavioral therapy. Practice through role-play. Trainings were conducted by one qualified cognitive therapist 1. Time constraint for training;
2. Under-developed training manuals and the inadequate practice, caused anxiety and a sense of incompetence;
3. Poor patient adherence - prefer medicine over CBT;
4. No financial incentive
1. Well designed (easy to understand the content) and organized (the use of role play) training;
2. Strong learning ability and interest; already have some relevant knowledge;
3. Local community trust;
4. Multi-disciplinary team
Xu et al. [64] 2016
Liuyang, Hunan Province
VD; Lay health supporters(LHS): mostly family members of the patients 1 year VD: 1) screening, as the “686” scheme requires; 2) report relapse signs and side effects (based on the texts from LHS) to psychiatrics; 3) team up with LHS, MHA and psychiatrists to assist urgent care.
LHS: 1) facilitate patient medication adherence with prompts from the e-reminders; 2) monitor for early signs of relapse and side effects using checklists from the e-monitor and report to VDs; and 3) team up with the VD and the township Mental Health Administrators (MHA) to facilitate treatment adjustments and urgent care
The built-in e-educator mHealth program will send periodic SMS messages to the patient, LHS, MHA and VDs to educate them on schizophrenia symptoms, medication, adherence strategies, relapse, rehabilitation and social resources 1. Local psychiatrists with limited training may deliver inappropriate services;
2. No sustainable funding;
1. Under the national “686” mental health scheme - government support;
2. Full individual and community engagement (mental health administrators, psychiatrists, VDs, patients and their families (i.e. LHS));
3. mhealth applications as a user-friendly health system strengthening tool in doctor-patient coordination;
VD: no additional workload;
LHS: care and love for their families (i.e. patients) = the major job motivation; non-monetary award system
NCD related - Cardiovascular diseases
Ajay et al. [66] 2014
Gongbujiangda county, Linzhou county, Tibet Province
CHWs 1 year With the smartphone-based electronic decision support, CHWs provide monthly follow-up care; identify high-risk patients; referral; provide therapeutic lifestyle advices (smoking cessation and salt reduction); prescribe two drugs (blood pressure lowering drugs and aspirin) Training on the intervention protocol, including education on targeted CVD lifestyle risk factors and medications being utilized. 1. Lack of economic and healthcare resources 1. Design of the intervention adapt to local context and culture;
2. Supportive national guidelines and policies on CVD prevention and control
Yan et al. [67] 2014
Hebei, Liaoning,
Ningxia, Shanxi and Shaanxi
VD 2 years 1. Identify high-risk individuals by screening all patients who visit the village clinics for any reason;
2. Contact patients with existing diseases or potentially at high risk based on their previous knowledge of the patients to maximize screening;
3. Measure blood pressure, provide lifestyle modification advice and monitor acute symptoms or early signs of clinical events on monthly follow-up with high-risk individuals;
4. Timely referral
A technical package developed to guide village doctors on how to screen, identify, treat, follow up and refer cardiovascular high-risk individuals during their routine services. Not reported 1. Performance-based feedback and financial incentive
payment increased VDs’ motivation of participating in CVD preventive services;
2. Interventions are designed to fit CVD management in resource-limited areas
Tian et al. [66] 2015
Gongbujiangda county, Linzhou county, Tibet Province
CHWs 1 year With the smartphone-based electronic decision support, CHWs provide monthly follow-up care; identify high-risk patients; referral; provide therapeutic lifestyle advices (smoking cessation and salt reduction); prescribe two drugs (blood pressure lowering drugs and aspirin); screening for new symptoms, diseases, and side effects since the last visit, measuring blood pressure, providing lifestyle counseling, Training on the intervention protocol, including education on targeted CVD lifestyle risk factors and medications being utilized. 1. The duration of the intervention is too short to observe significant health behavioral change;
2. Lack of economic and healthcare resources in the remote areas
1. Performance-based incentive;
2. Culturally adaptive (lifestyle health education materials are in Tibetan language with culture-specific images);
3. The mobile health technology simplified the intervention process, provided appropriate guidance/data and saved time
NCD related Health Education
Li et al. [70] 2016
Hebei, Liaoning, Shanxi and Shaanxi provinces; Ningxia
VD 18 months Work with township health educators to provide health education in forms of public lectures, distribute promotional materials, interactive education sessions with vascular high-risk population, promote salt substitute Not reported Not reported Not reported
Others (Shallow anterior chamber screening and verbal autopsy)
Nuriyah, et al. [73] 2010
CHWs; non-professional health worker Not reported Screening of shallow anterior chamber with oblique flashlight test. Not reported Not reported Not reported
Zhang, et al. [103] 2016
Hebei province
VD Not reported Conduct verbal autopsy in rural areas. VA method to become qualified interviewers 1. VD who are older or not familiar with technology may require multiple trainings. 1. Mobile phone-based shortened VA