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Table 1 Summary of studies addressing contextual factors and their influence on CHW performance

From: How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature

Category Sub-category Sub-category Detail on influence or association Studies
Community context Socio-cultural factors Social and cultural norms, values, practices and beliefs Influencing health-seeking behaviour and therefore directly influencing utilization of CHW services or the ability of CHWs to reach the client [20-32]
   Positively or negatively influencing acceptance of the CHW or the CHW intervention [33-37]
   Not corresponding with CHW’s advice and therefore hindering CHW performance [27,28,38-47]
   Social class of CHW could influence relationship between CHW and client [48,49]
   Influencing level of initiative of the CHW [33,50]
  Gender roles and norms Influencing women’s access to and uptake of CHW services [27,33,35,40,51-55]
   Preference regarding sex of the CHW influencing acceptance of the CHW [32,40,56,57]
   Influencing possibilities for interactions of female CHW with male clients and therefore hampering CHW performance [38,48,58]
   Influencing mobility of female CHW and therefore hampering CHW performance [59,60]
   Influencing choice of becoming or retaining as a CHW (for example, women seen as caring, men should be paid, women discouraged to become CHW by husband) [21,38,51,61-67]
  Disease related stigma Influencing information provision to the CHW and health-seeking behaviour and therefore hampering CHW performance [33,38,54,68-71]
Safety and security Feeling of unsafety could lower CHW motivation and conflict could hamper the functionality of programmes [45,72,73]
Education and knowledge level target group Low education and knowledge levels of clients could hinder CHW performance [33,57,74,75]
Economic context Economic hardship could influence willingness to become CHW, health-seeking behaviour, and could lead to stress of CHWs [55,62,64,74,76-78]
Environment Geography and distance Difficult geography and large distances to cover could hamper CHW performance [20,24,25,38,45,55,72,79-82]
Climate Flooding could hamper mobility and thus performance of CHWs [21,83-85]
Health system policy CHW and human resources policy CHW policy Existence of CHW policy could influence CHW performance [26,51,56,58,61,68,70,72,78,80,86-96]
Human resources policy Human resources policies, relating to incentives and career perspectives, influence CHW performance [59,61,62,68,78,80,97,98]
Legislation related to CHWs Regulatory frameworks about procedures CHWs are authorized to perform could influence their scope of work and could influence their acceptability [20,35,37,40,53,61,72,77,79,97,99-104]
Political commitment Political commitment towards CHW programmes could influence performance of CHWs [58,72,81,92,105]
Health system practice Health service functionality Embedment of CHW services with functional, well-supplied health services could enhance CHW performance [70,82,97]
Functioning, bidirectional referral, and feedback systems enhance CHW performance [71,106,107]
Human resources provisions and their match with CHWs’ expectations Expectations regarding career progression and incentives that are not corresponding with possibilities within health system could hinder CHW performance [49,62,108-111]
Well defined roles of CHWs and other workers could increase CHW performance [80,97,110]
Inadequate support of other staff or supervision could hinder CHW performance [55,58,74,77,88,112,113]
Outcome-based payment of CHWs could hinder their performance [29,49]
Level of decision-making Decentralization could have an effect on performance of CHWs [114]
Costs of health services User fees and income based on drug selling by CHWs could hinder their performance [65,95,96]
Governance/coordination structure Hierarchical structures and too many vertical programmes could hinder CHW performance [29,81]