title: How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature.
abstract: BACKGROUND
  Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors intersect to influence CHW performance. A systematic review with a narrative analysis was conducted to identify contextual factors influencing performance of CHWs.
  
  
  METHODS
  We searched six databases for quantitative, qualitative, and mixed-methods studies that included CHWs working in promotional, preventive or curative primary health care services in LMICs. We differentiated CHW performance outcome measures at two levels: CHW level and end-user level. Ninety-four studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programmes. Thematic coding was conducted and evidence on five main categories of contextual factors influencing CHW performance was synthesized.
  
  
  RESULTS
  Few studies had the influence of contextual factors on CHW performance as their primary research focus. Contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were community factors that influenced CHW performance. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes.
  
  
  CONCLUSIONS
  Research on CHW programmes often does not capture or explicitly discuss the context in which CHW interventions take place. This synthesis situates and discusses the influence of context on CHW and programme performance. Future health policy and systems research should better address the complexity of contextual influences on programmes. This insight can help policy makers and programme managers to develop CHW interventions that adequately address and respond to context to optimise performance.
authors.affiliation: Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. maryse.kok@kit.nl.|VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan, 1081 HV, Amsterdam, The Netherlands. maryse.kok@kit.nl.
authors.forename: Maryse C
authors.initials: MC
authors.lastname: Kok
authors.affiliation: Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. s.kane@kit.nl.
authors.forename: Sumit S
authors.initials: SS
authors.lastname: Kane
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. olivia.tulloch@lstmed.ac.uk.
authors.forename: Olivia
authors.initials: O
authors.lastname: Tulloch
authors.affiliation: Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. h.ormel@kit.nl.
authors.forename: Hermen
authors.initials: H
authors.lastname: Ormel
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. sally.theobald@lstmed.ac.uk.
authors.forename: Sally
authors.initials: S
authors.lastname: Theobald
authors.affiliation: Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. m.dieleman@kit.nl.
authors.forename: Marjolein
authors.initials: M
authors.lastname: Dieleman
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. miriam.taegtmeyer@lstmed.ac.uk.
authors.forename: Miriam
authors.initials: M
authors.lastname: Taegtmeyer
authors.affiliation: VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan, 1081 HV, Amsterdam, The Netherlands. j.e.w.broerse@vu.nl.
authors.forename: Jacqueline E W
authors.initials: JE
authors.lastname: Broerse
authors.affiliation: Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. k.d.koning@kit.nl.
authors.forename: Korrie A M
authors.initials: KA
authors.lastname: de Koning
mesh_terms: D002983:Clinical Competence; D003150:Community Health Workers; D016208:Databases, Factual; D003906:Developing Countries; D005260:Female; D006801:Humans; D008297:Male