Factors affecting the work performance and engagement of community health workers in maternal and child health services delivery: A systematic review in low- and middle-income Asian countries

Factors affecting the work performance and engagement of community health workers in maternal and child health services delivery: A systematic review in low- and middle-income Asian countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Factors affecting the work performance and engagement of community health workers in maternal and child health services delivery: A systematic review in low- and middle-income Asian countries Hendra Goh, Yan Fang Lee, Kakrona Sao, Sungwon Yoon, Truls Østbye, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6738418/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Despite their vital contributions, community health workers (CHWs) often face a complex range of factors that diminish their work performance and engagement. This in turn, affects their ability to effectively deliver maternal and child health (MCH) services and long-term commitment. Methods: A systematic review was conducted to identify factors that influence the work performance and engagement of CHWs delivering MCH services in Asia. We searched PubMed, EMBASE and Scopus from inception until August 2023. Findings were categorized according to the socioecological model. Findings: A total of 32 studies were included. At the personal level, sociodemographic characteristics, skills, and personal motivations were most influential. Interpersonal dynamics, including family and collegial relationships, played a critical role in sustaining job commitment. Organizational factors such as training opportunities, work environment, and access to resources were also significant. At the community level, social dynamics and safety consideration were emphasized for improving work performance. Finally, at the health system level, funding mechanisms and prevailing policies were found to shape long-term commitment. Several recommendations, including digital health solutions, were proposed as promising strategies to address these multilevel challenges. Interpretation: This study illustrates that CHWs’ performance and engagement are shaped by a range of interconnected factors across multiple levels. Fundamental issues limiting CHWs from functioning at work mainly revolved around not knowing enough, not having enough and not empowered enough . To enhance their work performance and engagement, future research should focus on exploring the potential of digital health solutions to address these foundational challenges. Funding: Nil maternal health services child health services community health worker developing country Asia Figures Figure 1 Introduction Pregnancy and childbirth complications are major contributors to mortality and severe morbidities, placing a substantial burden on both mothers and their children. 1 In Asian low and middle income countries (LMICs), approximately 85,000 women die annually from pregnancy and childbirth complications alone, accounting for nearly 30% of global maternal mortality. 2 , 3 The death rate is even more pronounced in rural areas, where the mortality risk for mothers and children is almost double. 4 , 5 In response to this urban-rural divide, community health workers (CHWs) emerge as a potential strategy to extend care to hard-to-reach mothers and children in remote areas. 6 , 7 CHWs are frontline public health providers who live and work within the community they serve. Their embedded role in the community allows them to act as a bridge in connecting people to essential healthcare services. 8 , 9 Traditionally, CHWs have been involved in primary healthcare delivery, with a strong emphasis on maternal and child health (MCH). They facilitate MCH services such as delivering antenatal services and helping to identify potential complications early during pregnancy. After delivery, they also offer essential postnatal follow-up, including newborn monitoring, breastfeeding support, and maternal health counselling, ensuring continuity of care for both mother and child. 10 – 12 Despite their vital contributions, CHWs often face a complex range of factors that influence their work performance and engagement. In our context, work performance refers to the overall ability with which CHWs fulfill their assigned responsibilities to deliver community health services 13 while engagement reflects CHWs’ level of motivation and commitment to their roles within the community. 14 The relationship between work performance and engagement has been studied extensively over time. 15 Early findings from the Hawthorne study demonstrated that an individual’s work performance is strongly influenced by social dimensions such as actors, institutions, cultures and economies. 16 These elements significantly shape the individual’s need for social belonging and involvement in workplace decision-making. At the same time, ecological dimensions like working environment and policy landscape also play an integral role in affecting productivity and sustaining engagement. 17 Recognizing that many of these multifactorial influences are not inherent to the health system itself, it is therefore essential to further explore these underlying socioecological factors. As MCH programs continue to expand across Asia, the challenges faced by CHWs in this context remain insufficiently addressed. Existing literature predominantly focuses on African countries, which may not directly apply to the unique social and health landscape of Asian LMICs. 18 – 20 Additionally, most research primarily examines the impact of CHWs on health outcomes rather than emphasizing the intricacies of CHWs’ performance and engagement in service delivery. 6 , 7 , 21 This narrow focus does not fully illuminate the dynamic interplay of socioecological factors that strongly influence the work performance and engagement of CHWs. To bridge the knowledge gap, this systematic review examines socioecological factors that may influence the work performance and engagement of CHWs in delivering MCH services within the health systems of Asian LMIC settings. Understanding the nuanced interplay of these factors is important for informing future evidence-based policy formulations aimed at improving CHWs’ ability to deliver MCH services. Methods Registration and reporting We registered the protocol for this review in PROSPERO (registration ID: CRD42023461721). In addition, adherence to the reporting standards was outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement (Appendix 1). 22 Eligibility This systematic review explored factors that motivate or hinder the work performance and engagement of CHWs delivering MCH services in Asian LMICs, as defined by the World Bank classification of economies. 23 CHWs were determined following the definition outlined by the World Health Organization (WHO) as described by Lewin et al. 9 In this review, CHW was characterized as a health worker who 1) Undertakes tasks associated with healthcare delivery, 2) Undergoes relevant training within the scope of the intervention, and 3) Lacks a formal tertiary education and/or professional degree in relevant fields. MCH services were defined as any services aimed at improving the general health of children, caring for the reproductive health of women, and promoting healthy pregnancy. 9 In addition, we included studies published in English without date restrictions. Studies had to be empirical, as defined by the mixed methods appraisal tool (MMAT). 24 The eligibility criteria were systematically organized according to the Population, Intervention, Control group, Outcome, and Study design (PICOS) framework (Appendix 2). Information sources Primary literature sources were accessed through a structured search of electronic databases, including PubMed, EMBASE, and Scopus, to identify pertinent peer-reviewed articles up to August 2023. The search strategy was developed in three phases. Initially, a preliminary search was conducted on PubMed to identify relevant keywords in titles, abstracts, and subject descriptors. Subsequently, the terms and synonyms identified were utilized in an extensive literature search across the databases. Lastly, the reference lists of eligible full-text articles were screened to include any relevant publications that might have been indexed in the databases. The search process was meticulously devised in consultation with a medical librarian. The search included a broad range of Medical Subject Headings terms and keywords related to MCH services and CHWs (Appendix 3). Grey literature was also searched to ensure a comprehensive inclusion of unpublished or less accessible studies, minimizing publication bias and enhancing the robustness of the findings. Article screening The articles retrieved from each database search were initially imported into Endnote for citation management. Subsequently, two reviewers trained in systematic review methodologies (YFL and KS) conducted title-abstract screening and thoroughly examined full-text articles against the eligibility criteria for potentially eligible studies. Any discrepancies were resolved through iterative consultation with a senior team member (HG). The screening process was documented using the PRISMA flow chart. 25 Data extraction Following full-text screening, two reviewers (YFL and KS) independently extracted data from the included articles. Subsequently, the extracted data were compared and reconciled to produce a consensus version. A data extraction form was developed according to JBI Systematic Review Guidelines. 26 The details included the following information from each article: study characteristics (authors and publication year, country, study aim, study design, sample size, setting), multilevel facilitators and barriers influencing CHWs’ performance and engagement in the context of MCH activities, and suggestions for improvement. Assessment of methodological quality The assessment of methodological rigor in this review was conducted by two independent reviewers (YFL and KS) and cross-checked by a senior member (HG) using the MMAT checklists. 24 MMAT incorporates a series of questions tailored to different study designs, each of which can be answered with a ‘yes,’ ‘no,’ or ‘cannot tell’ response option. Subsequently, a scoring system was used to compute an overall quality score, ranging from 0–100%, indicating the percentage of quality criteria met. 27 Reviewers calculated the overall quality score based on the points obtained, with a 20% increment in overall quality for every 1 point awarded, as determined through consensus among the reviewers. Data synthesis A qualitative synthesis of all included studies was done by summarising the study characteristics and findings of the individual studies. Concurrently, quantitative data underwent a process of "qualitization" before analysis. 28 A framework method was used to ensure a systematic and adaptable approach to data synthesis. 29 , 30 Specifically, the socioecological model was adopted as a framework due to its distinctive focus on the multilevel determinants influencing CHWs’ performance and engagement. 31 , 32 This framework proposes that factors at various levels, including personal, interpersonal, organizational, community, and health system levels, uniquely and collectively contribute to health interventions. 33 , 34 Reviewer 1 (YFL) and 2 (KS) coded the data according to the five levels of the socioecological model, a process validated by Reviewer 3 (HG). Subsequently, mapping was conducted, examining concordant findings, disconformity data, and associations between themes and subthemes. Interpretations were guided by the review objectives and emergent themes, with mapping executed through iterative team discussions. Results Characteristics of included articles Figure 1 shows the PRISMA flow diagram representing the stages of study identification, screening, and inclusion process for this review. Initially, a total of 14,038 articles were identified for screening. After removing 2,518 duplicates, title abstract screening was performed on 11,520 articles. Of these, 11,416 articles were excluded due to their lack of focus on the specified outcomes of interest or because they represented other non-relevant publication types. Further, full-text reports were sought for 104 articles, with three reports being unretrievable. The remaining 101 articles were evaluated in full text, resulting in the inclusion of 32 articles in this review. Table 1 provides a detailed overview of the characteristics of the studies included in this review. The studies originated from nine Asian LMICs, distributed as follows: India (15), Bangladesh (5), Pakistan (3), Myanmar (3), Philippines (2), Indonesia (1), Nepal (1), China (1), and Kyrgyzstan (1). These studies were predominantly conducted in rural settings and urban slums, with a majority of the CHWs being female. Table 1 . Characteristics of included studies No Study Country Study Aim Study Design Sample Size Setting Quality 35 Alam et al., 2012a Bangladesh To explore the relative importance of factors associated with the level of activity of Manoshi CHWs in Dhaka urban slums and make recommendations to improve their activity. Mixed-method study 148 active community health workers 124 inactive community health workers Urban slums *** 36 Alam et al., 2012b Bangladesh To better understand factors associated with Manoshi CHWs retention, and consequently recommend strategies for increasing their retention. Case-control study 542 retained community health workers 146 dropped out community health workers Urban slums **** 37 Alam & Oliveras, 2014 Bangladesh To gather evidence on any long-term effects of previously identified retention factors and to determine whether there are any new factors associated with Manoshi CHWs retention. Prospective cohort study 422 retained community health workers 120 dropped out community health workers Urban slums **** 38 Bhattarai et al., 2020 Nepal To identify the factors associated with the child health service delivery by FCHVs. Cross-sectional study 4302 female community health volunteers Nationwide *** 39 Charantimath et al., 2023 India To assess the experience of peer counsellors on a community-based intervention to improve rates of early breastfeeding. Qualitative study 22 peer counsellors Rural ***** 40 Dykes et al., 2012 Pakistan To explore and contextualize meanings, beliefs and practices surrounding maternal and infant nutrition and to use the findings to inform the development of a nutritional improvement program adapted to local needs. Qualitative study 16 lady health workers Rural ***** 41 George et al., 2017 India To identify key motivating and demotivating factors reported by community health workers working on Ante Natal and Child Healthcare in Urban Slums project Qualitative study Not reported Urban slums ***** 42 Gopalakrishnan et al., 2021 India To investigate the association between supportive supervision and community health worker performance in a large-scale nutrition program using multi-level models. Longitudinal study 809 community health workers Rural **** 43 Gopalan et al., 2012 India This study had three objectives: (1) assessing the current level of performance motivation among the Accredited Social Health Activists, (2) understanding the factors affecting their level of motivation and (3) their perceptions and experiences on the current status of the motivational determinants. Mixed-methods study Survey questionnaire: 386 community health workers Focus group discussion: 78 community health workers Rural **** 44 Jaffari & Troxel, 2018 India To assess competency of birth attendants in a high focus area and pinpoint the specific areas of deficiency, so that the limited resources and interventions in these areas can be more focused and potentially more effective Cross-sectional study 23 auxiliary nurse midwives 30 staff nurses Rural *** 45 Johariyah et al., 2020 Indonesia To evaluate the community preeclampsia screening based on midwives experiences and the possibility of involving community health volunteers in screening preeclampsia at the community level. Qualitative study 10 community health volunteers Rural ***** 46 John et al., 2020 India To explore Anganwadi workers' perceptions of what and how individual, program, community, and organizational factors influence their performance. Qualitative study 30 Anganwadi workers Rural ***** 47 Kari & Angolkar, 2021a India To assess the knowledge and practice of birth preparedness and complication readiness among accredited social health activists. Cross-sectional study 28 accredited social health activists Rural ** 48 Kari & Angolkar, 2021b India To assess the knowledge of accredited social health activists regarding intranatal and postnatal care services. Cross-sectional study 100 accredited social health activists Rural *** 49 Li et al., 2012 China To assess the current situation of the health system of rural health care and evaluating the clinical competency of village doctors in management of childhood illnesses prior to implementing integrated management of childhood illness program in remote border rural areas Mixed-methods study 154 village doctors Rural * 50 Lonimath et al., 2023 India To assess the performance of accredited social health activists under National Urban Health Mission project. Cross-sectional study 130 accredited social health activists Urban ***** 51 Mahajan & Kaur, 2022 India To analyze the role of accredited social health activists in improving maternal health outcomes in the rural community Cross-sectional study 57 accredited social health activists 420 mothers Rural ** 52 Mondal & Murhekar, 2018 India To identify the factors associated with low performance of accredited social health activists with respect to maternal care. Case-control study 261 adequate performing accredited social health activists 261 low performing accredited social health activists Rural ***** 53 Ngaya-An & Fowler, 2014 Philippines To examine community health teams contribution to maternal and child health project Qualitative study 21 community health teams Rural ***** 54 Peterson et al., 2014 India To investigate village health workers level of knowledge of treatment, risks, and prevention of complications of labor and delivery and to evaluate current teaching methods. Qualitative study 18 village health workers Rural **** 55 Puett et al., 2015 Bangladesh To examine the interactions of structural barriers to community health workers quality of care at multiple levels, including supply-side issues from the government health system and demand‐side issues of community resource constraints. Qualitative study 83 community health workers Rural ***** 56 Rabbani et al., 2016 Pakistan To explore lady health supervisors motivating factors, with particular interest in how their views on supportive supervision contribute to the literature and inform on ways that community health worker programs can facilitate motivating supervisory relationships. Qualitative study 29 lady health supervisors Rural ***** 57 Rahman et al., 2010 Bangladesh To explore the causes of attrition, as well as how community health workers attrition was analyzed and addressed by this community-based newborn care intervention in rural Bangladesh. Mixed-methods study 69 community health workers Rural * 58 Rao et al., 2021 India To assess the working condition of accredited social health activists, the extent and types of violence they experienced, and the corresponding perpetrators of this violence in two districts of Northern Karnataka Mixed-methods study 396 accredited social health activists Rural **** 59 Sarfraz & Hamid, 2014 Pakistan To explore role of community midwives as home based skilled service providers and the challenges they face in provision of skilled maternal care. Qualitative study 16 community midwives 27 lady health worker 30 lady health supervisors Rural ***** 60 Shin et al., 2023 Kyrgyzstan To understand community health workers activities in Kyrgyzstan migrant villages and their impact on individuals and communities. Mixed-methods study Survey questionnaire: 46 community health workers Reflection note: 10 community health workers Rural * 61 Sommanustweechai et al., 2016 Myanmar To assess the socioeconomic profiles, contributions of community health workers to primary health care services and their needs for supports to maintain their quality contributions in rural hard to reach areas in Myanmar. Cross-sectional study 715 community health workers Nationwide ***** 62 Teela et al., 2009 Myanmar To understand maternal health workers role in facilitating program and policy efforts to overcome critical delays and insufficient management of maternal complications linked to maternal mortality. Qualitative study Detailed case study: 14 maternal health workers Focus group discussion: 9 maternal health workers In-depth interviews: 18 maternal health workers Rural ** 63 Thacker et al., 2013 India To assess the attitudes and practices of frontline health workers in India regarding polio immunization in Uttar Pradesh and Bihar. Cross-sectional study 720 auxiliary nurse midwives 722 accredited social health activists Rural *** 64 Wahid et al., 2020 India To characterize mechanisms in which accredited social health activists engage with, and are affected by the implementation of Bihar’s community health workers program. Qualitative study 20 accredited social health activists 32 women. Rural ***** 65 Wangmo et al., 2016 Myanmar To understand AMW’s strengths, weakness and support needed, to better inform future policy decision in strengthening the AMW program in Myanmar. Cross-sectional study 1185 auxiliary midwives Rural ***** 66 Yamashita et al., 2015 Philippines To understand postpartum healthcare services and to explore the challenges and motivations of maternal health service providers. Qualitative study 13 Barangay health workers Rural **** Critical appraisal The evaluation using the MMAT revealed a varying adherence to quality criteria across the included studies. 14 studies (44%) achieved 100% compliance with the quality criteria, with the majority (10 out of 14) being qualitative studies. Additionally, seven studies (22%) met 80% of the quality criteria, and five (16%) met 60%. Furthermore, three studies (9%) achieved 40% compliance with the quality criteria, while three mixed-methods studies (9%) met only 20% of the quality criteria. Most qualitative studies (16 out of 19) satisfied at least 80% of the quality criteria. However, MMAT assessments identified several concerns, particularly in quantitative and mixed-method studies. A primary concern involved the appropriateness of measures used in the studies. Specifically, seven out of 13 studies received a 'no' or 'can't tell' rating concerning the appropriateness of the measurements employed. Most studies did not confirm whether the measurement instruments were validated, or reliability tested, and several studies were marked down for having poorly defined or inaccurately measured variables. Another concern was the reporting of divergences. Notably, five out of six mixed-methods studies failed to address divergent results arising from their quantitative and qualitative components, nor did they propose strategies for reconciling these discrepancies. Complete MMAT ratings for each study are detailed in Appendix 4. No studies were excluded based on their quality; instead, the appraisal results were utilized to refine data interpretation, enhancing the validity of the review’s findings and conclusions. Multilevel perceived facilitators affecting the performance and engagement of CHWs Table 2 presents facilitators influencing CHWs’ performance and engagement according to the five levels of determinants in the socioecological model (a detailed description of each subtheme is presented in Appendix 5). Our review identified 17 key themes and 28 subthemes of perceived facilitators by CHWs. Personal level Several sociodemographic characteristics were identified to impact CHWs performance and engagement. Older CHWs tended to perform work with greater confidence, likely reflecting their years of practice and familiarity with their roles, 61 , 65 while those with higher educational attainment were found to reflect a better understanding of health conditions and danger signs. 48 Additionally, skills and competence, marked by prior work experience and clinical competency, were critical for effective performance and managing role complexities. 50 Meanwhile, CHWs from lower socioeconomic backgrounds showed higher job engagement, likely due to limited alternative employment opportunities. 37 Personal motives, including the desire to use time productively and personal experiences with health crises, inspired CHWs to continue serving in the communities. 41 , 60 This sense of purpose was further reinforced by professional dedication deeply rooted in altruistic values to improve collective health. 39 , 41 , 43 , 46 , 51 , 53 , 56 , 57 , 60 , 61 , 64 – 66 Lastly, satisfaction and value derived from the vocation further reinforced their willingness to be continuously engaged at work. 35 , 37 , 39 , 41 , 43 , 51 , 56 , 57 , 60 , 64 , 66 Interpersonal level Family support and positive attitudes towards CHWs’ responsibilities were critical to empowering CHWs to commit to their duties. 35 , 39 , 41 , 46 , 56 , 57 This support included encouragement and practical help in balancing work and family responsibilities, which was essential for sustaining CHWs' long-term engagement. At the same time, strong collegial relationships improved workplace dynamics by facilitating teamwork, knowledge sharing, and emotional support. 43 , 53 , 56 , 57 , 62 , 64 These relationships were instrumental in creating a supportive environment that promoted problem-solving and resilience in challenging work settings. Moreover, adequate top-to-bottom supervision provided through appropriate guidance and support enhanced CHWs’ performance in delivery of MCH services. 42 , 43 , 46 , 56 , 57 , 60 , 61 , 65 Organizational level Training and development opportunities were of utmost importance in impacting CHWs’ performance. Comprehensive on-the-job training equipped them with technical skills that boosted their performance in delivering care and credibility in community health roles. 36 , 39 , 41 , 43 , 56 , 60 , 62 , 64 , 65 Moreover, opportunities for career growth, such as the possibility of securing a permanent position with a stable income, motivated CHWs to remain dedicated and continue their services. 51 , 57 The job context, including the flexibility and autonomy inherent in their roles, contributed positively to their job satisfaction and commitment, enabling them to effectively manage their responsibilities and adapt to community needs. 41 Finally, a supportive work environment with sufficient resources, such as medications and supplies enabled sufficient performance and continuity of care. 38 , 39 , 44 , 50 Community level Supportive social dynamics and cultural context were touted to enhance CHWs' performance and engagement. A positive community attitude toward CHWs’ work boosted their morale at work. When their efforts were appreciated and respected, CHWs in turn felt more committed to their roles. 35 , 37 , 39 , 45 , 56 , 60 , 61 , 64 , 65 The trust that community members had in CHWs was another salient theme. This trust was cultivated through consistent, positive interactions and the visible effectiveness of their health services. Such support and trust validated CHWs’ work and enabled them to perform their duties with increased confidence. 41 , 43 , 54 Health system level At the health system level, several key facilitators influenced CHWs’ performance and engagement. Financial resources, including stable income and program funding, were paramount as they provided CHWs with the means to support their families and sustain operational expenses, thus ensuring commitment to work. 35 , 37 , 38 , 43 , 44 , 46 , 50 , 51 , 53 , 56 , 57 , 64 Guidance through clear policies and guidelines helped CHWs adhere to standardized procedures, ensuring consistent delivery of health services across regions. 46 , 53 Additionally, professional recognition from a broader healthcare context provided a sense of appreciation that strengthened their professional identity. 56 , 60 Finally, leveraging technological integration, especially through mobile health (mHealth) platforms, enhanced their performance. Many perceived it as a handy job aid that enabled a wider reach to underserved patients. 38 , 64 Multilevel perceived barriers affecting the performance and engagement of CHWs Table 2 presents barriers influencing CHWs’ performance and engagement according to the five levels of determinants in the socioecological model (detailed description of each subtheme is presented in Appendix 5). Our review identified 17 key themes and 32 subthemes of perceived barriers by CHWs. Personal level Several personal-level barriers affected CHWs’ performance and engagement, including sociodemographic characteristics, skills and experience, personal motives, and perceived social valuation. Key sociodemographic challenges such as limited education, insufficient training, and illiteracy, were identified to hinder CHWs' ability to perform their roles effectively. 47 – 49 , 54 , 57 Social dynamics like caste-based stigma further impeded service delivery, with CHWs from lower castes facing resistance to deliver care to patients of higher caste. 38 , 46 , 54 Meanwhile, skill-related barriers, such as inexperience with complex diseases reduced confidence at work. 49 , 50 Personal belief also posed as an obstacle; for example, cognitive dissonance among CHWs who preferred home births but had to advocate for health facility deliveries. 53 Concerning willingness for long-term commitment, changes in domicile, such as leaving a slum, led CHWs to discontinue their services. 36 , 65 Conflicting commitments also led to high dropout rates as CHWs had to prioritize other economic generating activities. 37 , 57 , 58 , 60 Lastly, perceived devaluation of social status and a lack of appreciation further diminished one's motivation to commit long-term. 35 , 46 Interpersonal level CHWs faced several interpersonal-level barriers, including challenges in family relationships, workplace dynamics and competition. At home, resistance from family members who upheld traditional gender roles forced many female CHWs to discontinue their roles. 35 – 37 , 56 – 58 , 60 In the workplace, CHWs encountered three key interpersonal challenges. First, poor cooperation and maltreatment from higher-ranking colleagues created a hostile environment. 41 , 51 , 54 , 58 , 59 Second, hierarchical and punitive supervision fostered dissatisfaction that diminished enthusiasm for their roles. 43 , 46 , 52 , 57 , 59 , 62 , 64 Lastly, unhealthy competition—whether with fellow CHWs or other healthcare providers—promoted rivalry over collaboration. 35 , 59 Collectively, these factors undermined the overall motivation of CHWs engage in the service. Organizational level Barriers at the organizational level encompassed issues concerning training and development, job context and demands, work environment, and resource availability. Inadequate on-the-job training and limited career progression opportunities left CHWs feeling ill-prepared and stagnant in their roles. 49 , 57 , 59 , 66 These challenges were compounded by taxing job conditions, such as the frequent proliferation of job scope with limited support. 57 – 59 On the other hand, a shortage of qualified manpower often led to less stringent recruitment standards, resulting in the recruitment of CHWs with varying competence levels who struggled to meet work demands. 43 , 46 , 51 , 52 , 57 , 59 , 60 , 63 , 64 , 66 Lastly, resource constraints, such as poor infrastructure and limited medical supplies, hampered CHWs’ ability to deliver effective care despite their proficiency. 41 , 43 , 46 , 49 , 51 – 53 , 55 – 57 , 59 – 63 , 65 Community level Challenges at the community level were multifaceted, influenced by sociocultural dynamics and concerns for safety and well-being. Negative community attitudes towards CHWs included disapproval, rudeness, and unrealistic expectations. 37 , 41 , 57 , 58 , 60 , 63 , 66 Resistance and refusal from patients and families, fuelled by low levels of trust and misconceptions about CHWs’ skills further diminished motivation for work continuity. 43 , 49 , 54 , 55 , 59 , 62 , 63 Societal norms discouraging women's participation in public roles contributed to female CHWs' withdrawal from MCH service delivery, as they frequently faced negative judgment for delivering care during nighttime hours. 37 , 45 , 46 , 49 , 53 , 54 , 58 , 59 , 63 Furthermore, harassment and violence against female CHWs posed additional significant safety concerns that demotivated them from continuing their service. 46 , 58 , 59 Health system level Limited financial resources presented a significant challenge, as many CHWs worked without regular salaries. An inadequate compensation mechanism was identified as the most salient factor driving CHWs to leave their positions. 36 , 37 , 41 , 43 , 46 , 49 – 51 , 56 , 57 , 59 , 60 , 64 Limited program funding further exacerbated the situation, leaving CHWs to cover operational costs out of pocket and restricting the scope of services they could provide. 46 , 51 , 53 , 59 , 60 , 65 Moreover, a lack of professional recognition within the broader health system reduced motivation, as they faced ill-treatment from health staff and encountered skepticism regarding their case management skills. 55 , 62 At the macro level, economic inequality and corruption within the health system contributed to resource shortages, further hindering capacity in MCH service delivery and discouraging CHWs’ engagement with the communities. 46 , 53 , 55 Table 2 Multilevel facilitators and barriers affecting the performance and engagement of CHWs Domain Theme Subtheme Facilitator Barrier Personal Sociodemographic characteristics Level of education 48 49, 54 Older age 61, 65 Socioeconomic status 37 Social group 38, 46, 54 Domicile changes 35, 65 Skill and competence Amount of work experience 50 49 Clinical competency 42, 47, 54, 62 47, 48, 49, 54, 57 Level of confidence 49, 60 Personal motives and reasons Desire for better use of time 41, 67, 46, 51, 60 Personal autonomy 41, 67, 56, 57, 62, 64 Personal experience 41, 45, 59 Prior engagement in community activities 35, 36, 38, 67, 64 Perceived level of self-efficacy 39, 67, 56, 61, 64, 65 Cognitive dissonance 53 Other competing commitments 37, 57, 58, 60 Professional dedication Altruistic value 41, 67, 46, 51, 53, 56, 57, 60, 61, 64, 65, 66 Professional development and achievement 39, 41, 67, 56, 57, 60, 64 Satisfaction Job satisfaction 37, 39, 67, 57, 60, 66 Perceived level of valuation of their roles 36, 37, 41, 67, 51, 56, 64 36, 46 Interpersonal Family relationship Family attitude and support 36, 39, 41, 46, 56, 57 35, 36, 37, 56, 57, 58, 60 Collegial relationship Support and collaboration within the workplace 67, 53, 57, 62, 64 54, 58, 59 Top-to-bottom supervision 42, 67, 46, 56, 57, 60, 61, 65 46, 52, 57, 59, 62, 64 Workplace competition 36, 59 Organizational Training and development Adequacy of on-the-job training 35, 39, 41, 67, 56, 60, 62, 64, 65 49, 59, 66 Career growth and progression opportunity 51, 57 57 Job context and demands Nature of the job 41, 67 57, 58 Perceived workload 67, 46, 51, 52, 57, 59, 64 Work environment and resources availability Availability of resources 38, 39, 44, 50 67, 46, 49, 52, 53, 55, 56, 59, 60, 63, Availability of qualified manpower 59, 60, 63, 66 Infrastructure 41, 46, 49, 51, 53, 56, 57, 59, 60, 61, 62, 63, 65 Communication 37, 67, 59 Community Social dynamics and cultural context Community attitude and expectation 36, 37, 39, 45, 56, 61, 64, 65 37, 41, 58, 60, 63, 66 Community's level of trust 41, 67, 54 67, 49, 54, 55, 59, 62, 63 Prevailing societal norms and practices 37, 45, 46, 49, 53, 54, 58, 59, 63 Level of health literacy in the community 40, 63 Safety and well-being Harassment and violence 46, 58, 59 Health system Financial resource allocation Availability and adequacy of financial remuneration 36, 37, 67, 44, 46, 50, 51, 53, 56, 57, 64 35, 37, 41, 67, 46, 49, 50, 51, 56, 57, 59, 60, 64 Availability of program funding 38 46, 51, 53, 59, 60, 65 Guidance and policies Availability of guidelines 46, 53 59 Recognition within broader health system context Professional recognition and respect 56, 60 41, 51, 55, 57, 62 Economic inequality and vulnerable practices Corruption 46 Widespread poverty in society 40, 53, 55 Technological integration Potential of mHealth in improving care delivery 38, 64 Multilevel recommendations to improve CHWs’ performance and engagement Table 3 presents 10 recommendations to improve CHW’s performance and engagement (detailed description of each recommendation is presented in Appendix 6). At the personal level, CHWs advocated for a transition toward more personalized care patterns. Emphasizing direct and individualized patient interactions allowed CHWs to strengthen patient-provider relationships that enhances trust with community members, making their work more meaningful and rewarding. 39 Interpersonally, adopting regular top-to-bottom supervision was deemed essential by providing CHWs with ongoing guidance, constructive feedback, and emotional support, thereby fostering professional growth. 67 Within the organization, optimizing “hardware” and “software” capacities were crucial. This could be achieved by ensuring the availability of essential equipment, 55 , 61 , 65 diversifying resources, 39 and revising training schemes. 54 , 55 , 67 These measures would bolster CHWs’ performance by equipping them with the necessary supplies (“hardware” capacities) and knowledge (“software” capacities) . While enhancing reward schemes was also mentioned to sustain retention, enhanced workplace benefits, including free healthcare services for family members, 36 and employee recognition, 36 , 37 were considered desirable. At the community level, implementing community health education and outreach programs might ease CHWs’ workload and build their credibility by fostering positive attitudinal changes and enhancing health-seeking behaviors among the general public. 40 From a health system perspective, restructuring financial incentives through better remuneration would enhance the economic stability of CHWs. By ensuring job security, such measure contributed to the likelihood of retention in their roles. 36 , 37 Lastly, integrating digital health technology (DHS), such as mobile health platforms, was also mentioned as a potential strategy to support CHWs’ work by providing access to online multimedia resources and facilitating information dissemination. It was perceived that these digital tools might facilitate better communication, personalized care delivery, and medical records management. 38 , 39 Table 3 Multilevel recommendations to improve the performance and engagement of CHWs Domain Theme Recommendation Personal Shifting to personalized care pattern 39 Interpersonal Strengthening top-to-bottom support 67 Organizational Optimizing resource accessibility and availability 39, 55, 61, 65 Enhancing staff benefits 36 Improving organizational support 67, 54, 55, 61, 65 Increasing recognition of CHWs 36, 37 Community Promoting social and behavioral change through community health education 40 Strengthening community partnership 67 Health system Increasing remuneration and compensation schemes 36, 37 Potential of integrating digital health technology 38, 39 Discussion To our knowledge, this is the first review to explore the multilevel determinants of CHWs’ performance and engagement in MCH service delivery in Asian LMICs. Through a socioecological framework analysis, we demonstrate that CHWs’ performance and engagement are influenced by various reinforcing and interdependent contextual factors at multiple levels. Among these, the most fundamental issues preventing CHWs from functioning at work and long-term commitment can be grouped mainly into not knowing enough, not having enough, and not empowered enough. Not knowing enough The shortage of skilled healthcare workers has led many LMICs to rely heavily on CHWs to bridge gaps in service delivery. 68 However, these health systems often lack the capacity to deliver comprehensive training to CHWs. 69 , 70 Compounding this issue, many CHWs enter the workforce with limited formal qualifications, leaving them further inadequately prepared to carry out their assigned responsibilities. 49 , 54 While limited training opportunities are a key factor contributing to restricted working knowledge, this study further revealed that the expansion of job responsibilities—commonly implemented as a stopgap measure for workforce shortages—stretches their already limited expertise even thinner. 71 , 72 The practice of assigning CHWs with new roles without foundational training to consolidate their expertise places immense stress on the already overwhelmed workforce, compromising their ability to deliver expanded care due to undue familiarity. Therefore, it is crucial to carefully define the job scope of CHWs and ensure their training is aligned with these expectations. Prioritizing in-depth mastery over broadening job roles indiscriminately may yield a more sustainable and confident workforce. 73 In addition, our findings indicated that CHWs with varying competencies are frequently recruited to deliver MCH services. 47 – 49 , 54 , 57 This inconsistency can be attributed to the lack of standardized selection criteria and relaxing hiring requirements in response to the high manpower needs. 74 As a result, CHWs’ competencies are not always aligned with the demands of their roles. To address these challenges, establishing a competency-based recruitment criteria to identify CHWs best suited for their roles could prove beneficial. 75 This approach may allow program planners to assign CHWs to appropriate roles within the health system, ensuring effective performance according to their skill sets. Additionally, it may also help to guide targeted training program by ensuring that those with less experience and skills receive the most support, thereby enhancing their overall work performance. 76 , 77 Not having enough The way in which CHWs are perceived by communities they serve can be a significant factor, as they are frequently assumed to be paid government employees with regular salaries and adequate resources to perform their duties. 21 However, this assumption is rarely accurate. Despite advocacy for fair compensation and ample support, 78 many CHWs, such as those in Cambodia and Indonesia continue to operate as unpaid volunteers. 79 , 80 This expectation gap creates a conundrum where CHWs struggle to deliver high-quality services with minimal resources. 81 Although CHWs are strategically positioned to facilitate community health initiatives, the matter of adequate remuneration can be overlooked during policymaking processes. It is recommended to evaluate and revisit remuneration policies regularly to ensure their sustainability and commitment. This may also contribute to the wider effort of formalizing an equitable employment model that commensurate CHWs fairly. 82 Not empowered enough This review also highlights that CHWs face disempowerment due to unfair labor conditions. 46 , 50 , 51 , 57 , 67 Empirical evidence indicates that CHWs tend to accept unfavorable working conditions, particularly those in regions with high unemployment rates. 82 In contexts where poverty is prevalent and access to decent employment opportunities is limited—particularly for women—accepting such positions is often not a matter of choice. 58 , 83 Many accept these roles with the hope that volunteering will eventually lead to a salaried position. 63 , 84 , 85 While the narrative of women's empowerment is sometimes invoked to justify the predominance of female CHWs, it can obscure the reality that female labor is often undervalued in areas with low female literacy, high unemployment, and entrenched gender norms that disadvantage women. 37 , 86 Disempowerment is further reinforced by traditional perceptions of female roles. In patriarchal Asian societies, men position themselves as superior to women and assume the role of primary decision-makers within their families. 58 , 87 , 88 Consequently, the act of women delivering care to strangers is perceived as socially inappropriate and a source of embarrassment. 89 For instance, female CHWs may face discomfort when discussing sensitive health topics, such as reproductive health, with male members of the household. 37 In some cases, they are required to seek male permission even before speaking with female household members, further reinforcing gender hierarchies. 58 These societal perceptions not only limit their autonomy but also expose female CHWs to personal safety risks, with reports of physical and sexual harassment being a troubling reality. 46 , 58 , 59 As a result, formalizing CHW roles through transparent employment contracts can not only elevate their work from voluntary, undervalued labor to recognized professional contributions, but also accord them with stronger protections against harassment. 90 By formally integrating CHWs into the health system, their status within the community will be elevated, encouraging a level of respect comparable to that afforded to formally trained healthcare professionals. Recommendation: Potential of digital health technologies While several recommendations were identified, this review highlighted the untapped potential of DHS in enhancing CHWs’ capability across multiple levels of the socioecological model. 38 , 39 A key advantage is the integration of clinical decision support systems, which may address the challenge of limited working knowledge (personal level). This tool can help CHWs make informed decisions, even in complex or unfamiliar situations, by offering evidence-based recommendations and step-by-step procedures. 91 Additionally, modalities like mobile apps and online platforms can host vast libraries of electronic materials that are conveniently accessible. These broad-based educational resources can be utilized as a tool for self-directed learning, enabling CHWs to independently improve their knowledge base. 91 Furthermore, DHS can leverage in-app communication networks to strengthen connectivity between CHWs and health center staff (interpersonal level). One such example is TigerConnect, which enables users to send encrypted text messages and share files securely, thereby improving interprofessional care coordination. 92 DHS may also mitigate resource deficiencies (organizational level) and gendered barriers (community level) that hinder CHWs work performance. Telemedicine services, for example, can connect CHWs and their patients remotely, enabling access to care that would otherwise be unavailable in resource-constrained settings. This can substantially reduce the need for in-person visits, saving both time and manpower requirements while expanding the reach of healthcare services to remote areas. 93 , 94 At the same time, it may help to overcome cultural stigmas by enabling CHWs to deliver care more effectively regardless of gender, while also addressing sensitive health issues that may be considered taboo in certain cultural contexts. 95 Lastly, DHS may improve labor conditions (health system level) by enhancing transparency and accountability in the management of CHWs. For instance, digital platforms can standardize and monitor workloads, ensuring that CHWs are not overburdened. These platforms can also track working hours and accurate remuneration, minimizing payment delays that often contribute to the exploitation of CHWs. 96 By ensuring CHWs receive the compensation and welfare they deserve, it may empower them to be more committed in their roles. 97 Limitations The findings should be considered in light of a few limitations. The exclusive inclusion of studies based on workers in Asian LMICs might limit the generalizability of the findings to other regions due to the diversity of socioeconomic, cultural, and health system contexts. However, this deliberate approach allowed a focused understanding of the unique challenges affecting the work performance and engagement of CHWs in the Asian LMIC context. Secondly, this review only included English documents, which may have resulted in the omission of studies published in country-specific languages that could offer findings relevant to their respective settings. Lastly, many of the studies were ranked poorly, according to the MMAT. However, none of the studies were excluded due to the lack of adequate details for a thorough quality assessment. This limitation introduced uncertainty regarding whether the low ratings were due to inherent methodological rigor issues or insufficient and lack of details in the reporting. Consequently, including these studies might lead to less definitive conclusions and could impact the validity of the synthesized evidence. Conclusion In Asian LMICs, transforming CHW programs by enhancing CHWs’ performance and engagement should be a priority to ensure a responsive delivery of MCH services. This transformation should be guided by a tailored approach informed by the socioecological model. Fundamental issues limiting CHWs from functioning at work include not knowing enough, not having enough and not empowered enough . 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Goh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYBACAyCWALMkmA8gCxKlhS2BZC08BsiCuIE5e+/B2xU1DHb90j3fJBh3HLZnYG/eJoFPi2XPuWTLM8cYkmfOObtNgvHM4cQGnmNleLUY3Mgxk2xgY0g2uJEL1NJ2OIFBIscMv5b7b4Ba/oG05DwDabFnkH9DQMsNHjPJxjYGO6AWNpAWxgYJHgJazuQYWzb2SSRIzkgztkhsS09s40krtsCr5fgZw5sN32zs+SWSH9742GZtz89+eOMNfFqgQCKxAUQlADEbEcrBwJ5YhaNgFIyCUTACAQAba0NNzrnOvQAAAABJRU5ErkJggg==","orcid":"","institution":"Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore","correspondingAuthor":true,"prefix":"","firstName":"Hendra","middleName":"","lastName":"Goh","suffix":""},{"id":461295935,"identity":"d75f189f-eece-4ff7-8930-d6ef823398b7","order_by":1,"name":"Yan Fang Lee","email":"","orcid":"","institution":"Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"Fang","lastName":"Lee","suffix":""},{"id":461295936,"identity":"73dbf73f-e940-4591-a83c-4eef5ac19da5","order_by":2,"name":"Kakrona Sao","email":"","orcid":"","institution":"National Maternal and Child Health Center, Phnom Penh, Cambodia","correspondingAuthor":false,"prefix":"","firstName":"Kakrona","middleName":"","lastName":"Sao","suffix":""},{"id":461295937,"identity":"0c8dd68a-6fdb-44cf-a296-7391a555c658","order_by":3,"name":"Sungwon Yoon","email":"","orcid":"","institution":"Health Services and Systems Research, Duke-NUS Medical School, Singapore","correspondingAuthor":false,"prefix":"","firstName":"Sungwon","middleName":"","lastName":"Yoon","suffix":""},{"id":461295938,"identity":"8b5c6ecb-a251-46d5-ab07-ee99ffae4d29","order_by":4,"name":"Truls Østbye","email":"","orcid":"","institution":"2.\tHealth Services and Systems Research, Duke-NUS Medical School, Singapore","correspondingAuthor":false,"prefix":"","firstName":"Truls","middleName":"","lastName":"Østbye","suffix":""},{"id":461295939,"identity":"af0d88ec-486e-48a6-b6d4-2f5085bb07d9","order_by":5,"name":"Siyan Yi","email":"","orcid":"","institution":"Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore","correspondingAuthor":false,"prefix":"","firstName":"Siyan","middleName":"","lastName":"Yi","suffix":""}],"badges":[],"createdAt":"2025-05-24 10:21:17","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6738418/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6738418/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83681005,"identity":"97f6d704-7a70-4040-9c2e-40b16f6f85d9","added_by":"auto","created_at":"2025-05-30 16:08:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6738418/v1/9a5ccc4fe8a7c12341074bdd.png"},{"id":83681532,"identity":"bf0233a8-871d-41bc-9d20-e1792223ab91","added_by":"auto","created_at":"2025-05-30 16:16:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1395923,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6738418/v1/90d97300-e7bf-45db-a3b1-91abfea60f5b.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eFactors affecting the work performance and engagement of community health workers in maternal and child health services delivery: A systematic review in low- and middle-income Asian countries\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePregnancy and childbirth complications are major contributors to mortality and severe morbidities, placing a substantial burden on both mothers and their children.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In Asian low and middle income countries (LMICs), approximately 85,000 women die annually from pregnancy and childbirth complications alone, accounting for nearly 30% of global maternal mortality.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e The death rate is even more pronounced in rural areas, where the mortality risk for mothers and children is almost double.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn response to this urban-rural divide, community health workers (CHWs) emerge as a potential strategy to extend care to hard-to-reach mothers and children in remote areas.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e CHWs are frontline public health providers who live and work within the community they serve. Their embedded role in the community allows them to act as a bridge in connecting people to essential healthcare services.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Traditionally, CHWs have been involved in primary healthcare delivery, with a strong emphasis on maternal and child health (MCH). They facilitate MCH services such as delivering antenatal services and helping to identify potential complications early during pregnancy. After delivery, they also offer essential postnatal follow-up, including newborn monitoring, breastfeeding support, and maternal health counselling, ensuring continuity of care for both mother and child.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite their vital contributions, CHWs often face a complex range of factors that influence their work performance and engagement. In our context, work performance refers to the overall ability with which CHWs fulfill their assigned responsibilities to deliver community health services\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e while engagement reflects CHWs\u0026rsquo; level of motivation and commitment to their roles within the community.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The relationship between work performance and engagement has been studied extensively over time.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Early findings from the Hawthorne study demonstrated that an individual\u0026rsquo;s work performance is strongly influenced by social dimensions such as actors, institutions, cultures and economies.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e These elements significantly shape the individual\u0026rsquo;s need for social belonging and involvement in workplace decision-making. At the same time, ecological dimensions like working environment and policy landscape also play an integral role in affecting productivity and sustaining engagement.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Recognizing that many of these multifactorial influences are not inherent to the health system itself, it is therefore essential to further explore these underlying socioecological factors.\u003c/p\u003e \u003cp\u003eAs MCH programs continue to expand across Asia, the challenges faced by CHWs in this context remain insufficiently addressed. Existing literature predominantly focuses on African countries, which may not directly apply to the unique social and health landscape of Asian LMICs.\u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Additionally, most research primarily examines the impact of CHWs on health outcomes rather than emphasizing the intricacies of CHWs\u0026rsquo; performance and engagement in service delivery.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e This narrow focus does not fully illuminate the dynamic interplay of socioecological factors that strongly influence the work performance and engagement of CHWs. To bridge the knowledge gap, this systematic review examines socioecological factors that may influence the work performance and engagement of CHWs in delivering MCH services within the health systems of Asian LMIC settings. Understanding the nuanced interplay of these factors is important for informing future evidence-based policy formulations aimed at improving CHWs\u0026rsquo; ability to deliver MCH services.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRegistration and reporting\u003c/h2\u003e \u003cp\u003eWe registered the protocol for this review in PROSPERO (registration ID: CRD42023461721). In addition, adherence to the reporting standards was outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement (Appendix 1).\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility\u003c/h3\u003e\n\u003cp\u003eThis systematic review explored factors that motivate or hinder the work performance and engagement of CHWs delivering MCH services in Asian LMICs, as defined by the World Bank classification of economies.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e CHWs were determined following the definition outlined by the World Health Organization (WHO) as described by Lewin et al.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In this review, CHW was characterized as a health worker who 1) Undertakes tasks associated with healthcare delivery, 2) Undergoes relevant training within the scope of the intervention, and 3) Lacks a formal tertiary education and/or professional degree in relevant fields. MCH services were defined as any services aimed at improving the general health of children, caring for the reproductive health of women, and promoting healthy pregnancy.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In addition, we included studies published in English without date restrictions. Studies had to be empirical, as defined by the mixed methods appraisal tool (MMAT).\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e The eligibility criteria were systematically organized according to the Population, Intervention, Control group, Outcome, and Study design (PICOS) framework (Appendix 2).\u003c/p\u003e\n\u003ch3\u003eInformation sources\u003c/h3\u003e\n\u003cp\u003ePrimary literature sources were accessed through a structured search of electronic databases, including PubMed, EMBASE, and Scopus, to identify pertinent peer-reviewed articles up to August 2023. The search strategy was developed in three phases. Initially, a preliminary search was conducted on PubMed to identify relevant keywords in titles, abstracts, and subject descriptors. Subsequently, the terms and synonyms identified were utilized in an extensive literature search across the databases. Lastly, the reference lists of eligible full-text articles were screened to include any relevant publications that might have been indexed in the databases. The search process was meticulously devised in consultation with a medical librarian. The search included a broad range of Medical Subject Headings terms and keywords related to MCH services and CHWs (Appendix 3). Grey literature was also searched to ensure a comprehensive inclusion of unpublished or less accessible studies, minimizing publication bias and enhancing the robustness of the findings.\u003c/p\u003e\n\u003ch3\u003eArticle screening\u003c/h3\u003e\n\u003cp\u003eThe articles retrieved from each database search were initially imported into Endnote for citation management. Subsequently, two reviewers trained in systematic review methodologies (YFL and KS) conducted title-abstract screening and thoroughly examined full-text articles against the eligibility criteria for potentially eligible studies. Any discrepancies were resolved through iterative consultation with a senior team member (HG). The screening process was documented using the PRISMA flow chart.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003eFollowing full-text screening, two reviewers (YFL and KS) independently extracted data from the included articles. Subsequently, the extracted data were compared and reconciled to produce a consensus version. A data extraction form was developed according to JBI Systematic Review Guidelines.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e The details included the following information from each article: study characteristics (authors and publication year, country, study aim, study design, sample size, setting), multilevel facilitators and barriers influencing CHWs\u0026rsquo; performance and engagement in the context of MCH activities, and suggestions for improvement.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAssessment of methodological quality\u003c/h2\u003e \u003cp\u003eThe assessment of methodological rigor in this review was conducted by two independent reviewers (YFL and KS) and cross-checked by a senior member (HG) using the MMAT checklists.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e MMAT incorporates a series of questions tailored to different study designs, each of which can be answered with a \u0026lsquo;yes,\u0026rsquo; \u0026lsquo;no,\u0026rsquo; or \u0026lsquo;cannot tell\u0026rsquo; response option. Subsequently, a scoring system was used to compute an overall quality score, ranging from 0\u0026ndash;100%, indicating the percentage of quality criteria met.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Reviewers calculated the overall quality score based on the points obtained, with a 20% increment in overall quality for every 1 point awarded, as determined through consensus among the reviewers.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData synthesis\u003c/h3\u003e\n\u003cp\u003eA qualitative synthesis of all included studies was done by summarising the study characteristics and findings of the individual studies. Concurrently, quantitative data underwent a process of \"qualitization\" before analysis.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e A framework method was used to ensure a systematic and adaptable approach to data synthesis.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Specifically, the socioecological model was adopted as a framework due to its distinctive focus on the multilevel determinants influencing CHWs\u0026rsquo; performance and engagement.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e This framework proposes that factors at various levels, including personal, interpersonal, organizational, community, and health system levels, uniquely and collectively contribute to health interventions.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Reviewer 1 (YFL) and 2 (KS) coded the data according to the five levels of the socioecological model, a process validated by Reviewer 3 (HG). Subsequently, mapping was conducted, examining concordant findings, disconformity data, and associations between themes and subthemes. Interpretations were guided by the review objectives and emergent themes, with mapping executed through iterative team discussions.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of included articles\u003c/h2\u003e \u003cp\u003eFigure 1 shows the PRISMA flow diagram representing the stages of study identification, screening, and inclusion process for this review. Initially, a total of 14,038 articles were identified for screening. After removing 2,518 duplicates, title abstract screening was performed on 11,520 articles. Of these, 11,416 articles were excluded due to their lack of focus on the specified outcomes of interest or because they represented other non-relevant publication types. Further, full-text reports were sought for 104 articles, with three reports being unretrievable. The remaining 101 articles were evaluated in full text, resulting in the inclusion of 32 articles in this review.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eprovides a detailed overview of the characteristics of the studies included in this review. The studies originated from nine Asian LMICs, distributed as follows: India (15), Bangladesh (5), Pakistan (3), Myanmar (3), Philippines (2), Indonesia (1), Nepal (1), China (1), and Kyrgyzstan (1). These studies were predominantly conducted in rural settings and urban slums, with a majority of the CHWs being female.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Characteristics of included studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudy Aim\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStudy Design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSample Size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eSetting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eQuality\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlam et al., 2012a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo explore the relative importance of factors associated with the level of activity of Manoshi CHWs in Dhaka urban slums and make recommendations to improve their activity.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMixed-method study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e148 active community health workers\u003c/p\u003e \u003cp\u003e124 inactive community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eUrban slums\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlam et al., 2012b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo better understand factors associated with Manoshi CHWs retention, and consequently recommend strategies for increasing their retention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCase-control study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e542 retained community health workers\u003c/p\u003e \u003cp\u003e146 dropped out community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eUrban slums\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlam \u0026amp; Oliveras, 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo gather evidence on any long-term effects of previously identified retention factors and to determine whether there are any new factors associated with Manoshi CHWs retention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProspective cohort study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e422 retained community health workers\u003c/p\u003e \u003cp\u003e120 dropped out community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eUrban slums\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBhattarai et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNepal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo identify the factors associated with the child health service delivery by FCHVs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4302 female community health volunteers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eNationwide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharantimath et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the experience of peer counsellors on a community-based intervention to improve rates of early breastfeeding.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22 peer counsellors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDykes et al., 2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo explore and contextualize meanings, beliefs and practices surrounding maternal and infant nutrition and to use the findings to inform the development of a nutritional improvement program adapted to local needs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 lady health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeorge et al., 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo identify key motivating and demotivating factors reported by community health workers working on Ante Natal and Child Healthcare in Urban Slums project\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eUrban slums\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGopalakrishnan et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo investigate the association between supportive supervision and community health worker performance in a large-scale nutrition program using multi-level models.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLongitudinal study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e809 community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGopalan et al., 2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThis study had three objectives: (1) assessing the current level of performance motivation among the Accredited Social Health Activists, (2) understanding the factors affecting their level of motivation and (3) their perceptions and experiences on the current status of the motivational determinants.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMixed-methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurvey questionnaire: 386 community health workers\u003c/p\u003e \u003cp\u003eFocus group discussion: 78 community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJaffari \u0026amp; Troxel, 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess competency of birth attendants in a high focus area and pinpoint the specific areas of deficiency, so that the limited resources and interventions in these areas can be more focused and potentially more effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23 auxiliary nurse midwives\u003c/p\u003e \u003cp\u003e30 staff nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJohariyah et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndonesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate the community preeclampsia screening based on midwives experiences and the possibility of involving community health volunteers in screening preeclampsia at the community level.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 community health volunteers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJohn et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo explore Anganwadi workers' perceptions of what and how individual, program, community, and organizational factors influence their performance.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30 Anganwadi workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKari \u0026amp; Angolkar, 2021a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the knowledge and practice of birth preparedness and complication readiness among accredited social health activists.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28 accredited social health activists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKari \u0026amp; Angolkar, 2021b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the knowledge of accredited social health activists regarding intranatal and postnatal care services.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100 accredited social health activists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLi et al., 2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the current situation of the health system of rural health care and evaluating the clinical competency of village doctors in management of childhood illnesses prior to implementing integrated management of childhood illness program in remote border rural areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMixed-methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e154 village doctors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLonimath et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the performance of accredited social health activists under National Urban Health Mission project.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e130 accredited social health activists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMahajan \u0026amp; Kaur, 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo analyze the role of accredited social health activists in improving maternal health outcomes in the rural community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57 accredited social health activists\u003c/p\u003e \u003cp\u003e420 mothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMondal \u0026amp; Murhekar, 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo identify the factors associated with low performance of accredited social health activists with respect to maternal care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCase-control study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e261 adequate performing accredited social health activists \u003c/p\u003e \u003cp\u003e261 low performing accredited social health activists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNgaya-An \u0026amp; Fowler, 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhilippines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo examine community health teams contribution to maternal and child health project\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21 community health teams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeterson et al., 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo investigate village health workers level of knowledge of treatment, risks, and prevention of complications of labor and delivery and to evaluate current teaching methods.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 village health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePuett et al., 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo examine the interactions of structural barriers to community health workers quality of care at multiple levels, including supply-side issues from the government health system and demand‐side issues of community resource constraints.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83 community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRabbani et al., 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo explore lady health supervisors motivating factors, with particular interest in how their views on supportive supervision contribute to the literature and inform on ways that community health worker programs can facilitate motivating supervisory relationships.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29 lady health supervisors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRahman et al., 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo explore the causes of attrition, as well as how community health workers attrition was analyzed and addressed by this community-based newborn care intervention in rural Bangladesh.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMixed-methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e69 community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRao et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the working condition of accredited social health activists, the extent and types of violence they experienced, and the corresponding perpetrators of this violence in two districts of Northern Karnataka\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMixed-methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e396 accredited social health activists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSarfraz \u0026amp; Hamid, 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo explore role of community midwives as home based skilled service providers and the challenges they face in provision of skilled maternal care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 community midwives\u003c/p\u003e \u003cp\u003e27 lady health worker \u003c/p\u003e \u003cp\u003e30 lady health supervisors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShin et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKyrgyzstan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo understand community health workers activities in Kyrgyzstan migrant villages and their impact on individuals and communities.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMixed-methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurvey questionnaire: 46 community health workers\u003c/p\u003e \u003cp\u003eReflection note: 10 community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSommanustweechai et al., 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMyanmar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the socioeconomic profiles, contributions of community health workers to primary health care services and their needs for supports to maintain their quality contributions in rural hard to reach areas in Myanmar.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e715 community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNationwide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeela et al., 2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMyanmar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo understand maternal health workers role in facilitating program and policy efforts to overcome critical delays and insufficient management of maternal complications linked to maternal mortality.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDetailed case study: 14 maternal health workers\u003c/p\u003e \u003cp\u003eFocus group discussion: 9 maternal health workers\u003c/p\u003e \u003cp\u003eIn-depth interviews: 18 maternal health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThacker et al., 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the attitudes and practices of frontline health workers in India regarding polio immunization in Uttar Pradesh and Bihar.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e720 auxiliary nurse midwives\u003c/p\u003e \u003cp\u003e722 accredited social health activists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWahid et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo characterize mechanisms in which accredited social health activists engage with, and are affected by the implementation of Bihar\u0026rsquo;s community health workers program.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20 accredited social health activists \u003c/p\u003e \u003cp\u003e32 women.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWangmo et al., 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMyanmar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo understand AMW\u0026rsquo;s strengths, weakness and support needed, to better inform future policy decision in strengthening the AMW program in Myanmar.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1185 auxiliary midwives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e*****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYamashita et al., 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhilippines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo understand postpartum healthcare services and to explore the challenges and motivations of maternal health service providers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 Barangay health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e****\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCritical appraisal\u003c/h2\u003e \u003cp\u003eThe evaluation using the MMAT revealed a varying adherence to quality criteria across the included studies. 14 studies (44%) achieved 100% compliance with the quality criteria, with the majority (10 out of 14) being qualitative studies. Additionally, seven studies (22%) met 80% of the quality criteria, and five (16%) met 60%. Furthermore, three studies (9%) achieved 40% compliance with the quality criteria, while three mixed-methods studies (9%) met only 20% of the quality criteria. Most qualitative studies (16 out of 19) satisfied at least 80% of the quality criteria. However, MMAT assessments identified several concerns, particularly in quantitative and mixed-method studies. A primary concern involved the appropriateness of measures used in the studies. Specifically, seven out of 13 studies received a 'no' or 'can't tell' rating concerning the appropriateness of the measurements employed. Most studies did not confirm whether the measurement instruments were validated, or reliability tested, and several studies were marked down for having poorly defined or inaccurately measured variables. Another concern was the reporting of divergences. Notably, five out of six mixed-methods studies failed to address divergent results arising from their quantitative and qualitative components, nor did they propose strategies for reconciling these discrepancies. Complete MMAT ratings for each study are detailed in Appendix 4. No studies were excluded based on their quality; instead, the appraisal results were utilized to refine data interpretation, enhancing the validity of the review\u0026rsquo;s findings and conclusions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMultilevel perceived facilitators affecting the performance and engagement of CHWs\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents facilitators influencing CHWs\u0026rsquo; performance and engagement according to the five levels of determinants in the socioecological model (a detailed description of each subtheme is presented in Appendix 5). Our review identified 17 key themes and 28 subthemes of perceived facilitators by CHWs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePersonal level\u003c/h2\u003e \u003cp\u003eSeveral sociodemographic characteristics were identified to impact CHWs performance and engagement. Older CHWs tended to perform work with greater confidence, likely reflecting their years of practice and familiarity with their roles,\u003csup\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e while those with higher educational attainment were found to reflect a better understanding of health conditions and danger signs.\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e Additionally, skills and competence, marked by prior work experience and clinical competency, were critical for effective performance and managing role complexities.\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e Meanwhile, CHWs from lower socioeconomic backgrounds showed higher job engagement, likely due to limited alternative employment opportunities.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e Personal motives, including the desire to use time productively and personal experiences with health crises, inspired CHWs to continue serving in the communities.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e This sense of purpose was further reinforced by professional dedication deeply rooted in altruistic values to improve collective health.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e Lastly, satisfaction and value derived from the vocation further reinforced their willingness to be continuously engaged at work.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eInterpersonal level\u003c/h2\u003e \u003cp\u003eFamily support and positive attitudes towards CHWs\u0026rsquo; responsibilities were critical to empowering CHWs to commit to their duties.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e This support included encouragement and practical help in balancing work and family responsibilities, which was essential for sustaining CHWs' long-term engagement. At the same time, strong collegial relationships improved workplace dynamics by facilitating teamwork, knowledge sharing, and emotional support.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e These relationships were instrumental in creating a supportive environment that promoted problem-solving and resilience in challenging work settings. Moreover, adequate top-to-bottom supervision provided through appropriate guidance and support enhanced CHWs\u0026rsquo; performance in delivery of MCH services.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eOrganizational level\u003c/h2\u003e \u003cp\u003eTraining and development opportunities were of utmost importance in impacting CHWs\u0026rsquo; performance. Comprehensive on-the-job training equipped them with technical skills that boosted their performance in delivering care and credibility in community health roles.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e Moreover, opportunities for career growth, such as the possibility of securing a permanent position with a stable income, motivated CHWs to remain dedicated and continue their services.\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e The job context, including the flexibility and autonomy inherent in their roles, contributed positively to their job satisfaction and commitment, enabling them to effectively manage their responsibilities and adapt to community needs.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e Finally, a supportive work environment with sufficient resources, such as medications and supplies enabled sufficient performance and continuity of care.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCommunity level\u003c/h2\u003e \u003cp\u003eSupportive social dynamics and cultural context were touted to enhance CHWs' performance and engagement. A positive community attitude toward CHWs\u0026rsquo; work boosted their morale at work. When their efforts were appreciated and respected, CHWs in turn felt more committed to their roles.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e The trust that community members had in CHWs was another salient theme. This trust was cultivated through consistent, positive interactions and the visible effectiveness of their health services. Such support and trust validated CHWs\u0026rsquo; work and enabled them to perform their duties with increased confidence.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eHealth system level\u003c/h2\u003e \u003cp\u003eAt the health system level, several key facilitators influenced CHWs\u0026rsquo; performance and engagement. Financial resources, including stable income and program funding, were paramount as they provided CHWs with the means to support their families and sustain operational expenses, thus ensuring commitment to work.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e Guidance through clear policies and guidelines helped CHWs adhere to standardized procedures, ensuring consistent delivery of health services across regions.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e Additionally, professional recognition from a broader healthcare context provided a sense of appreciation that strengthened their professional identity.\u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e Finally, leveraging technological integration, especially through mobile health (mHealth) platforms, enhanced their performance. Many perceived it as a handy job aid that enabled a wider reach to underserved patients.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eMultilevel perceived barriers affecting the performance and engagement of CHWs\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents barriers influencing CHWs\u0026rsquo; performance and engagement according to the five levels of determinants in the socioecological model (detailed description of each subtheme is presented in Appendix 5). Our review identified 17 key themes and 32 subthemes of perceived barriers by CHWs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePersonal level\u003c/h2\u003e \u003cp\u003eSeveral personal-level barriers affected CHWs\u0026rsquo; performance and engagement, including sociodemographic characteristics, skills and experience, personal motives, and perceived social valuation. Key sociodemographic challenges such as limited education, insufficient training, and illiteracy, were identified to hinder CHWs' ability to perform their roles effectively.\u003csup\u003e\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e Social dynamics like caste-based stigma further impeded service delivery, with CHWs from lower castes facing resistance to deliver care to patients of higher caste.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e Meanwhile, skill-related barriers, such as inexperience with complex diseases reduced confidence at work.\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e Personal belief also posed as an obstacle; for example, cognitive dissonance among CHWs who preferred home births but had to advocate for health facility deliveries.\u003csup\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e Concerning willingness for long-term commitment, changes in domicile, such as leaving a slum, led CHWs to discontinue their services.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e Conflicting commitments also led to high dropout rates as CHWs had to prioritize other economic generating activities.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e Lastly, perceived devaluation of social status and a lack of appreciation further diminished one's motivation to commit long-term.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eInterpersonal level\u003c/h2\u003e \u003cp\u003eCHWs faced several interpersonal-level barriers, including challenges in family relationships, workplace dynamics and competition. At home, resistance from family members who upheld traditional gender roles forced many female CHWs to discontinue their roles.\u003csup\u003e\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e In the workplace, CHWs encountered three key interpersonal challenges. First, poor cooperation and maltreatment from higher-ranking colleagues created a hostile environment.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e Second, hierarchical and punitive supervision fostered dissatisfaction that diminished enthusiasm for their roles.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e Lastly, unhealthy competition\u0026mdash;whether with fellow CHWs or other healthcare providers\u0026mdash;promoted rivalry over collaboration.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e Collectively, these factors undermined the overall motivation of CHWs engage in the service.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eOrganizational level\u003c/h2\u003e \u003cp\u003eBarriers at the organizational level encompassed issues concerning training and development, job context and demands, work environment, and resource availability. Inadequate on-the-job training and limited career progression opportunities left CHWs feeling ill-prepared and stagnant in their roles.\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e These challenges were compounded by taxing job conditions, such as the frequent proliferation of job scope with limited support.\u003csup\u003e\u003cspan additionalcitationids=\"CR58\" citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e On the other hand, a shortage of qualified manpower often led to less stringent recruitment standards, resulting in the recruitment of CHWs with varying competence levels who struggled to meet work demands.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e Lastly, resource constraints, such as poor infrastructure and limited medical supplies, hampered CHWs\u0026rsquo; ability to deliver effective care despite their proficiency.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan additionalcitationids=\"CR52\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan additionalcitationids=\"CR60 CR61 CR62\" citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eCommunity level\u003c/h2\u003e \u003cp\u003eChallenges at the community level were multifaceted, influenced by sociocultural dynamics and concerns for safety and well-being. Negative community attitudes towards CHWs included disapproval, rudeness, and unrealistic expectations.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e Resistance and refusal from patients and families, fuelled by low levels of trust and misconceptions about CHWs\u0026rsquo; skills further diminished motivation for work continuity.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e Societal norms discouraging women's participation in public roles contributed to female CHWs' withdrawal from MCH service delivery, as they frequently faced negative judgment for delivering care during nighttime hours.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e Furthermore, harassment and violence against female CHWs posed additional significant safety concerns that demotivated them from continuing their service.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eHealth system level\u003c/h2\u003e \u003cp\u003eLimited financial resources presented a significant challenge, as many CHWs worked without regular salaries. An inadequate compensation mechanism was identified as the most salient factor driving CHWs to leave their positions.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e Limited program funding further exacerbated the situation, leaving CHWs to cover operational costs out of pocket and restricting the scope of services they could provide.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e Moreover, a lack of professional recognition within the broader health system reduced motivation, as they faced ill-treatment from health staff and encountered skepticism regarding their case management skills.\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e At the macro level, economic inequality and corruption within the health system contributed to resource shortages, further hindering capacity in MCH service delivery and discouraging CHWs\u0026rsquo; engagement with the communities.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultilevel facilitators and barriers affecting the performance and engagement of CHWs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"18\" rowspan=\"19\"\u003e \u003cp\u003ePersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eSociodemographic characteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49, 54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOlder age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61, 65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSocioeconomic status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSocial group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38, 46, 54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDomicile changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35, 65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSkill and competence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAmount of work experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical competency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42, 47, 54, 62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47, 48, 49, 54, 57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLevel of confidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49, 60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003ePersonal motives and reasons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDesire for better use of time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41, 67, 46, 51, 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePersonal autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41, 67, 56, 57, 62, 64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePersonal experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41, 45, 59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrior engagement in community activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35, 36, 38, 67, 64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerceived level of self-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39, 67, 56, 61, 64, 65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCognitive dissonance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOther competing commitments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37, 57, 58, 60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfessional dedication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAltruistic value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41, 67, 46, 51, 53, 56, 57, 60, 61, 64, 65, 66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProfessional development and achievement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39, 41, 67, 56, 57, 60, 64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSatisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJob satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37, 39, 67, 57, 60, 66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerceived level of valuation of their roles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36, 37, 41, 67, 51, 56, 64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36, 46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eInterpersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFamily relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily attitude and support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36, 39, 41, 46, 56, 57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35, 36, 37, 56, 57, 58, 60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCollegial relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSupport and collaboration within the workplace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67, 53, 57, 62, 64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54, 58, 59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTop-to-bottom supervision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42, 67, 46, 56, 57, 60, 61, 65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46, 52, 57, 59, 62, 64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWorkplace competition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36, 59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eOrganizational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTraining and development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdequacy of on-the-job training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35, 39, 41, 67, 56, 60, 62, 64, 65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49, 59, 66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCareer growth and progression opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51, 57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eJob context and demands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNature of the job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41, 67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57, 58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerceived workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67, 46, 51, 52, 57, 59, 64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eWork environment and resources availability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAvailability of resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38, 39, 44, 50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67, 46, 49, 52, 53, 55, 56, 59, 60, 63,\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAvailability of qualified manpower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59, 60, 63, 66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInfrastructure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41, 46, 49, 51, 53, 56, 57, 59, 60, 61, 62, 63, 65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37, 67, 59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSocial dynamics and cultural context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunity attitude and expectation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36, 37, 39, 45, 56, 61, 64, 65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37, 41, 58, 60, 63, 66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunity's level of trust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41, 67, 54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67, 49, 54, 55, 59, 62, 63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrevailing societal norms and practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37, 45, 46, 49, 53, 54, 58, 59, 63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLevel of health literacy in the community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40, 63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSafety and well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHarassment and violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46, 58, 59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eHealth system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFinancial resource allocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAvailability and adequacy of financial remuneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36, 37, 67, 44, 46, 50, 51, 53, 56, 57, 64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35, 37, 41, 67, 46, 49, 50, 51, 56, 57, 59, 60, 64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAvailability of program funding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46, 51, 53, 59, 60, 65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGuidance and policies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAvailability of guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46, 53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecognition within broader health system context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProfessional recognition and respect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56, 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41, 51, 55, 57, 62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEconomic inequality and vulnerable practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWidespread poverty in society\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40, 53, 55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTechnological integration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePotential of mHealth in improving care delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38, 64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eMultilevel recommendations to improve CHWs\u0026rsquo; performance and engagement\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents 10 recommendations to improve CHW\u0026rsquo;s performance and engagement (detailed description of each recommendation is presented in Appendix 6). At the personal level, CHWs advocated for a transition toward more personalized care patterns. Emphasizing direct and individualized patient interactions allowed CHWs to strengthen patient-provider relationships that enhances trust with community members, making their work more meaningful and rewarding.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Interpersonally, adopting regular top-to-bottom supervision was deemed essential by providing CHWs with ongoing guidance, constructive feedback, and emotional support, thereby fostering professional growth.\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e Within the organization, optimizing \u0026ldquo;hardware\u0026rdquo; and \u0026ldquo;software\u0026rdquo; capacities were crucial. This could be achieved by ensuring the availability of essential equipment,\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e diversifying resources,\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e and revising training schemes.\u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e These measures would bolster CHWs\u0026rsquo; performance by equipping them with the necessary supplies \u003cem\u003e(\u0026ldquo;hardware\u0026rdquo; capacities)\u003c/em\u003e and knowledge \u003cem\u003e(\u0026ldquo;software\u0026rdquo; capacities)\u003c/em\u003e. While enhancing reward schemes was also mentioned to sustain retention, enhanced workplace benefits, including free healthcare services for family members,\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e and employee recognition,\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e were considered desirable. At the community level, implementing community health education and outreach programs might ease CHWs\u0026rsquo; workload and build their credibility by fostering positive attitudinal changes and enhancing health-seeking behaviors among the general public.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e From a health system perspective, restructuring financial incentives through better remuneration would enhance the economic stability of CHWs. By ensuring job security, such measure contributed to the likelihood of retention in their roles.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e Lastly, integrating digital health technology (DHS), such as mobile health platforms, was also mentioned as a potential strategy to support CHWs\u0026rsquo; work by providing access to online multimedia resources and facilitating information dissemination. It was perceived that these digital tools might facilitate better communication, personalized care delivery, and medical records management.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultilevel recommendations to improve the performance and engagement of CHWs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecommendation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShifting to personalized care pattern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterpersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrengthening top-to-bottom support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eOrganizational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOptimizing resource accessibility and availability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39, 55, 61, 65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnhancing staff benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImproving organizational support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67, 54, 55, 61, 65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncreasing recognition of CHWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36, 37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePromoting social and behavioral change through community health education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrengthening community partnership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHealth system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncreasing remuneration and compensation schemes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36, 37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential of integrating digital health technology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38, 39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first review to explore the multilevel determinants of CHWs\u0026rsquo; performance and engagement in MCH service delivery in Asian LMICs. Through a socioecological framework analysis, we demonstrate that CHWs\u0026rsquo; performance and engagement are influenced by various reinforcing and interdependent contextual factors at multiple levels. Among these, the most fundamental issues preventing CHWs from functioning at work and long-term commitment can be grouped mainly into \u003cem\u003enot knowing enough, not having enough, and not empowered enough.\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eNot knowing enough\u003c/h2\u003e \u003cp\u003eThe shortage of skilled healthcare workers has led many LMICs to rely heavily on CHWs to bridge gaps in service delivery.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e However, these health systems often lack the capacity to deliver comprehensive training to CHWs.\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e Compounding this issue, many CHWs enter the workforce with limited formal qualifications, leaving them further inadequately prepared to carry out their assigned responsibilities.\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e While limited training opportunities are a key factor contributing to restricted working knowledge, this study further revealed that the expansion of job responsibilities\u0026mdash;commonly implemented as a stopgap measure for workforce shortages\u0026mdash;stretches their already limited expertise even thinner.\u003csup\u003e\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u003c/sup\u003e The practice of assigning CHWs with new roles without foundational training to consolidate their expertise places immense stress on the already overwhelmed workforce, compromising their ability to deliver expanded care due to undue familiarity. Therefore, it is crucial to carefully define the job scope of CHWs and ensure their training is aligned with these expectations. Prioritizing in-depth mastery over broadening job roles indiscriminately may yield a more sustainable and confident workforce.\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn addition, our findings indicated that CHWs with varying competencies are frequently recruited to deliver MCH services.\u003csup\u003e\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e This inconsistency can be attributed to the lack of standardized selection criteria and relaxing hiring requirements in response to the high manpower needs.\u003csup\u003e\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u003c/sup\u003e As a result, CHWs\u0026rsquo; competencies are not always aligned with the demands of their roles. To address these challenges, establishing a competency-based recruitment criteria to identify CHWs best suited for their roles could prove beneficial.\u003csup\u003e\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e This approach may allow program planners to assign CHWs to appropriate roles within the health system, ensuring effective performance according to their skill sets. Additionally, it may also help to guide targeted training program by ensuring that those with less experience and skills receive the most support, thereby enhancing their overall work performance.\u003csup\u003e\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eNot having enough\u003c/h2\u003e \u003cp\u003eThe way in which CHWs are perceived by communities they serve can be a significant factor, as they are frequently assumed to be paid government employees with regular salaries and adequate resources to perform their duties.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e However, this assumption is rarely accurate. Despite advocacy for fair compensation and ample support,\u003csup\u003e\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u003c/sup\u003e many CHWs, such as those in Cambodia and Indonesia continue to operate as unpaid volunteers.\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e\u003c/sup\u003e This expectation gap creates a conundrum where CHWs struggle to deliver high-quality services with minimal resources.\u003csup\u003e\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e\u003c/sup\u003e Although CHWs are strategically positioned to facilitate community health initiatives, the matter of adequate remuneration can be overlooked during policymaking processes. It is recommended to evaluate and revisit remuneration policies regularly to ensure their sustainability and commitment. This may also contribute to the wider effort of formalizing an equitable employment model that commensurate CHWs fairly.\u003csup\u003e\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eNot empowered enough\u003c/h2\u003e \u003cp\u003eThis review also highlights that CHWs face disempowerment due to unfair labor conditions.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e Empirical evidence indicates that CHWs tend to accept unfavorable working conditions, particularly those in regions with high unemployment rates.\u003csup\u003e\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u003c/sup\u003e In contexts where poverty is prevalent and access to decent employment opportunities is limited\u0026mdash;particularly for women\u0026mdash;accepting such positions is often not a matter of choice.\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e Many accept these roles with the hope that volunteering will eventually lead to a salaried position.\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u003c/sup\u003e While the narrative of women's empowerment is sometimes invoked to justify the predominance of female CHWs, it can obscure the reality that female labor is often undervalued in areas with low female literacy, high unemployment, and entrenched gender norms that disadvantage women.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDisempowerment is further reinforced by traditional perceptions of female roles. In patriarchal Asian societies, men position themselves as superior to women and assume the role of primary decision-makers within their families.\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e\u003c/sup\u003e Consequently, the act of women delivering care to strangers is perceived as socially inappropriate and a source of embarrassment.\u003csup\u003e\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e\u003c/sup\u003e For instance, female CHWs may face discomfort when discussing sensitive health topics, such as reproductive health, with male members of the household.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e In some cases, they are required to seek male permission even before speaking with female household members, further reinforcing gender hierarchies.\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e These societal perceptions not only limit their autonomy but also expose female CHWs to personal safety risks, with reports of physical and sexual harassment being a troubling reality.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs a result, formalizing CHW roles through transparent employment contracts can not only elevate their work from voluntary, undervalued labor to recognized professional contributions, but also accord them with stronger protections against harassment.\u003csup\u003e\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e\u003c/sup\u003e By formally integrating CHWs into the health system, their status within the community will be elevated, encouraging a level of respect comparable to that afforded to formally trained healthcare professionals.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRecommendation: Potential of digital health technologies\u003c/h3\u003e\n\u003cp\u003eWhile several recommendations were identified, this review highlighted the untapped potential of DHS in enhancing CHWs\u0026rsquo; capability across multiple levels of the socioecological model.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e A key advantage is the integration of clinical decision support systems, which may address the challenge of limited working knowledge \u003cem\u003e(personal level).\u003c/em\u003e This tool can help CHWs make informed decisions, even in complex or unfamiliar situations, by offering evidence-based recommendations and step-by-step procedures.\u003csup\u003e\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e\u003c/sup\u003e Additionally, modalities like mobile apps and online platforms can host vast libraries of electronic materials that are conveniently accessible. These broad-based educational resources can be utilized as a tool for self-directed learning, enabling CHWs to independently improve their knowledge base.\u003csup\u003e\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurthermore, DHS can leverage in-app communication networks to strengthen connectivity between CHWs and health center staff \u003cem\u003e(interpersonal level).\u003c/em\u003e One such example is TigerConnect, which enables users to send encrypted text messages and share files securely, thereby improving interprofessional care coordination.\u003csup\u003e\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e\u003c/sup\u003e DHS may also mitigate resource deficiencies \u003cem\u003e(organizational level)\u003c/em\u003e and gendered barriers \u003cem\u003e(community level)\u003c/em\u003e that hinder CHWs work performance. Telemedicine services, for example, can connect CHWs and their patients remotely, enabling access to care that would otherwise be unavailable in resource-constrained settings. This can substantially reduce the need for in-person visits, saving both time and manpower requirements while expanding the reach of healthcare services to remote areas.\u003csup\u003e\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e, \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u003c/sup\u003e At the same time, it may help to overcome cultural stigmas by enabling CHWs to deliver care more effectively regardless of gender, while also addressing sensitive health issues that may be considered taboo in certain cultural contexts.\u003csup\u003e\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLastly, DHS may improve labor conditions \u003cem\u003e(health system level)\u003c/em\u003e by enhancing transparency and accountability in the management of CHWs. For instance, digital platforms can standardize and monitor workloads, ensuring that CHWs are not overburdened. These platforms can also track working hours and accurate remuneration, minimizing payment delays that often contribute to the exploitation of CHWs.\u003csup\u003e\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e\u003c/sup\u003e By ensuring CHWs receive the compensation and welfare they deserve, it may empower them to be more committed in their roles.\u003csup\u003e\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe findings should be considered in light of a few limitations. The exclusive inclusion of studies based on workers in Asian LMICs might limit the generalizability of the findings to other regions due to the diversity of socioeconomic, cultural, and health system contexts. However, this deliberate approach allowed a focused understanding of the unique challenges affecting the work performance and engagement of CHWs in the Asian LMIC context. Secondly, this review only included English documents, which may have resulted in the omission of studies published in country-specific languages that could offer findings relevant to their respective settings. Lastly, many of the studies were ranked poorly, according to the MMAT. However, none of the studies were excluded due to the lack of adequate details for a thorough quality assessment. This limitation introduced uncertainty regarding whether the low ratings were due to inherent methodological rigor issues or insufficient and lack of details in the reporting. Consequently, including these studies might lead to less definitive conclusions and could impact the validity of the synthesized evidence.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn Asian LMICs, transforming CHW programs by enhancing CHWs\u0026rsquo; performance and engagement should be a priority to ensure a responsive delivery of MCH services. This transformation should be guided by a tailored approach informed by the socioecological model. Fundamental issues limiting CHWs from functioning at work include \u003cem\u003enot knowing enough, not having enough\u003c/em\u003e and \u003cem\u003enot empowered enough\u003c/em\u003e. To better support the work performance and engagement of CHWs, future research should focus on exploring the potential of digital health technologies to overcome these underlying challenges.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFink DA, Kilday D, Cao Z, Larson K, Smith A, Lipkin C, et al. Trends in Maternal Mortality and Severe Maternal Morbidity During Delivery-Related Hospitalizations in the United States, 2008 to 2021. JAMA Netw Open. 2023;6(6):e2317641.\u003c/li\u003e\n \u003cli\u003eWHO. Maternal Mortality 2024 [Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.\u003c/li\u003e\n \u003cli\u003eUNFPA. Maternal mortality in Asia-Pacific - 5 key facts. 2018.\u003c/li\u003e\n \u003cli\u003eSidze EM, Wekesah FM, Kisia L, Abajobir A. Inequalities in Access and Utilization of Maternal, Newborn and Child Health Services in sub-Saharan Africa: A Special Focus on Urban Settings. 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Automatic Work-Hours Recorder for Medical Staff (Staff Hours): Mobile App Development. JMIR Mhealth Uhealth. 2020;8(2):e16063.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"National University of Singapore","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"maternal health services, child health services, community health worker, developing country, Asia","lastPublishedDoi":"10.21203/rs.3.rs-6738418/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6738418/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Despite their vital contributions, community health workers (CHWs) often face a complex range of factors that diminish their work performance and engagement. This in turn, affects their ability to effectively deliver maternal and child health (MCH) services and long-term commitment.\u003c/p\u003e\n\u003cp\u003eMethods: A systematic review was conducted to identify factors that influence the work performance and engagement of CHWs delivering MCH services in Asia. We searched PubMed, EMBASE and Scopus from inception until August 2023. Findings were categorized according to the socioecological model.\u003c/p\u003e\n\u003cp\u003eFindings: A total of 32 studies were included. At the personal level, sociodemographic characteristics, skills, and personal motivations were most influential. Interpersonal dynamics, including family and collegial relationships, played a critical role in sustaining job commitment. Organizational factors such as training opportunities, work environment, and access to resources were also significant. At the community level, social dynamics and safety consideration were emphasized for improving work performance. Finally, at the health system level, funding mechanisms and prevailing policies were found to shape long-term commitment. Several recommendations, including digital health solutions, were proposed as promising strategies to address these multilevel challenges.\u003c/p\u003e\n\u003cp\u003eInterpretation: This study illustrates that CHWs’ performance and engagement are shaped by a range of interconnected factors across multiple levels. Fundamental issues limiting CHWs from functioning at work mainly revolved around \u003cem\u003enot knowing enough, not having enough \u003c/em\u003eand\u003cem\u003e not empowered enough\u003c/em\u003e. To enhance their work performance and engagement, future research should focus on exploring the potential of digital health solutions to address these foundational challenges.\u003c/p\u003e\n\u003cp\u003eFunding: Nil\u003c/p\u003e","manuscriptTitle":"Factors affecting the work performance and engagement of community health workers in maternal and child health services delivery: A systematic review in low- and middle-income Asian countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-30 16:08:17","doi":"10.21203/rs.3.rs-6738418/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51d3175b-1d8a-470a-8031-4c8826e59f52","owner":[],"postedDate":"May 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-30T16:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-30 16:08:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6738418","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6738418","identity":"rs-6738418","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}