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The overall individual and collective understanding of the scope and limits of public health system, their knowledge and attitudes in relation to health services, service delivery modes and health professionals, including CHWs, as well as their understanding and views about health and disease, were widely acknowledged amongst factors that could facilitate or hamper CHWs’ performance (Table 16).

Table 16 Summary of findings on individual and collective knowledge, attitudes and expectations in relation to health and health services

Factors Mediators of effect L.C. References

A. Understanding of scope and limits of public health system: * health services ; * models of care; * health professional roles

* CHWs’ tasks. B. views about health and disease

C. Social recognition of and trust in CHWs

CHWs’ KAPs

A poor comprehension of A. and B. might impact negatively on the interactions with the community and so the potential of CHWs’ practice and knowledge on certain dimensions, which all have

consequences on CHWs’ stress, frustration, professional satisfaction and identity. Otherwise, a better or less resistant understanding can inversely benefits this cycle and CHWs motivation.

C. is a consequence of the interplay of various factors already

mentioned. Similarly to A. and B.,

↑↓ 2; 3; 5; 6; 8; 10; 12; 13; 14; 17; 19; 21; 23; 25; 27; 28; 29; 30; 31; 33; 34; 35; 36; 37; 38; 39; 40; 42; 43; 44; 45; 45; 46; 47; 48; 50

when weak, it negatively affects CHWs’ KAPs, but when strong it boosts primarily CHWs’ positive attitudes.

Understanding of scope and limits of public health system

The opinion of CHWs and other health professionals emphasized very often the lack. By community members, of a thorough understanding of the goals of health services, models of care, and existing constraints in service delivery, with negative consequences for their views about CHWs and their work.

According to CHWs and other health professionals, the majority of their patients hold a narrow and distorted view of health care and health services, which is based on a biomedical, disease-and-treatment centered approach to health. As a consequence, for example, health units and health professionals are hardly perceived and accepted for purposes that go beyond disease treatment. CHWs’ performance, and especially their ability to organize and carry out activities focused on health promotion, counseling and education (such as health groups), get severely hampered as they get often refused, ignored or discredited as perceived far from the health and disease needs of the population. Health professionals and CHWs’ attribute to a poor understanding of determinants of disease, resistances of community members to change personal behaviors and lifestyles at individual and collective level. For them, these perceptions contribute to decrease their social recognition, and impacts directly on CHWs’ frustration. This overall attitude impacts directly on CHWs. Mainly biomedical views about health and disease may undervalue actions promoted by CHWs, seen as belonging to a lower category of health professionals when compared to what is offered by other health professionals, such as doctors and nurses.

The distance between community members and primary health care professionals, including CHWs, could be attributed, according to our review, to other characteristics and dynamics that are depending on the organizational deficiencies of health services. The poor responsiveness of the overall health network and its professionals, particularly health specialists and providers at secondary and third level facilities, boosts community skepticism for primary health care professionals, who are viewed as responsible for what is perceived as a failure of the system, such as delays in getting a consultancy, a drug or a laboratory test.

At the level of direct interactions between community members and CHWs, contrasts and frustrations of community expectations were found to be linked with the perception of some patients to be neglected by their CHWs, or the attitude to think that CHWs are lacking of problem solving skills, that should be otherwise faced by referencing to other FHTs’ health professionals or higher levels of the health service network. In addition, the inability of CHWs, to schedule their activities as expected or preferred by their patients is poorly accepted. This is the case, for example, of complaints in relation to home visits, where the CHWs’ availability, generally set for morning shifts, is not matching with community members preferences for the afternoon ones.

Accordingly to the reports of health professionals and CHWs, the objectives, professional role and contextual limitations of CHWs’ work are poorly understood and easily misinterpreted by community members with consequences that range from lack of respect, trust and recognition for CHWs, to an excess of expectations about their problem solving capabilities.

Views about health and disease

Especially according to health professionals, the social and educational background of community members belonging to the areas where CHWs operate could affect profoundly their views of health and disease, their perception of their own needs and therefore their acceptance and reactions of CHWs’ services and orientations. Strong cultural beliefs and stereotypes together with a low educational level were consistently reported across the studies as factors that could increase community members’ resistance to CHWs’ counseling, and to health-related behavior change.

Social recognition of and trust in CHWs

Social recognition of CHWs’ role and services across their communities deserves particular attention, since it is enhanced, or viceversa undermined, by almost all factors previously described and it is acknowledged by all studies as a powerful non financial form of incentive or disincentive for CHWs.

Social recognition of CHWs as health professionals was described as a requisite for establishing or strengthening ties between CHWs and their communities. The creation of strong bonds was found to facilitate an open dialogue between CHWs and their patients, as well as a way for get more proximal to intimate life contexts. These aspects are considered crucial for an appropriate and comprehensive delivery of CHW services, including risk identification, counseling and community empowerment. Social recognition was found to be strictly connected with the possibility for CHWs to expand the reach of their services beyond health units, and start a dialogue on health and its determinants within the daily spaces and routines of community members, such as churches, markets or schools. Social recognition, trust and credibility were reported to be particularly important when interacting with hard-to-reach population group, such as gangs and drug dealers.

When population feedback is positive, CHWs described it as a powerful non financial reward for their work and personal development. Indeed, it was reported to positively increase their motivation, gratification and satisfaction, which supports a more favorable perception of their workload and tasks. Under these conditions being a CHWs evolves into a positive life experience, a mission and an important opportunity to learn and help others, rather than being viewed as a mere duty.

On the contrary, when social recognition of CHWs is undermined, trust in CHWs is lost and thus their services are not sought or accepted. All these factors and dynamics were said to negatively impact CHWs’ performance in various ways. For example by jeopardizing contacts and communications between CHWs and patients, or exacerbating shame, or fear of privacy breaches and inappropriate use of personal information, especially in hard-to-reach population groups. At the same time, lack of social recognition and respect for CHWs’ role was reported as a reason for community members attempts to obtaining personal favors by CHWs.