Healthcare interventions involving community healthcare workers in the management of people with multiple long-term conditions: scoping review

The patient and public involvement statement

This study did not use patients or the public. The findings of this scoping review will inform the development of interventions for patients living with multiple long-term conditions.

Step 1: Establishing the research questions

The following questions guided the review:

Step 2: Identifying potentially relevant studies

We searched PubMed, Scopus, EBSCOhost, Cochrane, and CINAHL databases from January 2013 to January 2025, and we re-ran the search from November to December 2025. Our search strategy was developed with the assistance of a university librarian and included controlled vocabulary and free text terms, informed by previous literature. We used a variety of Medical Subject Headings (MeSH) and free text terms to refer to community health workers, such as aid workers, support workers, and advocate workers (Appendix 1a PubMed Search Strategy). We further manually searched and identified articles from the reference lists of two systematic reviews.^24,25 These reviews were not included in the analysis because articles that were identified from the reviews are already included. We used the Participant, Concept, Context (PCC) approach proposed by the Joanna Briggs Institute (JBI) to develop the inclusion criteria, as detailed in Table 1.²² We targeted the population of CHWs; the concept was health interventions, defined as any treatments or strategies that improve outcomes and make a difference in the MLTCs.²⁶ Studies that use interventions that involve CHWs in the management of people who are living with MLTCs. The context included all studies that were conducted globally in communities or primary health care. The type of sources included all types of original studies. We limited our studies to those published in English, and we excluded study protocols, systematic reviews, conference abstracts, opinion pieces, and editorials. We reviewed reference lists of relevant systematic reviews.

Step 3: Selecting relevant studies

Before undertaking title and abstract screening, one reviewer (OM), piloted the screening criteria on 10 articles and refined them. Then the titles and abstracts of studies identified in Step 2 were independently screened by two reviewers (OM and LV) to identify those that¹: involved CHWs (defined as individuals who did not have tertiary education, such as volunteers, support workers and lay workers),² included interventions that addressed MLTCs (two or more chronic conditions including mental health conditions). Differences between reviewers’ assessments were discussed and resolved by consensus. For included studies, the full text was extracted by one reviewer (OM). The screening of titles, abstracts, and full texts was conducted and completed on Rayyan software for systematic reviews (https://new.rayyan.ai/).

Step 4: Data charting

An Excel data extraction form was developed and pilot tested by one reviewer (OM) on 10 articles and subsequently revised by two reviewers (OM and NL). The form can be viewed here https://zenodo.org/records/18908847 (DOI 10.5281/zenodo.18908846.) It included study title, author, published year, study design (quantitative, qualitative, mixed methods), article type (peer-reviewed, original article, guidelines, unpublished reports/grey literature), aims and objectives, location or setting (e.g. country where the study was conducted, communities, clinics), population (adults), research methods (e.g. sample size, methods of data collection), and description of interventions.

Step 5: Collating and summarizing of results

We completed a narrative synthesis that summarised the description of the responsibilities of the CHWs, their training, the tools they used, including whether they were digital or paper-based, and the support received.

Characteristics of included studies

Table 2 (refer to extended data)shows the characteristics of the included studies, including the countries, the settings where the studies were undertaken, study designs, and participants’ mean age. Three qualitative studies, six randomised controlled trials (RCTs), three mixed-method studies, a cross-sectional study, and one quasi-experimental study. More than half (57%) of the studies were conducted in primary healthcare centres and communities; six studies were conducted in the United States of America (USA), one in England, and one in Australia. The remainder were conducted in India, China, and Nepal. The studies in high-income countries focused primarily on rural settings (37%) or urban areas where most people had low socioeconomic status. Most of the participants of the included studies were females (3721), but two studies did not report the gender. Their ages ranged from 15 to 78 years. The studies reported conditions that participants had; participants in three studies had diabetes, hypertension, depression in addition to heart-related conditions such as myocardial infarction, heart failure, coronary heart disease, and ischaemic heart disease. Three studies reported patients with hypertension and diabetes, plus other diseases such as obesity, stroke, arthritis, chronic pulmonary disease (COPD), and tobacco dependence. Three studies did not report the conditions, and the five remaining studies reported other MLTCs. Across all the included studies, approximately 5788 participants were enrolled, including professionals such as CHWs, doctors and nurses.

Roles of CHWs

As detailed in Table 3 (refer to extended data), CHWs had a range of roles in the selected studies in managing people living with MLTCs. The CHWs’ roles were then categorised and subcategorized as follows:

Patient care management

Patient care management involves the coordination and oversight of patients’ treatment plans to ensure they receive comprehensive and effective care. Six studies reported management of physical health, treatment compliance, and retention. Physical health management involves monitoring patients’ physical well-being and coordinating care that addresses both their physical health and other health needs.²⁷ During these visits, CHWs provided patients with blood pressure machines and digital scales and developed a care plan with each patient.^28–31

Education and empowerment

Five studies reported that CHWs promoted self-management behaviours, which involved empowering patients to take responsibility for their health, such as being able to set goals in a health diary and monitor weight and blood pressure.^{24,28,32–34} In four studies, CHWs promoted treatment literacy and health literacy among patients and their families.^24,30,33,35 Treatment compliance involved supporting patients in adhering to treatment plans, and adopting dietary changes and healthier behaviours.^{25,29,30,34,35} Health education focused on chronic condition risk factors and exercise advice, which included checking of joints. Additionally, CHWs delivered family-based education aimed at addressing social taboos and fostering a healthy family environment^30,36–38 . Four studies focused on reinforcing healthy lifestyles, such as providing support to quit tobacco use and to engage in physical activity and meditation.^{27,30,37–39}

Coaching and support

Two studies reported that CHWs also served as health coaches, providing guidance and support to patients in managing their health. This role included helping patients to develop healthier habits and make informed choices about their wellbeing.^34,39 CHWs provided tailored health coaching, supported patients in areas related to social welfare, and offered counselling services.^27,39

Coordination and follow-up

CHWs served as liaisons between health systems, patients, and families, provided appointment reminders to ensure patients stay engaged with their care, and assisted patients with health system navigation, and acted as patients’ advocates.^24,36,39 The frequency of home visits conducted by CHWs in delivering the interventions varied. Three studies reported interactions at their homes, by telephone, and via video contacts.^28,31,33 The number of home visits varied from one to 12 in the studies; One study reported (n = 2) home visits³⁴ and two studies reported (n = 3) home visits^31,35 The studies did not specify whether the visits were conducted weekly or monthly. One study noted that CHWs provided up to four visits daily for six weeks.³² Four studies reported more than 12 home visit sessions; some of these sessions were conducted bi-weekly.^29,33,36,38 Three studies did not report on CHWs’ home visits.³⁷

Interventions

Of the included studies, six reported collaborative or interprofessional interventions ( Table 3- refer to extended data), which comprised healthcare providers from different disciplines, including CHWs. Four studies reported coaching programs, one reported a self-management intervention, one study reported a health literacy intervention, one intervention involved an exercise program, and one study reported a care coordination intervention.

Collaborative interventions included: (i) the Transition Clinic Network (TCN) that used former incarcerated CHWs to provide support to patients returning from imprisonment with health and social needs²⁷; (ii) the Healthier Options through Empowerment (HOPE) intervention in which female CHWs partnered with nurses, doctors, and psychiatrists to diagnose and treat depression in patients with co-morbid diabetes and cardiovascular conditions³⁶; (iii) The HOPE qualitative study highlighted the perception of CHWs who provided the intervention²⁹; (iv) The Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) intervention used advanced practice clinicians (APC), nurse practitioners, or physician assistants together with the CHWs to address lifestyle factors, health literacy, medication adherence and obstacles to behaviour changes in patients with stroke and history of hypertension³¹; (v) The Chinese Older Adults Collaborations in Health (COACH) tested the effect of the collaborative care approach, consisting of the COACH team: a village doctor, a CHW referred to as an aging worker, and a psychiatrist, to treat comorbid hypertension and depression³⁰;(vi) and an interprofessional model of Bridges Self-Management (SMS) intervention supported clinicians to integrate self-management.³²

The coaching intervention was community-based, where CHWs promoted medication safety and mentored discharged adults in following self-care plans and improving disease self-management.^{27,28,31,33–35,39} Only one intervention focused on exercise for people with arthritis and co-morbid COPD.³⁸ A health literacy intervention was delivered by CHWs to educate and support self-management of health.³³ Lastly, the care coordination and support intervention explored the impacts of training design to enhance the role of CHWs.⁴⁰

CHW Training

Thirteen studies reported the training of CHWs, which ranged from 1 hour to under four weeks in duration, including some details of the training, excluding four that did not include details on training duration.^27,29,36,38 One study did not report training.³⁷ The training of CHWs was conducted in universities, colleges, and community centres. Training covered various topics, which included educating, coaching, conducting assessments, risk factor screening, and motivational interviewing.

Tools used by CHWs

Seven of the studies reported tools used by the CHWs; of these, three studies reported both digital tools and paper-based tools, three studies reported the use of paper-based tools only, and one study used a digital tool only. The paper-based tools included: (a) a health activity log, which was used to report the interaction with the patient, such as the mode of communication and the purpose of the interaction.²⁷; (b) a health literacy booklet with a self-management tool that included health information, using pictures, colours, and symbols to engage with illiterate participants; nutrition and immunity building, chronic ailment management that included dosage/equipment management and follow-up visits, as well as hygiene, sanitation, and coronavirus prevention management³³; (c) the 10 keys™ tool provided participants with ten keys to healthy aging and gave the participants the type of questions that they can ask their clinicians and ways to ask those questions³⁸; and (d) a medication safety guide (MSG) tool containing medication safety principles, attitude reinforcement, consultation resources, and medication schedule reminder³⁵ .

Digital tools included: (a) Activities of daily living, Weight and nutrition, Awareness, Condition, Cognition, and social activities (AWACCS). This tool was used to identify any important changes in weight, eating, and drinking habits. It also captured changes in general conditions, including walking, strength, and endurance, as well as changes in memory and social activities.⁴⁰ (b) Health literacy videos were used as an addition to the health literacy booklet.

Strengths and limitations of the review

Our search was comprehensive, ensuring we captured a wide range of studies that reported interventions that evaluated CHWs’ roles in the management of people with MLTCs. A limitation is that the review only included publications/studies in English; therefore, we may have missed publications in other languages. Notably, however, the review has highlighted the limited literature in which interventions have involved CHWs in the management of people with MLTCs. While several studies reported on the tools that CHWs used to manage people with MLTCs, most of these were paper-based and did not provide instructions or algorithms for CHWs to follow.