Effectiveness of interventions by non-professional community-level workers or family caregivers to improve outcomes for physical impairments or disabilities in low resource settings: systematic review of task-sharing strategies
Authors: Kumurenzi Anne , Richardson Julie , Thabane Lehana , Kagwiza Jeanne , Urimubenshi Gerard , Hamilton Leah , Bosch Jackie , Jesus Tiago 
Published: June 2023

Abstract
Background
In low-resource settings, access to basic rehabilitation could be supplemented by community-level interventions provided by community health workers, health volunteers, or family caregivers. Yet, it is unclear whether basic physical rehabilitation interventions delivered to adults by non-professional alternative resources in the community, under task-shifting or task-sharing approaches, are effective as those delivered by skilled rehabilitation professionals. We aim to synthesize evidence on the effectiveness of community-level rehabilitation interventions delivered by non-professional community-level workers or informal caregivers to improve health outcomes for persons with physical impairments or disabilities.

Methods
We performed a systematic review with a PROSPERO registration. Eight databases were searched for (PubMed, CINAHL, Global Health, PDQ Evidence, Scopus, ProQuest, CENTRAL, and Web of Science), supplemented by snowballing and key-informant recommendations, with no time restrictions, applied. Controlled and non-controlled experiments were included if reporting the effects of interventions on mobility, activities of daily living (ADLs), quality of life, or social participation outcomes. Two independent investigators performed the eligibility decisions, data extraction, risk of bias, and assessed the quality of the evidence using the GRADE approach.

Results
Ten studies (five randomized controlled trials [RCTs]) involving 2149 participants were included. Most common targeted stroke survivors (n = 8); family caregivers were most frequently used to deliver the intervention (n = 4); and the intervention was usually provided in homes (n = 7), with training initiated in the hospital (n = 4). Of the four RCTs delivered by family caregivers, one demonstrated a statistically significant improvement in mobility (effect size: 0.3; confidence interval [CI] 121.81–122.19; [p = 0.04]) and another one in ADLs (effect size: 0.4; CI 25.92–35.08; [p = 0.03]). Of the five non-RCT studies by community health workers or volunteers, one demonstrated a statistically significant improvement in mobility (effect size: 0.3; CI 10.143–16.857; [p < 0.05]), while two demonstrated improved statistically significant improvement in ADLs (effect size: 0.2; CI 180.202–184.789 [p = 0.001]; 0.4; CI − 7.643–18.643; [p = 0.026]). However, the quality of evidence, based on GRADE criteria, was rated as low to very low.

Conclusions
While task-sharing is a possible strategy to meet basic rehabilitation needs in low-resource settings, the current evidence on the effectiveness of delivering rehabilitation interventions by non-professional community-level workers and informal caregivers is inconclusive. We can use the data and experiences from existing studies to better design studies and improve the implementation of interventions.
Trial registration PROSPERO registration number: CRD42022319130