Training Community Health Workers for Diabetes Management in Low- and Middle-Income Countries: Systematic Review

Type 2 diabetes mellitus, a public health challenge, disproportionately impacts low- and middle-income countries (LMICs), accounting for 73% of global cases. Due to resource constraints, these nations have adopted task-shifting strategies using community health workers (CHWs). However, evidence on the effectiveness of training CHWs in diabetes management is limited and, at most, indirect due to the limited studies, variable training methods, and complex interventions that make it difficult to isolate training effects.

A systematic review was conducted to answer the question: Does training CHWs in type 2 diabetes improve the efficacy of diabetes screening and management at the community level in LMICs?

A total of 2 reviewers, supervised by 2 supervisors, conducted the review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. They searched databases, including PubMed, MEDLINE Ovid, Scopus, EBMR, and CINAHL, for studies published between January 2000 and April 2024, including randomized and nonrandomized controlled trials and observational studies assessing CHW training in diabetes management in LMICs. The primary outcome was the mean change in glycated hemoglobin (HbA1c) percentage levels. Data were narratively synthesized for training characteristics and study outcomes, and quality was assessed using the Risk of Bias 2 and ROBINS-I tools.

A total of 3387 studies were screened; 69 were eligible for full-text review, and 4 studies (3 randomized controlled trials [RCTs] and 1 observational stepped-wedge study, ~1000 patients) were included for narrative analysis. One of the 3 RCTs reported a statistically significant mean HbA1c reduction of -0.24% (P=.001), but HbA1c was not the primary outcome, and most patients were normoglycemic, prediabetic, or had diabetes. Other studies reported nonsignificant HbA1c reductions. The risk of bias among RCTs was moderate (some concerns, 1 trial at high risk), and the observational study had a serious risk of bias. No meta-analysis was performed due to the limited number of RCTs.

Training CHWs in type 2 diabetes management has shown limited and, at most, indirect effects in improving glycemic control in LMIC settings. These findings are constrained by the small number of eligible studies, heterogeneity in training methodologies, and the multicomponent nature of the included interventions, with 1 trial demonstrating a statistically significant yet small reduction in HbA1c (-0.24%). Our review included only 4 eligible studies with a small representation of CHWs and multicomponent interventions. Considering the limited number of eligible studies, the heterogeneity in training methodologies and study designs, and the multicomponent nature of the included interventions, the existing evidence remains inadequate to definitively conclude whether CHW training significantly improves diabetes management across LMICs. Therefore, strengthening and standardizing CHW training might be an effective strategy to enhance diabetes care in underserved settings. Future larger trials and implementation research can help maximize the impact of CHWs against the growing diabetes burden.