Article Text

A household-based community health worker programme for non-communicable disease, malnutrition, tuberculosis, HIV and maternal health: a stepped-wedge cluster randomised controlled trial in Neno District, Malawi
  1. Emily B Wroe1,2,3,
  2. Basimenye Nhlema1,
  3. Elizabeth L Dunbar1,4,
  4. Alexandra V Kulinkina1,5,6,
  5. Chiyembekezo Kachimanga1,
  6. Moses Aron1,
  7. Luckson Dullie1,
  8. Henry Makungwa1,
  9. Benson Chabwera1,
  10. Benson Phiri1,
  11. Lawrence Nazimera7,
  12. Enoch P L Ndarama7,
  13. Annie Michaelis8,
  14. Ryan McBain8,9,
  15. Celia Brown10,
  16. Daniel Palazuelos2,3,8,
  17. Richard Lilford11,
  18. Samuel I Watson11
  1. 1Partners In Health, Neno, Malawi
  2. 2Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
  3. 3Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
  4. 4Human Centered Design & Engineering, University of Washington, Seattle, Washington, USA
  5. 5Swiss Tropical and Public Health Institute, Basel, Switzerland
  6. 6University of Basel, Basel, Switzerland
  7. 7Ministry of Health, Neno, Malawi
  8. 8Partners In Health, Boston, Massachusetts, USA
  9. 9RAND, Boston, Massachusetts, USA
  10. 10University of Warwick, Coventry, UK
  11. 11Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  1. Correspondence to Dr Emily B Wroe; emwroe{at}gmail.com

Abstract

Background Community health worker (CHW) programmes are a valuable component of primary care in resource-poor settings. The evidence supporting their effectiveness generally shows improvements in disease-specific outcomes relative to the absence of a CHW programme. In this study, we evaluated expanding an existing HIV and tuberculosis (TB) disease-specific CHW programme into a polyvalent, household-based model that subsequently included non-communicable diseases (NCDs), malnutrition and TB screening, as well as family planning and antenatal care (ANC).

Methods We conducted a stepped-wedge cluster randomised controlled trial in Neno District, Malawi. Six clusters of approximately 20 000 residents were formed from the catchment areas of 11 healthcare facilities. The intervention roll-out was staggered every 3 months over 18 months, with CHWs receiving a 5-day foundational training for their new tasks and assigned 20–40 households for monthly (or more frequent) visits.

Findings The intervention resulted in a decrease of approximately 20% in the rate of patients defaulting from chronic NCD care each month (−0.8 percentage points (pp) (95% credible interval: −2.5 to 0.5)) while maintaining the already low default rates for HIV patients (0.0 pp, 95% CI: −0.6 to 0.5). First trimester ANC attendance increased by approximately 30% (6.5pp (−0.3, 15.8)) and paediatric malnutrition case finding declined by 10% (−0.6 per 1000 (95% CI −2.5 to 0.8)). There were no changes in TB programme outcomes, potentially due to data challenges.

Interpretation CHW programmes can be successfully expanded to more comprehensively address health needs in a population, although programmes should be carefully tailored to CHW and health system capacity.

  • HIV
  • child health
  • health services research
  • maternal health
  • diabetes

Data availability statement

Data are available on reasonable request. Data collected for this study will be made available to others as aggregate and de-identified data. The study protocol is published in a peer-reviewed journal, and supplemental materials include the CHW procedures and the data forms and data flow used in the project. Data and programmatic documents will both be shared via email request to the first author, and additional analysis proposals must be discussed and approved by the first and last authors to ensure dataset is well understood.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Data availability statement

Data are available on reasonable request. Data collected for this study will be made available to others as aggregate and de-identified data. The study protocol is published in a peer-reviewed journal, and supplemental materials include the CHW procedures and the data forms and data flow used in the project. Data and programmatic documents will both be shared via email request to the first author, and additional analysis proposals must be discussed and approved by the first and last authors to ensure dataset is well understood.

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Supplementary materials

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Footnotes

  • Handling editor Stephanie M Topp

  • Twitter @emwroe, @siwatson

  • Contributors EBW, ELD, BN, CK, RM, AVK, HM, BC and LN conceptualised the household model, tailored it to the setting, designed the training and data collection system, and led its implementation and data collection. SIW, RL, CB, ELD, EBW, RM, AM and LD developed the methodology to evaluate the model, with SIW developing the quantitative analysis plan. Throughout the study, EBW, BN, ELD, AVK, CK, MA, HM, BC, BP, LN and EPLN provided ongoing oversight, data review and quality control. EBW, SIW and AVK drafted the first version of the manuscript. BN, ELD, AVK, CK, MA, LD, HM, BC, BP, AM, RM, CB, LN, EPLN, DP and RL provided substantive comments and revisions to the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement statement The Ministry of Health in Neno District and its advisory committee, which includes community members, were involved in the design of the Community Health Worker program in Neno. For this trial, when the program was redesigned to incorporate more conditions, the committee was consulted and updated every 6 months during the program, which is routine for all health programming in Neno District by Partners In Health. In addition, community members and community health workers are consulted and involved in the design of the CHW intervention and the monitoring of its progress.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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