RT Journal Article SR Electronic T1 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 JF BMJ Global Health JO BMJ Global Health FD BMJ Publishing Group Ltd SP e006535 DO 10.1136/bmjgh-2021-006535 VO 6 IS 9 A1 Emily B Wroe A1 Basimenye Nhlema A1 Elizabeth L Dunbar A1 Alexandra V Kulinkina A1 Chiyembekezo Kachimanga A1 Moses Aron A1 Luckson Dullie A1 Henry Makungwa A1 Benson Chabwera A1 Benson Phiri A1 Lawrence Nazimera A1 Enoch P L Ndarama A1 Annie Michaelis A1 Ryan McBain A1 Celia Brown A1 Daniel Palazuelos A1 Richard Lilford A1 Samuel I Watson YR 2021 UL http://gh.bmj.com/content/6/9/e006535.abstract AB 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.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.