A continuous quality improvement intervention to improve the effectiveness of community health workers providing care to mothers and children: a cluster randomised controlled trial in South Africa

Abstract

BackgroundCommunity health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs.MethodsThis is a cluster randomised controlled trial to investigate the effectiveness of a continuous quality improvement (CQI) intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention (n = 15) and control (n = 15) arms. Four CHWs were randomly selected from those routinely supported by each supervisor (n = 60 per arm). In the intervention arm, these four CHWs and their supervisor formed a quality improvement team. Intervention CHWs received a 2-week training in WHO Community Case Management followed by CQI mentoring for 12 months (preceded by 3 months lead-in to establish QI processes). Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs.ResultsInterviews were conducted with 736 and 606 mothers at baseline and follow-up respectively; socio-demographic characteristics were similar in both study arms and at each time point.At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy (75.7 vs 29.0%, p < 0.0001) and the postnatal period (72.6 vs 30.3%, p < 0.0001). Intervention mothers had higher maternal and child health knowledge scores (49 vs 43%, p = 0.02) and reported higher exclusive breastfeeding rates to 6 weeks (76.7 vs 65.1%, p = 0.02). HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW (78.7 vs 50.0%, p = 0.007). Uptake of facility-based interventions were not significantly different.ConclusionsImproved training and CQI-based mentoring of CHWs can improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers’ knowledge and infant feeding practices.Trial registrationClinicalTrials.Gov NCT01774136

Evaluation of the effectiveness of a quality improvement intervention to support integration of maternal, child and HIV care in primary health care facilities in South Africa

“…In South Africa, QI has been successfully used to improve the quality of prevention of mother-to-child transmission (PMTCT) programmes in health facilities in KwaZulu-Natal (KZN) province [13], becoming a template for PMTCT national scale up in South Africa [14]. In addition, QI has been used in community settings [15] and has been shown to significantly increase exclusive breastfeeding among mothers served by community health workers (CHWs) exposed to a QI intervention [16]. Results from QI interventions using nonrandomised designs have been criticized as being methodologically weak [13].…”

The cost of the training and supervision of community health workers to improve exclusive breastfeeding amongst mothers in a cluster randomised controlled trial in South Africa

“…A cluster randomised controlled trial (RCT) investigated the effectiveness of a CQI intervention amongst CHWs providing home-based education and support to selected households, including pregnant women and mothers, in the Ugu Health District in the KwaZulu-Natal (KZN) province, South Africa, between May 2012 and November 2013 [19]. The RCT aimed to measure if the intervention was successful in; 1) improving household caregiving practices including breastfeeding practices, 2) improving uptake of MCH services, and 3) developing clear referral pathways between the community and the local primary healthcare clinic [19]. The RCT consisted of 150 CHWs randomly allocated to standard of care (SOC) and intervention arms (n = 75 in each arm).…”

“…In addition, quarterly learning sessions took place over the 12-month CQI mentoring period. Quality mentors, who were registered nurses employed by the project and experienced in the use of quality-improvement methods [19], facilitated both the fortnightly mentoring and quarterly learning sessions. This RCT and setting is described in further detail elsewhere [19].…”

“…In total, 736 mothers received a CHW visit at baseline, and 606 at follow up [19]. This cost analysis focuses on mothers of infants > 6 weeks (629 at baseline and 531 at follow up) as illustrated in Table 1.…”

“…The objective of this study is, therefore, to cost an intervention using the WHO adapted continuous care management (CCM) training materials and a continuous quality improvement (CQI) mentoring and supervision approach targeting CHWs in South Africa [18]. The intervention aimed to achieve a number of objectives as described elsewhere [19]. This costing analysis will express outcomes as natural units represented by the number of women practicing exclusive breastfeeding (EBF) for the first 6 weeks.…”