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

Abstract

BackgroundCommunity 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).MethodsWe 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.FindingsThe 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.InterpretationCHW 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.

Economic evaluation of integrated services for non-communicable diseases and HIV: costs and client outcomes in rural Malawi

“…However, among those retained in care, the viral suppression rate after 1 year of enrolment remained high: 81%, on par with the rest of Malawi during this period 29. It should also be noted that, in subsequent years after the transition to incorporate NCDs, HIV retention rates have restabilised around 85% 15 22. Nevertheless, the findings within the analytic window of this study suggest that—in the initial phase of expansion—retention in HIV care among newly enrolled individuals was reduced.…”

“…This may be attributable, at least in part, to Neno District’s CHW network and its associated client tracking programme. 22 PIH employs CHWs in Neno District to visit households on a routine basis and to physically track all clients who have missed appointments to ensure that clients return to facilities for continuation of care. Additionally, the provision of food packages and social support through the programme likely contribute to high rates of retention.…”

“…Of all clients enrolled over this period, four-fifths (80%) were retained. This may be attributable, at least in part, to Neno District’s CHW network and its associated client tracking programme 22. PIH employs CHWs in Neno District to visit households on a routine basis and to physically track all clients who have missed appointments to ensure that clients return to facilities for continuation of care.…”

“…Since 2007, PIH has supported the HIV programme through staff salaries, training efforts, social support and food packages for vulnerable clients, community outreach events and a large cadre of community health workers (CHWs) to support government Health Surveillance Assistants 15 21 22. Between 2011 and 2015, routine screening programmes for NCDs did not exist, but clients identified with common NCDs such as hypertension were seen at an outpatient clinic at one of the two hospitals in the district.…”

Non-communicable disease burden among inpatients at a rural district hospital in Malawi

“…Neno District is remote and impoverished, with a majority of the population relying on subsistence farming, and only 4.5% of the population with access to electricity [25]. Since 2007, Partners In Health (PIH) has been working with the MOH to strengthen both primary and secondary healthcare services [26] [27][28] [29] [30].…”