Evaluating the impact of a community health worker programme on non-communicable disease, malnutrition, tuberculosis, family planning and antenatal care in Neno, Malawi: protocol for a stepped-wedge, cluster randomised controlled trial

Dunbar, Elizabeth L; Wroe, Emily; Nhlema, Basimenye; Kachimanga, Chiyembekezo; Gupta, Ravi; Taylor, Celia A.; Michaelis, Annie; Cundale, Katie; Dullie, Luckson; Jumbe, Arnold; Nazimera, Lawrence; McBain, Ryan; Lilford, Richard; Watson, Samuel

doi:10.1136/bmjopen-2017-019473

Cited by 30 publications

(26 citation statements)

References 19 publications

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“…Alongside patient self-management strategies [ 48 ], this could help to offset the burden of personnel shortages and reduce barriers along the patient flow pathway by promoting uniformity, reducing stigma and harmonizing tasks among cadres rather than creating new ones. More importantly, it can help to promote a united vision to guide health workers and community gatekeepers for NCD-related preventive, promotive, curative and rehabilitative approaches that cascade along the continuum of service levels from primary care (including community) to tertiary and specialized care [ 49 , 50 ].…”

Section: Discussionmentioning

confidence: 99%

Reorienting Primary Health Care Services for Non-Communicable Diseases: A Comparative Preparedness Assessment of Two Healthcare Networks in Malawi and Zambia

Shiroya

Shawa

Matanje

et al. 2021

IJERPH

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Despite positive NCD policies in recent years, majority of Sub-Saharan African (SSA) health systems are inadequately prepared to deliver comprehensive first-line care for NCDs. Primary health care (PHC) settings in countries like Malawi and Zambia could be a doorway to effectively manage NCDs by moving away from delivering only episodic care to providing an integrated approach over time. As part of a collaborative health system strengthening project, we assessed and compared the preparedness and operational capacity of two target networks of public PHC settings in Lilongwe (Malawi) and Lusaka (Zambia) to integrate NCD services within routine service delivery. Data was collected and analyzed using validated health facility survey tools. These baseline assessments conducted between August 2018 and March 2019, also included interviews with 20 on-site health personnel and focal persons, who described existing barriers in delivering NCD services. In both countries, policy directives to decentralize disease-specific NCD services to the primary care level were initiated to meet increased demand but lacked operational guidance. In general, the assessed PHC sites were inadequately prepared to integrate NCDs into various service delivery domains, thus requiring further support. In spite of existing multi-faceted limitations, there was motivation among healthcare staff to provide NCD services.

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Section: Discussionmentioning

confidence: 99%

Reorienting Primary Health Care Services for Non-Communicable Diseases: A Comparative Preparedness Assessment of Two Healthcare Networks in Malawi and Zambia

Shiroya

Shawa

Matanje

et al. 2021

IJERPH

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“… 41 These principles were applied to IC3, with the CHW network undergoing a gradual transformation in 2017 and 2018 so that all patients with NCD were eventually assigned a CHW. 51 …”

Section: Methodsmentioning

confidence: 99%

Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD–HIV model

Wroe

Kalanga²,

Dunbar³

et al. 2020

BMJ Open

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ObjectivesNon-communicable diseases (NCDs) account for one-third of disability-adjusted life years in Malawi, and access to care is exceptionally limited. Integrated services with HIV are widely recommended, but few examples exist globally. We report descriptive outcomes from an Integrated Chronic Care Clinic (IC3).DesignThis is a retrospective cohort study.SettingThe study includes an HIV–NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi.ParticipantsAll new patients, including 6233 HIV–NCD diagnoses, enrolled between January 2015 and December 2017 were included. This included 3334 patients with HIV (59.7% women) and 2990 patients with NCD (67.3% women), 10% overall under age 15 years.InterventionsPatients were seen at their nearest health centre, with a hospital team visiting routinely to reinforce staffing. Data were collected on paper forms and entered into an electronic medical record.Primary and secondary outcome measuresRoutine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis.ResultsNCD diagnoses were 1693 hypertension, 668 asthma, 486 epilepsy, 149 diabetes and 109 severe mental illness. By December 2018, 8.3% of patients with NCD over 15 years were also on HIV treatment. One-year retention was 85% for HIV and 72% for NCDs, with default in 8.4% and 25.5% and deaths in 4.0% and 1.4%, respectively. Clinical outcomes showed statistically significant improvement for hypertension, diabetes, asthma and epilepsy. Of the 1807 (80%) of patients with HIV with viral load results, 85% had undetectable viral load.ConclusionsThe IC3 model, built on an HIV platform, facilitated rapid decentralisation and access to NCD services in rural Malawi. Clinical outcomes and retention in care are favourable, suggesting that integration of chronic disease care at the primary care level poses a way forward for the large dual burden of HIV and chronic NCDs.

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“…Additionally, the package of services provided by CHWs was increased to cover an additional five medical conditions. This new approach, which was rolled out in phases beginning in 2017, will be evaluated in mid-2019 [35].…”

Section: Conclusion and Recommendationsmentioning

confidence: 99%

Increasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi

Kachimanga

Dunbar²,

Watson

et al. 2020

BMC Pregnancy Childbirth

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Background: By 2015, Malawi had not achieved Millennium Development Goal 4, reducing maternal mortality by about 35% from 675 to 439 deaths per 100,000 livebirths. Hypothesised reasons included low uptake of antenatal care (ANC), intrapartum care, and postnatal care. Involving community health workers (CHWs) in identification of pregnant women and linking them to perinatal services is a key strategy to reinforce uptake of perinatal care in Neno, Malawi. We evaluated changes in uptake after deployment of CHWs between March 2014 and June 2016. Methods: A CHW intervention was implemented in Neno District, Malawi in a designated catchment area of about 3100 women of childbearing age. The pre-intervention period was March 2014 to February 2015, and the postintervention period was March 2015 to June 2016. A 5-day maternal health training package was delivered to 211 paid and supervised CHWs. CHWs were deployed to identify pregnant women and escort them to perinatal care visits. A synthetic control method, in which a "counterfactual site" was created from six available control facilities in Neno District, was used to evaluate the intervention. Outcomes of interest included uptake of first-time ANC, ANC within the first trimester, four or more ANC visits, intrapartum care, and postnatal care follow-up. Results: Women enrolled in ANC increased by 18% (95% Credible Interval (CrI): 8, 29%) from an average of 83 to 98 per month, the proportion of pregnant women starting ANC in the first trimester increased by 200% (95% CrI: 162, 234%) from 10 to 29% per month, the proportion of women completing four or more ANC visits increased by 37% (95% CrI: 31, 43%) from 28 to 39%, and monthly utilisation of intrapartum care increased by 20% (95% CrI: 13, 28%) from 85 to 102 women per month. There was little evidence that the CHW intervention changed utilisation of postnatal care (− 37, 95% CrI: − 224, 170%). Conclusions: In a rural district in Malawi, uptake of ANC and intrapartum care increased considerably following an intervention using CHWs to identify pregnant women and link them to care.

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Evaluating the impact of a community health worker programme on non-communicable disease, malnutrition, tuberculosis, family planning and antenatal care in Neno, Malawi: protocol for a stepped-wedge, cluster randomised controlled trial

Cited by 30 publications

References 19 publications

Reorienting Primary Health Care Services for Non-Communicable Diseases: A Comparative Preparedness Assessment of Two Healthcare Networks in Malawi and Zambia

Reorienting Primary Health Care Services for Non-Communicable Diseases: A Comparative Preparedness Assessment of Two Healthcare Networks in Malawi and Zambia

Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD–HIV model

Increasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi

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