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

Emily B Wroe; Basimenye Nhlema; Elizabeth L Dunbar; Alexandra V Kulinkina; Chiyembekezo Kachimanga; Moses Aron; Luckson Dullie; Henry Makungwa; Benson Chabwera; Benson Phiri; Lawrence Nazimera; Enoch P L Ndarama; Annie Michaelis; Ryan McBain; Celia Brown; Daniel Palazuelos; Richard Lilford; Samuel I Watson

doi:10.1136/bmjgh-2021-006535

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

Emily B Wroe, Basimenye Nhlema, Elizabeth L Dunbar, Alexandra V Kulinkina, Chiyembekezo Kachimanga, Moses Aron, Luckson Dullie, Henry Makungwa, Benson Chabwera, Benson Phiri, Lawrence Nazimera, Enoch P L Ndarama, Annie Michaelis, Ryan McBain, Celia Brown, Daniel Palazuelos, Richard Lilford, Samuel I Watson

Applied Health Sciences

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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.

Original language	English
Article number	e006535
Number of pages	13
Journal	BMJ Global Health
Volume	6
Issue number	9
DOIs	https://doi.org/10.1136/bmjgh-2021-006535
Publication status	Published - 15 Sept 2021

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Wroe, E. B., Nhlema, B., Dunbar, E. L., Kulinkina, A. V., Kachimanga, C., Aron, M., Dullie, L., Makungwa, H., Chabwera, B., Phiri, B., Nazimera, L., Ndarama, E. P. L., Michaelis, A., McBain, R., Brown, C., Palazuelos, D., Lilford, R., & Watson, S. I. (2021). 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. BMJ Global Health, 6(9), Article e006535. https://doi.org/10.1136/bmjgh-2021-006535

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title = "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 = "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.",

author = "Wroe, {Emily B} and Basimenye Nhlema and Dunbar, {Elizabeth L} and Kulinkina, {Alexandra V} and Chiyembekezo Kachimanga and Moses Aron and Luckson Dullie and Henry Makungwa and Benson Chabwera and Benson Phiri and Lawrence Nazimera and Ndarama, {Enoch P L} and Annie Michaelis and Ryan McBain and Celia Brown and Daniel Palazuelos and Richard Lilford and Watson, {Samuel I}",

note = "{\textcopyright} Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.",

year = "2021",

month = sep,

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doi = "10.1136/bmjgh-2021-006535",

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Wroe, EB, Nhlema, B, Dunbar, EL, Kulinkina, AV, Kachimanga, C, Aron, M, Dullie, L, Makungwa, H, Chabwera, B, Phiri, B, Nazimera, L, Ndarama, EPL, Michaelis, A, McBain, R, Brown, C, Palazuelos, D, Lilford, R & Watson, SI 2021, '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', BMJ Global Health, vol. 6, no. 9, e006535. https://doi.org/10.1136/bmjgh-2021-006535

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. / Wroe, Emily B; Nhlema, Basimenye; Dunbar, Elizabeth L et al.
In: BMJ Global Health, Vol. 6, No. 9, e006535, 15.09.2021.

Research output: Contribution to journal › Article › peer-review

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T2 - a stepped-wedge cluster randomised controlled trial in Neno District, Malawi

AU - Wroe, Emily B

AU - Nhlema, Basimenye

AU - Dunbar, Elizabeth L

AU - Kulinkina, Alexandra V

AU - Kachimanga, Chiyembekezo

AU - Aron, Moses

AU - Dullie, Luckson

AU - Makungwa, Henry

AU - Chabwera, Benson

AU - Phiri, Benson

AU - Nazimera, Lawrence

AU - Ndarama, Enoch P L

AU - Michaelis, Annie

AU - McBain, Ryan

AU - Brown, Celia

AU - Palazuelos, Daniel

AU - Lilford, Richard

AU - Watson, Samuel I

PY - 2021/9/15

Y1 - 2021/9/15

N2 - 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.

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.

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