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 Dunbar, Alexandra V. Kulinkina, Chiyembekezo Kachimanga, Moses Banda Aron, Luckson Dullie, Henry Makungwa, Benson Chabwera, Benson Phiri, Lawrence Nazimera, Enoch Ndarama, Annie Michaelis, Ryan K. McBain, Celia Brown, Daniel Palazuelos, Richard Lilford, Sam Watson
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.