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

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

Underreporting of maternal and neonatal complications: A comparison of information in maternity registers and client charts at a rural community hospital in Malawi

Aim: To determine the rate and types of unreported maternal and neonatal complications in a rural community hospital in Malawi. Background: The problem of maternal and neonatal morbidity and mortality may be underestimated, with underreporting of complications often noted. Reliable data is needed to make key decisions at the local, district, and national level. This study investigated whether there were unreported complications among women receiving intrapartum care at a rural community hospital in Malawi. Methods: A retrospective cross-sectional study was conducted comparing maternity register records to client charts from January-March 2018. Descriptive data analysis using SPSS v20 was performed to calculate percentages and frequencies. Results: 360 client cases were identified, of which 33 cases were excluded from analysis due to missing charts. Of the remaining 327 cases included in the final analysis, only 34% (n = 31) of maternal and 34% (n = 33) of neonatal complications were recorded in both the maternity register and the chart. When the additional complications found in the chart review were included, the rates of maternal and neonatal complications tripled from 9.5% (n = 31) and 10% (n = 33) to 28% (n = 90) and 30% (n = 98), respectively. Conclusions: There was poor record keeping, underreporting of maternal and neonatal complications, and discrepancies between the data recorded in the monthly maternity register and client charts in the first quarter of 2018. The actual rate of complications suggests a need to verify data at the facility level to prevent release and reporting of inaccurate data. Measures are needed to mitigate the gaps in data reporting

wAn innovative longitudinal nurse-midwife mentorship program in rural Malawi: The global Action in nursing (GAIN) project

The Global Action in Nursing (GAIN) project is a partnership between University of California, San Francisco, Partners In Health, and the Ministry of Health, Neno District, Malawi that aims to reduce maternal and neonatal morbidity and mortality by improving the quality of perinatal care rendered by nurse-midwives. In this report, we describe the design and implementation of a nursing training and mentorship program for frontline nurse-midwives in leadership, quality improvement, and midwifery skills, including the implementation of the World Health Organization Safe Childbirth Checklist and Respectful Maternity Care. Short course trainings were followed by one year of on-site clinical mentorship with the goal of improving systems factors (such as ensuring adequate availability of supplies) as well as reinforcing clinical skills.The program was implemented in Neno District, Malawi, a rural district in southwestern Malawi where approximately 5,000 births occur annually. The program is now in its fifth year of implementation and has become well-embedded in the district. Key lessons learned included stakeholder involvement; flexible and responsive program design; nurse-centered model for mentorship; and program transition to local leadership. Since nurses and midwives are the frontline providers of reproductive health care in Malawi, sustained investment in clinical and leadership training for nurse-midwives, accompanied by health systems strengthening, has the potential to improve quality deficits and therefore the health of mothers and babies in low-resource settings

Implementation of a non-communicable disease clinic in rural Sierra Leone: early experiences and lessons learned

This study is an evaluation of the first cohort of patients enrolled in an outpatient non-communicable disease clinic in Kono, Sierra Leone. In the first year, the clinic enrolled 916 patients. Eight months after the enrollment of the last patient, 53% were still active in care, 43% had been lost to follow-up (LTFU) and 4% had defaulted. Of the LTFU patients, 47% only came for the initial enrollment visit and never returned. Treatment outcomes of three patient groups [HTN only (n = 720), DM only (n = 51), and HTN/DM (n = 96)] were analyzed through a retrospective chart review. On average, all groups experienced reductions in blood pressure and/or blood glucose of approximately 10% and 20%, respectively. The proportions of patients with their condition controlled also increased. As NCDs remain underfunded and under-prioritized in low-income countries, the integrated program in Kono demonstrates the possibility of improving outpatient NCD care in Sierra Leone and similar settings

Adoption of mHealth Technologies by Community Health Workers to Improve the Use of Maternal Health Services in Sub-Saharan Africa: Protocol for a Mixed Method Systematic Review

Background: Studies have shown that mobile health technologies (mHealth) enhance the use of maternal health services. However, there is limited evidence of the impact of mHealth use by community health workers (CHWs) on the use of maternal health services in sub-Saharan Africa. Objective: This mixed method systematic review will explore the impact of mHealth use by CHWs on the use of the maternal health continuum of care (antenatal care, intrapartum care, and postnatal care [PNC]), as well as barriers and facilitators of mHealth use by CHWs when supporting maternal health services. Methods: We will include studies that report the impact of mHealth by CHWs on the use of antenatal care, facility-based births, and PNC visits in sub-Saharan Africa. We will search 6 databases (MEDLINE, CINAHL, Web of Science, Embase, Scopus, and Africa Index Medicus), with additional articles identified from Google Scholar and manual screening of references of the included studies. The included studies will not be limited by language or year of publication. After study selection, 2 independent reviewers will perform title and abstract screening, followed by full-text screening to identify the final papers to be included. Data extraction and risk-of-bias assessment will be performed using Covidence software by 2 independent reviewers. We will use a Mixed Methods Appraisal Tool to perform risk-of-bias assessments on all included studies. Finally, we will perform a narrative synthesis of the outcomes, integrating information about the effect of mHealth on maternal health use and barriers and facilitators of mHealth use. This protocol follows the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) guidelines. Results: In September 2022, we conducted an initial search in the eligible databases. After removing duplicates, we identified 1111 studies that were eligible for the title and abstract screening. We will finalize the full-text assessment for eligibility, data extraction, assessment of methodological quality, and narrative synthesis by June 2023. Conclusions: This systematic review will present new and up-to-date evidence on the use of mHealth by CHWs along the pregnancy, childbirth, and PNC continuum of care. We anticipate the results will inform program implementation and policy by highlighting the potential impacts of mHealth and presenting contextual factors that should be addressed to ensure the success of the programs