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Kletter M, Harris B, Connolly E, Namathanga C, Nhlema B, Makungwa H, Chabwera B, Phiri B, Brown C. Mixed method evaluation of a learning from excellence programme for community health workers in Neno, Malawi. BMC Health Serv Res 2024; 24:355. [PMID: 38504273 PMCID: PMC10953074 DOI: 10.1186/s12913-024-10686-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/05/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Community Health Workers (CHWs) play an essential role in linking communities to facility-based healthcare. However, CHW programmes have often been hampered by low levels of staff motivation, and new tools aimed at improving staff motivation and work environment are needed. One such intervention is the "Learning from Excellence" (LfE) programme. We aimed to assess feasibility, outputs, and impact of a co-designed LfE programme on CHW motivation, in Neno District. METHODS We conducted a convergent mixed-method evaluation of the LfE programme. Co-design of the programme and forms took place between October 2019 and January 2020. LfE forms submitted between September and November 2020 were analysed using descriptive statistics and memos summarising answers to the open-ended question. To investigate experiences with LfE we conducted in-depth semi-structured interviews with key stakeholders, CHWs, and site supervisors, which were analysed thematically. A pre-post intervention questionnaire was developed to assess the impact of the co-designed LfE intervention on CHW motivation and perceived supervision. Outcomes were triangulated into a logic model. RESULTS In total 555 LfE forms were submitted, with 34.4% of CHWs in Neno District submitting at least one LfE report. Four themes were identified in the interviews: LfE implementation processes, experience, consequences, and recommendations. A total of 50 CHWs participated in the questionnaire in January 2020 and 46 of them completed the questionnaire in December 2020. No statistically significant differences were identified between pre-and post-LfE measurements for both motivation (Site F: p = 0.86; Site G: p = 0.31) and perceived supervision (Site F: p = 0.95; Site G: p = 0.45). A logic model, explaining how the LfE programme could impact CHWs was developed. CONCLUSIONS Many CHWs participated in the LfE intervention between September 2020 and November 2020. LfE was welcomed by CHWs and stakeholders as it allowed them to appreciate excellent work in absence of other opportunities to do so. However, no statistically significant differences in CHW motivation and perceived supervision were identified. While the intervention was feasible in Neno District, we identified several barriers and facilitators for implementation. We developed a logic model to explain contextual factors, and mechanisms that could lead to LfE outcomes for CHWs in Neno District. The developed logic model can be used by those designing and implementing interventions like LfE for health workers.
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Affiliation(s)
- Maartje Kletter
- The University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - Bronwyn Harris
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Emilia Connolly
- Partners In Health/Abwenzi Pa Za Umoyo, Neno, PO Box 56, Malawi
| | | | | | - Henry Makungwa
- Partners In Health/Abwenzi Pa Za Umoyo, Neno, PO Box 56, Malawi
| | - Benson Chabwera
- Partners In Health/Abwenzi Pa Za Umoyo, Neno, PO Box 56, Malawi
| | - Benson Phiri
- Partners In Health/Abwenzi Pa Za Umoyo, Neno, PO Box 56, Malawi
| | - Celia Brown
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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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. 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 Glob Health 2021; 6:bmjgh-2021-006535. [PMID: 34526321 PMCID: PMC8444244 DOI: 10.1136/bmjgh-2021-006535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/27/2021] [Indexed: 11/04/2022] Open
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.
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Affiliation(s)
- Emily B Wroe
- Partners In Health, Neno, Malawi .,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Elizabeth L Dunbar
- Partners In Health, Neno, Malawi.,Human Centered Design & Engineering, University of Washington, Seattle, Washington, USA
| | - Alexandra V Kulinkina
- Partners In Health, Neno, Malawi.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | | | | | | | | | | | | | | | | | - Ryan McBain
- Partners In Health, Boston, Massachusetts, USA.,RAND, Boston, Massachusetts, USA
| | | | - Daniel Palazuelos
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Partners In Health, Boston, Massachusetts, USA
| | - Richard Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Samuel I Watson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Lemani C, Tang J, Kopp D, Phiri B, Kumvula C, Chikosi L, Mwale M, Rosenberg N. Contraceptive uptake after a couples counseling intervention with community health workers: a cluster randomized trial. Contraception 2016. [DOI: 10.1016/j.contraception.2016.07.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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