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Background: Community Health Volunteers (CHVs) can be effective in improving pregnancy and newborn outcomes through community education. Inadequate supervision of CHVs, whether due to poor planning, irregular visits, or ineffective supervisory methods, is, however, recognized as a weakness in many programs. There has been little research on best practice supervisory or accompaniment models. Methods: From March 2014 to February 2015 a proof of concept study was conducted to compare training alone versus training and supportive supervision by paid CHWs (n = 4) on the effectiveness of CHVs (n = 82) to deliver education about pregnancy, newborn care, family planning and hygiene. The pair-matched cluster randomized trial was conducted in eight villages (four intervention and four control) in Budondo sub-county in Jinja, Uganda. Results: Increases in desired behaviors were seen in both the intervention and control arms over the study period. Both arms showed high retention rates of CHVs (95 %). At 1 year follow-up there was a significantly higher prevalence of installed and functioning tippy taps for hand washing (p < 0.002) in the intervention villages (47 %) than control villages (35 %). All outcome and process measures related to home-visits to homes with pregnant women and newborn babies favored the intervention villages. The CHVs in both groups implemented what they learnt and were role models in the community. Conclusions: A team of CHVs and CHWs can facilitate families accessing reproductive health care by addressing cultural norms and scientific misconceptions. Having a team of 2 CHWs to 40 CHVs enables close to community access to information, conversation and services. Supportive supervision involves creating a non-threatening, empowering environment in which both the CHV and the supervising CHW learn together and overcome obstacles that might otherwise demotivate the CHV. While the results seem promising for added value with supportive supervision for CHVs undertaking reproductive health activities, further research on a larger scale will be needed to substantiate the effect.
The proof of concept study took place in eight villages in the sub-county of Budondo in Jinja district, East Uganda. The largest government health facility, where the majority of women deliver their babies, is 20 km from the nearest hospital in Jinja town that can offer care, such as blood, oxygen and caesarean sections in obstetric emergencies. Located close to the River Nile, Budondo has a predominantly rural based population, who are mostly subsistence farmers, homemakers, shopkeepers and fishermen. Recent trends in growth of sugarcane as a cash crop has created issues with food insecurity at household level. The main ethnic group is Basoga. The cluster unit was the village. The researcher resident in Uganda selected the eight study villages, from two parishes. An attempt was made to find pairs of villages according to the distances to main roads and health facilities and the number of households in each arm of the study, as well as if they had received NGO support. All of the villages in the study had previous experience with the Village Health Team (VHT) program, which trained and deployed VHTs, the equivalent of a CHV. The VHT coordinator informed the research team that most of the VHTs/CHVs, while identifying as a VHT member, were inactive from 2010, and therefore at the time of the study. While focusing mostly on preventative health, VHTs/CHVs in Uganda have been trained in a variety of roles depending on the needs of the MoH. It was noted that home visiting was done only in the context of drug or mosquito net distribution. Community members would, at times, visit the VHT/CHV at their home for advice or treatment. Interventions by other organizations were also taken into account, with villages with high levels of input excluded to prevent contamination. There was a buffer zone of at least one village between villages included in the study. Meetings with community leaders were conducted in all villages to explain the study and there were no refusals to join. The pair-matched cluster-randomized study was undertaken between March 2014 and February 2015. A modified WHO 1988 EPI sampling methodology was used to conduct baseline household surveys in March 2014, with participants being mothers of children under 5 years of age. The CHV coordinator and existing or previous CHVs who knew the village well moved with the research group. A random household was chosen in the centre of the village and a pen was spun to identify the initial direction taken and the sampling took place with every fifth household. If the household did not have a child under the age of five then the household to the right was visited until a child was identified. A total of 216 baseline household surveys conducted. Information on household hygiene and location of delivery were collected, as well as data related to newborn care, breastfeeding, infant feeding, weaning, immunization and family planning practices. Questions about the number of recommended antenatal visits; timing of initial breastfeeding; timing of first immunization; length of exclusive breastfeeding and introduction of solids were included in the post-intervention (n = 201) questionnaire. The names of the paired villages were then sent to the researchers at the University of Sydney who randomly allocated one village in each pair to the intervention group and one to the control (see Table 1). Randomization took place at the end of March 2014, following the baseline household surveys. A follow-up household survey was conducted in February 2015. Details of matched pairs of villages in Budondo aHealth Centre II, III, IV – hierarchy of health centres in Uganda bOther Health Centre The District health management team was informed and provided advice from the beginning of the study. Community leaders, who divided each village into four zones, convened meetings and representatives from each zone attended the meetings. Two or three of the 10 people in each village who became CHVs resided in each zone. Five of the CHVs in each village were selected during the community meeting according to criteria provided (over 18, respected, literate, resident and willing to volunteer) and five CHVs volunteered because of their interest in the study. This latter group will be referred to as self-selected. Self-selected CHVs were included to see how their retention rates, demographic and other characteristics differed from community-selected CHVs. A total of 82 CHVs were recruited for this study. Demographic information was collected from the CHVs for the purpose of comparing CHVs from intervention and control groups. Seven of the eight study villages had community leaders amongst the CHVs for a total of 26 community leaders: 13 in each arm of the study. A 2-day initial training was offered to all the CHVs in the study in a centralized location. Ongoing monthly training was offered to the groups of eight to twelve CHVs in their own village from a full-time CHW for two to three hours per month over a 10-month period on topics related to the role of the CHV in providing education through home visits and stimulating community action as a means to improve maternal and newborn health outcomes. Specific topics included village mapping, the importance of attending four antenatal visits, encouraging birth at a health facility, danger signs in pregnancy, birth preparation, early breastfeeding and immunization, newborn care including cord care and kangaroo care for small babies, family planning, use of ORS in diarrhea, hand-washing and how to build tippy taps. Hygiene was considered important to improve newborn outcomes. The educational content was aligned to the MoH priorities. The package was piloted during May to November 2013. Lack of trust of public health interventions was identified during focus groups and additional training materials related to trust building were included to overcome misconceptions in the community about public health interventions. The CHVs received 5000 Ugandan shillings (US$2) per month to cover their transport costs. The CHVs were asked to volunteer 5 to 10 h per week with a male and female CHV working in pairs so as to have access to the women and men in the family. The CHVs carried MoH flip charts on relevant issues and videos about breastfeeding and danger signs in newborns shown on computers or pico-projectors, which were shown to families in their homes and in antenatal clinics. While the men predominantly worked on environmental health and hygiene, they also engaged men on issues related to antenatal care, birth preparation and danger signs in pregnant women and newborn babies. Four full-time CHWs were involved in the project. They were paid the equivalent of US$80 per month. One had been a CHV coordinator for 18 years, one was a school-teacher with HIV counseling background and two had no health background. Weekly training for CHWs was provided by the researcher in Uganda and visiting doctors about the topic CHWs would train and supervise the CHVs in during the following month. CHWs reflected together after every visit to the villages and more formally during the weekly CHW training. They also had access to health professionals, the internet and books to answer specific questions that arose. The supervisory model therefore had the following characteristics: there were four full-time and paid CHWs receiving weekly training who were responsible for training all 82 CHVs. In the early learning phase, all four of the CHWs went together to all eight villages to conduct the training. Within 6 months, their capacity was built and their confidence grew, they divided into a male and female CHW team who trained the groups of four villages with approximately eight to twelve CHVs in their village monthly. The same CHWs also supervised the 43 CHVs in the intervention villages. Emphasis was placed on developing the relationship between supervising CHWs and CHVs. A gender appropriate CHW did home visits with 4–5 CHVs from two zones at a time, on the topic that had been covered in the previous training. The supervising CHW would model initial introductions and conversations with a family and then allow the CHVs to practice. He or she would also help the CHVs answer challenging questions that arose in the initial months of the intervention. The visit was referred to as accompaniment rather than supervision, during which the CHVs and CHWs learnt together with reflection at the end of the visit to discuss successes and challenges. On comparison with the usual practice of CHV training and supervision in Uganda, the control group received high quality monthly training in their own villages rather than intermittent training and centralized quarterly meetings if supervised. The following outcomes were expected from the intervention: (a) that supportive supervision would result in higher retention rates amongst the CHVs in the intervention compared to the control group; (b) that CHVs in the intervention villages would make more home visits to all homes in their zones and more home visits to pregnant women and newborn babies; and (c) that homes in the intervention villages would have higher utilization of methods to improve hygiene, including tippy taps, dish-racks, water purification and Oral Rehydration solution (ORS) for diarrhea. With 80 % power, and a design effect of 2.0, a total of 200 households (25 from each of the eight study villages) – 100 households in the four intervention villages and 100 in the four control villages – was enough to detect a 30 % difference at follow-up in the use of tippy taps and/or household dish-racks, use of purified water, women knowing a CHV and having been visited by them, visits to homes with pregnant women (2 visits) and newborn babies (3 visits in the first week) and use of ORS with diarrhoea. A p value of 0.05 was considered statistically significant. We calculated means and proportions of the baseline characteristics to identify any major differences between the households and the CHVs in the control and intervention villages. We used an intention to treat approach, with unmatched two sample t-tests, to compare process and outcome variables between the intervention and control arms [33]. This method, proposed by Diehr, takes into account the fact that randomisation was at the village level (cluster), not at the level of individual study subjects. The researcher in Uganda reviewed data for accuracy and completeness and the research team returned the following day to collect any missing data from the participants. Data were double entered and 10 % of entries re-checked.
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