Comparison of high- versus low-intensity community health worker intervention to promote newborn and child health in Northern Nigeria

Background: In Northern Nigeria, infant mortality rates are two to three times higher than in the southern states, and, in 2008, a partnership program to improve maternal, newborn, and child health was established to reduce infant and child mortality in three Northern Nigeria states. The program intervention zones received government-supported health services plus integrated interventions at primary health care posts and development of community-based service delivery (CBSD) with a network of community volunteers and community health workers (CHWs), who focus on educating women about danger signs for themselves and their infants and promoting appropriate responses to the observation of those danger signs, consistent with the approach of the World Health Organization Integrated Management of Neonatal and Childhood Illness strategy. Before going to scale in the rest of the state, it is important to identify the relative effectiveness of the low-intensity volunteer approach versus the more intensive CBSD approach with CHWs. Methods: We conducted stratified cluster sample household surveys at baseline (2009) and follow-up (2011) to assess changes in newborn and sick child care practices among women with births in the five prior years (baseline: n = 6,906; follow-up: n = 2,310). The follow-up respondents were grouped by level of intensity of the CHW interventions in their community, with “low” including group activities led only by a trained community volunteer and “high” including the community volunteer activities plus CBSD from a CHW providing one-on-one advice and assistance. t-tests were used to test for significant differences from baseline to follow-up, and F-statistics, which adjust for the stratified cluster design, were used to test for significant differences between the control, low-intensity, and high-intensity intervention groups at follow-up. These analyses focused on changes in newborn and sick child care practices. Results: Anti-tetanus vaccination coverage during pregnancy increased from 69.2% at baseline to 85.7% at follow-up in the intervention areas. Breastfeeding within 24 hours increased from 42.9% to 59.0% in the intervention areas, and more newborns were checked by health workers within 48 hours (from 16.8% at baseline to 26.8% at follow-up in the intervention areas). Newborns were more likely to be checked by trained health personnel, and they received more comprehensive newborn care. Compared to the control communities, more than twice as many women in intervention communities knew to watch for specific newborn danger signs. Compared to the control and low-intensity intervention communities, more mothers in the high-intensity communities learned about the care of sick children from CHWs, with a corresponding decline those seeking advice from family or friends or traditional birth attendants. Significantly fewer mothers did nothing when their child was sick. High-intensity intervention communities experienced the most decline. Those who did nothing for children with fever or cough declined from 35% to 30%, and with diarrhea from 40% to 31%. Use of medications, both traditional and modern, increased from baseline to follow-up, with no differentiation in use by intervention area. Conclusion: The community-based approach to promoting improved newborn and sick child care through community volunteers and CHWs resulted in improved newborn and sick child care. The low-intensity approach with community volunteers appears to have been as effective as the higher-intensity CBSD approach with CHWs for several of the key newborn and sick child care indicators, particularly in the provision of appropriate home care for children with fever or cough. © 2013 Findley et al.

The focus of this study is on the impact of the MNCH interventions, which were implemented in three of the four northern Nigerian states in which PRRINN has expanded its MNCH activities, namely Katsina, Yobe, and Zamfara, with respective populations of 5.8, 2.3, and 3.3 million, according to the 2006 population census of Nigeria.15 The program design focuses on improving MNCH care by clusters of local government areas (LGAs) per state, which each comprise a catchment area for EOC services. A total of 15 LGAs were selected as the first intervention clusters, with four to six LGAs per state. The cluster approach was based on the World Health Organization (WHO) comprehensive EOC model.16 Within the program, the cluster approach uses one comprehensive EOC facility per 500,000 people. Making referrals to this comprehensive EOC facility are four basic EOC facilities (each serving 100,000 people, with the comprehensive EOC facility serving the other 100,000 people) and eight “24/7” facilities providing maternal care. The remaining LGAs had statewide policy changes without focused clinical or community activities to improve health system infrastructure and MNCH care demand. The health system-strengthening component of the intervention includes upgrading EOC services within local health facilities, midwife training and posting through the Nigerian government’s Midwife Service Scheme, establishing planning and management techniques within existing facilities, and establishing the “Primary Health Care Under One Roof ” system, which consolidates and coordinates the different components of primary care in one health clinic or post. Complementing these supply-side changes are activities that create demand for MNCH services. Selected groups of villages served by primary care facilities linked to the upgraded EOC facility participate in a community engagement process, which aims to increase awareness, knowledge, and practices of healthy behaviors in response to MNCH barriers. The core of this process is a community discussion-group methodology, facilitated by trained community volunteers (CVs), which provides a space for reflection and problem-solving for the most prevalent MNCH problems affecting the community. CVs are recruited in each community and trained to do outreach and social mobilization, emphasizing the use of community discussion groups and jingles and other visual-auditory cues for education about critical MNCH issues, such as danger signs for a pregnancy or the timing of childhood vaccinations. In addition to these health education roles, the CVs also aid in identifying at-risk women and children and referring them to the nearest facility for care. The CVs were nominated by other community members and, in some cases, by traditional leaders. Training of CVs was community based and used a cascade or train-the-trainers model, with core trainers training CVs who, in turn, train new volunteers. The participatory training methodology was underpinned by key principles of adult learning and took trainees through a learning cycle, starting with discussions and reflection of personal experiences (sad memories), leading to consideration of potential responses/solutions, and eventually resulting in action. Body memory tools (eg, use of fingers to demonstrate the number of immunization visits required for children at specific ages, or mimicking movements of the body when affected by different danger signs) helped trainees remember key facts and were a highly effective aid to learning. Demonstration by a core trainer followed by repetitive practice sessions reviewed by other trainees was also highly effective. The CV training focused both on core content and on the facilitation techniques needed to engage appropriately with the community. Between 2010 and 2013, almost 30,000 CVs, primarily women, were recruited, mobilized and supported in their work in over 3,600 communities. Community discussion-group participants are encouraged and supported to establish emergency systems by which to tackle key barriers to access to and affordability of MNCH services, including establishment of blood donor groups, community emergency savings schemes, community emergency transport schemes, and a “mother’s helpers” system. Members of the discussion groups are encouraged to share what they know with their families and peers between sessions, leading to rapid saturation of the entire community with new ideas. This work is reinforced by mass communication activities, including the use of radio jingles to promote birth preparedness or childhood immunizations. Because the CVs focus on outreach and engagement through group discussions without any home visits or care activities, communities with CVs only were designated as having the low-intensity CHW intervention. In 2010, the year before this evaluation, the program also developed a small cadre of CHWs, community-based health workers providing selected primary health services directly to families through rotating visits or extended availability through residence in the communities. These CHWs were recruited among unemployed but previously trained Junior Community Health Extension Workers trained by the state Schools of Health Technology, who were then given 2 weeks of additional training and toolkits to enable them to make home visits, engage mothers using supportive communication techniques, provide basic preventive antenatal care and NCH services, basic treatment services through WHO Integrated Management of Neonatal and Childhood Illness strategy, and refer to the primary health care facility for treatment as needed. These community-based health workers are provided with transport to enable them to visit communities on a regular schedule, and they spend most of their time visiting families and providing preventive and basic treatment services in the community. At the time of the evaluation reported here, these CHWs were active in 25 communities, all of which also had CVs supporting their work through community education and mobilization. Communities with CVs and CHWs providing CBSD were designated as receiving the high-intensity CHW intervention. The assessment of the impact of the CBSD programs uses a quasi-experimental design using pre- and post-intervention household surveys in the intervention and control communities. The pre-intervention or baseline household survey (BHS) was conducted in 2009 and the post-intervention household survey or follow-up household survey (FHS) was conducted in 2011. This program is grounded in the hypothesis that this multi-component intervention will lead to changes in health knowledge and behaviors and attitudes toward existing services, resulting in increased service utilization and improved health outcomes. The evaluation of the impact of this integrated MNCH package takes into account both availability of the program and actual individual participation in any of the program’s community-based service activities. Availability of the program activities was assessed by comparison of intervention (categorized as low and high) and control areas. Low-intervention communities are defined as communities with community engagement activities by CVs only, whereas high-intervention communities are those with community engagement by CVs plus CBSD strategies. Individual exposure to the program was assessed by the women’s responses to questions eliciting sources of information or health care advice, which allowed for different sources corresponding to the alternative CBSD strategies. The study was approved by state ethics review committees in each of the three states, as both cross-state and individual state approval. These ethics review committees are certified by the Nigerian Federal Government’s National Health Research Ethics Committee to review and approve health research protocols for their states. The sampling plan was a stratified two-stage cluster sample, with oversampling of individuals in the MNCH intervention clusters. Individuals from MNCH clusters were oversampled using a ratio of 2:1, because MNCH clusters cover a significantly lower proportion of the population of each state. Oversampling therefore provided a sufficient sample in the intervention areas to assess the impact of key elements within the intervention package on the key MNCH outcomes. The primary sampling unit for this sample was the LGA, of which there were 24 in the BHS and 15 in the FHS. For the FHS, the same intervention LGAs as in the BHS were included, with the exception of LGAs of the state capitals (considered not to be an appropriate control for the largely rural intervention). The LGAs comprising the state capitals were included only during the baseline to assess the differences in services provided to residents patronizing urban versus rural facilities. This enabled the team to devise appropriate strategies for referral from rural to urban facilities. The state capitals were excluded in the analyses reported here. The number of households selected per LGA was proportional to the size of the LGA. The study was designed with an 80% power to detect even the smallest change (ie, 2.5% change) in the percentage of women delivering with the assistance of skilled birth attendants between the BHS and the FHS. The BHS was designed to be representative of all ever-married women in the household and required a sample of 5,560 households, while the FHS was designed to be representative only of ever-married women with a birth in the previous 5 years, requiring a sample of only 2,310 households. In the BHS, the sample of 5,560 households was 0.7% to 9.8% per LGA, while, for the FHS, the 2,310 households comprised 3.1% to 13.1% of all households. Within the LGA, the sample of households was allocated to intervention and control communities in proportion to the size of the community or village. The sampling fraction for each community was determined by information on the total households from the community leader. Households within each selected community were randomly sampled using a procedure similar to that used in the WHO-Expanded Program on Immunization cluster surveys,17 namely by numbering then sampling households according to the community sampling fraction along randomly selected paths leading out from the center of the village. The household was the ultimate sampling unit. In compounds that comprised one to three households, one household was randomly chosen for interviews; in compounds with four to six households, two were surveyed; in compounds with seven or more households, three were surveyed. Within each randomly selected household, in the baseline survey, all ever-married women of childbearing age (15–49 years) were interviewed, whereas in the FHS only one ever-married woman with at least one child born in the last 5 years was selected for interview. In the BHS, there were 6,842 women with successfully completed interviews, while, in the FHS, there were 2,310 completed interviews. Interviewers who had completed secondary school or higher were selected and trained to visit the selected women at home and administered a questionnaire that included translation of key concepts and terms in the local languages (eg, Hausa, Kanuri). Most of the interviewers were female, responding to cultural expectations and beliefs that encourage females to respond to female interviewers. In both the BHS and FHS, the questionnaires used adopted some of the close-ended questions from the 2008 Demographic and Health Survey14 to allow comparison of results with other national- or state-level data. Questions were modified in line with the program goals and focused on a series of topics related to perceptions, knowledge, and practices related to MNCH outcomes. Specifically, the topics included issues related to information such as age, parity, economic status, literacy in any language, wife rank (sequence in polygamous marriage), antenatal care and delivery characteristics, infant and child mortality, source of health advice for the woman or the baby during last pregnancy, and experience of labor and delivery complications. Among other things, the survey also collected information on husband–wife communication about MNCH issues. Comparable data sets were generated from the BHS and FHS, including only ever-married respondents who had had a birth in the previous 5 years. Respondents were assigned to the control or intervention groups based on the level of PRRINN-MNCH program intervention at the time of the survey. For the BHS, which was pre-intervention, the intervention LGAs included all LGAs in the first cluster receiving comprehensive emergency obstetrical care upgrades and related community engagement activities, while the balance were control LGAs. The FHS included the same intervention LGAs; LGAs that had been control in the BHS but had started to receive the intervention by the time that the FHS was administered were shifted to the intervention category. The intervention respondents were further classified as receiving the high-intensity intervention if they were in communities with the pilot CBSD program with CHWs, while the remainder of the intervention communities was designated as low-intensity intervention communities. The dependent variables were the key health behaviors pertaining to newborn care and care of sick children. The two sets of survey data were separately analyzed using sampling weights based on the intervention and control areas. We examined changes in the proportion with the designated MNCH behavior or outcome, and compared all pre-intervention responses (all BHS) with the post-intervention responses from the FHS, namely intervention only, both high and low intensity. We then assessed the degree to which the different intervention groups differed at follow-up (control versus low intensity versus high intensity) using the F-statistic, adjusted for the complex sampling design of the FHS (15 primary sampling unit and three strata [control, low-intensity intervention, high-intensity intervention]). Analyses were performed using Stata (v 12.0; Statacorp, College Station, TX, USA) and SPSS software (v 19.0; IBM Corporation, Armonk, NY, USA).

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