An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol

Abstract

BackgroundEvidence-based medicines, technologies, and protocols exist to prevent many of the annual 300,000 maternal, 2.7 million neonatal, and 9 million child deaths, but they are not being effectively implemented and utilized in rural areas. Nepal, one of South Asia’s poorest countries with over 80% of its population living in rural areas, exemplifies this challenge. Community health workers are an important cadre in low-income countries where human resources for health and health care infrastructure are limited. As local women, they are uniquely positioned to understand and successfully navigate barriers to health care access. Recent case studies of large community health worker programs have highlighted the importance of training, both initial and ongoing, and accountability through structured management, salaries, and ongoing monitoring and evaluation. A gap in the evidence regarding whether such community health worker systems can change health outcomes, as well as be sustainably adopted at scale, remains. In this study, we plan to evaluate a community health worker system delivering an evidence-based integrated reproductive, maternal, newborn, and child health intervention as it is scaled up in rural Nepal.MethodsWe will conduct a type 2 hybrid effectiveness-implementation study to test both the effect of an integrated reproductive, maternal, newborn, and child health intervention and the implementation process via a professional community health worker system. The intervention integrates five evidence-based approaches: (1) home-based antenatal care and post-natal care counseling and care coordination; (2) continuous surveillance of all reproductive age women, pregnancies, and children under age 2 years via a mobile application; (3) Community-Based Integrated Management of Newborn and Childhood Illness; (4) group antenatal and postnatal care; and 5) the Balanced Counseling Strategy to post-partum contraception. We will evaluate effectiveness using a pre-post quasi-experimental design with stepped implementation and implementation using the RE-AIM framework.DiscussionThis is the first hybrid effectiveness-implementation study of an integrated reproductive, maternal, newborn, and child health intervention in rural Nepal that we are aware of. As Nepal takes steps towards achieving the Sustainable Development Goals, the data from this three-year study will be useful in the detailed planning of a professionalized community health worker cadre delivering evidence-based reproductive, maternal, newborn, and child health interventions to the country’s rural population.Trial registrationClinicalTrials.gov Identifier: NCT03371186, registered 04 December 2017, retrospectively registered.Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0741-x) contains supplementary material, which is available to authorized users.

Incidence and characteristics of pregnancy‐related death across ten low‐ and middle‐income geographical regions: secondary analysis of a cluster randomised controlled trial

“…In the post-Millennium Development Goal era, the global health focus is on not just reducing mortality but also reducing morbidity. 15 Yet in this study more than 20-fold variation in mortality was observed between regions, suggesting that the focus on maternal mortality globally should not be lost.…”

Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal

“…In this context, the nongovernmental organization Nyaya Health Nepal developed a collaborative effort with the Ministry of Health and Population, Department of Health Services, Family Welfare Division to implement a CHW pilot program 21 that was closely aligned with WHO guidelines (Table 1), which may offer insight for Nepal's future CHW programs. This pilot program has had promising early results, described in detail elsewhere, 22,23 including between 2014 and 2016, improving antenatal care (ANC), institutional birth rate, and postpartum contraception ( Figure 1).…”

“…In 2017, the pilot study was implemented in both Achham and Dolakha districts (Province 3) targeting expansion to a catchment area population ultimately of more than 250,000 people. 21 The subpopulation of the pilot described in this analysis included the original program area, Sanfebagar municipality, and the first expansion area, Kamalbazaar municipality in Achham, which together have a population of 60,504 persons. 24 A total of 30 CHWs were employed in the 2 pilot municipalities during the time period of July 16, 2017 to July 15, 2018.…”

“…During home visits, CHWs conduct urine pregnancy testing; trimester-specific antenatal counseling and referral; postnatal counseling and referral (with a strong emphasis on contraception counseling); age-specific child health and nutrition counseling; childhood illness screening and referral (based on community-based Integrated Management of Neonatal and Childhood Illnesses, and NCD counseling and referral ( Figure 2). 21 Services delivered are determined based upon local and national priorities and morbidity and mortality burden. In addition to home visits, CHWs facilitate group ANC sessions at local health posts on a bimonthly schedule, with 1 of the monthly visits for early gestation (4-and 6-month pregnant women) and the other for late gestation (8-and 9-month pregnant women).…”

“…4,23 The pilot study has been described in detail previously. 21 In brief, the pilot is a Type II hybrid effectiveness-implementation research study, evaluating effectiveness using a pre-post, quasi-experimental design with stepped implementation and evaluating implementation using the RE-AIM framework. Enrollment began in 2017 and concluded in 2019, with the goal to enroll over 250,000 community members across both Dolakha and Achham districts.…”