Evaluation of community health worker's performance at home-based newborn assessment supported by mHealth in rural Bangladesh

Abstract

Background In low to middle-income countries where home births are common and neonatal postnatal care is limited, community health worker (CHW) home visits can extend the capability of health systems to reach vulnerable newborns in the postnatal period. CHW assessment of newborn danger signs supported by mHealth have the potential to improve the quality of danger sign assessments and reduce CHW training requirements. We aim to estimate the validity (sensitivity, specificity, positive and negative predictive value) of CHW assessment of newborn infants aided by mHealth compared to physician assessment. Methods In this prospective study, ten CHWs received five days of theoretical and hands-on training on the physical assessment of newborns including ten danger signs. CHWs assessed 273 newborn infants for danger signs within 48 h of birth and then consecutively for three days. A physician repeated 20% (n = 148) of the assessments conducted by CHWs. Both CHWs and the physician evaluated newborns for ten danger signs and decided on referral. We used the physician’s danger sign identification and referral decision as the gold standard to validate CHWs’ identification of danger signs and referral decisions. Results The referrals made by the CHWs had high sensitivity (93.3%), specificity (96.2%), and almost perfect agreement (K = 0.80) with the referrals made by the physician. CHW identification of all the danger signs except hypothermia showed moderate to high sensitivity (66.7–100%) compared to physician assessments. All the danger signs assessments except hypothermia showed moderate to high positive predictive value (PPV) (50–100%) and excellent negative predictive value (NPV) (99–100%). Specificity was high (99–100%) for all ten danger signs. Conclusion CHW's identification of neonatal danger signs aided by mHealth showed moderate to high validity in comparison to physician assessments. mHealth platforms may reduce CHW training requirements and while maintaining quality CHW physical assessment performance extending the ability of health systems to provide neonatal postnatal care in low-resource communities. Trial registration clinicaltrials.gov NCT03933423, January 05, 2019.

Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh

“…The hands-on training to assess newborns and mothers for danger signs and breastfeeding assessment included maintaining hand hygiene before examining the newborn, and examination of the newborn for ten danger signs adopted from the 2009 National Newborn Health Strategy [ 35 ] as described previously [ 31 , 36 – 40 ]. CHWs examined five babies under the supervision of a neonatologist and study physician and received feedback on their performance.…”

“…On each day, the physician collected the list of the households the CHWs visited and conveniently picked households to repeat assessments. The study physician and field supervisors observed CHW assessments of danger signs and phototherapy administration and provided feedback as necessary [ 36 ].…”

Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh

“…This included the responsibilities of CHWs, pregnancy care and maternal danger signs, delivery planning and safe delivery preparations, essential newborn care, breastfeeding and management of breastfeeding problems, postpartum services and the responsibilities of CHWs, neonatal jaundice types and symptoms, neonatal jaundice risk and management, descriptions of equipment and materials associated with jaundice management, and the sick newborn referral system and its components. In the second phase, CHWs received training on general examination of the newborn infant, physical examination for neonatal jaundice and assessment of neonates and mothers for other danger signs, [ 18 ] neonatal hyperbilirubinemia signs and symptoms, screening with transcutaneous bilimeter and management using mHealth application, assessment of breastfeeding, and management of breastfeeding problems.…”

Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh

“…During visits, CHWs counselled mothers on pregnancy care, safe delivery, essential newborn care, early initiation of breastfeeding, sensitized the mothers about the signs and symptoms of hyperbilirubinemia, and the importance of testing and treatment to prevent mortality and morbidity. [27] Parents were educated to make a plan for how they would get to the hospital if needed for emergency newborn care and treatment.…”

“…[48,49] In our study, this was overcome prenatal sensitization, the use of a point-of-care instant diagnostic device (transcutaneous bilimeter), and having access to a study physician to answer parental questions. [27] The objective measurement from the transcutaneous bilimeter helped improve con dence from families that phototherapy was needed. [42] The refusal rate for home phototherapy was 8%, which was low compared to other CHW-led home-based curative treatment approaches where refusal rates of home care for very severe disease and possible very severe disease were 23% and 38%, respectively.…”