Informing humanitarians worldwide 24/7 — a service provided by UN OCHA

South Africa

A continuous quality improvement intervention to improve the effectiveness of community health workers providing care to mothers and children: a cluster randomised controlled trial in South Africa

Attachments

Human Resources for Health201715:39 https://doi.org/10.1186/s12960-017-0210-7© The Author(s). 2017 Received: 5 January 2017Accepted: 31 May 2017Published: 13 June 2017 Open Peer Review reports

Abstract

Background Community health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs.

Methods

This is a cluster randomised controlled trial to investigate the effectiveness of a continuous quality improvement (CQI) intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention (n = 15) and control (n = 15) arms. Four CHWs were randomly selected from those routinely supported by each supervisor (n = 60 per arm). In the intervention arm, these four CHWs and their supervisor formed a quality improvement team. Intervention CHWs received a 2-week training in WHO Community Case Management followed by CQI mentoring for 12 months (preceded by 3 months lead-in to establish QI processes). Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs.

Results

Interviews were conducted with 736 and 606 mothers at baseline and follow-up respectively; socio-demographic characteristics were similar in both study arms and at each time point.

At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy (75.7 vs 29.0%, p < 0.0001) and the postnatal period (72.6 vs 30.3%, p < 0.0001). Intervention mothers had higher maternal and child health knowledge scores (49 vs 43%, p = 0.02) and reported higher exclusive breastfeeding rates to 6 weeks (76.7 vs 65.1%, p = 0.02). HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW (78.7 vs 50.0%, p = 0.007). Uptake of facility-based interventions were not significantly different.

Conclusions

Improved training and CQI-based mentoring of CHWs can improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers’ knowledge and infant feeding practices.

Trial registration

ClinicalTrials.Gov NCT01774136

Keywords

Community health worker Quality improvement Breastfeeding South Africa Maternal health Child health HIV Background

Community health workers (CHWs) are generally defined as community members chosen by their community to support or provide health interventions at household level; they are linked to the health system, but have shorter training than professional health workers [1]. Deployment of CHWs can address barriers to preventive and curative care, increasing coverage of key interventions including maternal and child health services, and improve continuity of care during pregnancy and the postnatal period [2]. Together, these can accrue substantial health benefits for communities including mothers and children [3].

In South Africa, where HIV prevalence amongst pregnant women varies between 16.9 and 37.4% across provinces [4], maternal and child mortality remain higher than expected despite evidence-based packages of care being available in primary health care (PHC) facilities [5]. To improve survival, coverage of key interventions must increase, particularly early antenatal care (ANC) attendance (before 22 weeks), postnatal care and infant feeding support, prevention of mother-to-child HIV transmission (PMTCT) interventions and early access to antiretroviral therapy (ART) for mothers living with HIV and their infants.

However, improvements in facility-based care for pregnant women, mothers and children may have limited impact. In South Africa, over half of child deaths occur outside of the health facility [6] largely due to a failure to recognise serious illness amongst children in the home, so that children present late to health facilities. CHW-based interventions may bridge this gap and, in some settings, have substantially reduced maternal and neonatal mortality [7, 8, 9, 10]. Elsewhere, however, CHW interventions that improved knowledge and care practices amongst mothers had no effect on maternal and child health outcomes [11]. The implementation and outcome of CHW programmes is dependent not only on appropriate training but also on support and effective supervision that is coordinated with PHC services [2].

In South Africa, most CHWs are recruited and employed by the Department of Health and receive a small stipend. CHWs fulfil a variety of roles in the community including home-based care, adherence support for antiretroviral and TB treatment as well as provision of maternal and child health (MCH) services. Their role in provision of MCH services in households includes counselling about early ANC attendance, identification of danger signs in newborns and support for breastfeeding and is clearly described in the Department of Health policy for community-based maternal, child and newborn care [12].

In this study, we implemented the WHO Community Case Management (CCM) training [13], combined with ongoing mentoring using a continuous quality improvement (CQI) approach [14], to improve and maintain skills of CHWs caring for mothers and children in the community. CCM is based on treatment algorithms developed for Integrated Management of Childhood Illness (IMCI) and broadens access to care by equipping CHWs with skills to support pregnant women and assess and manage sick infants and children in the household [15]. We adapted CCM materials to include interventions to support uptake and delivery of PMTCT and ART services.

CQI is a simple, low-tech approach to the management and supervision of health programmes which has been successfully used to improve PMTCT uptake at facility level in South Africa [16, 17]. The CQI method guides practitioners to better performance by using locally generated data to provide feedback on practices and knowledge. Once gaps in performance are shown, health workers generate, develop and test local solutions and track change in performance to achieve improvement [14, 18].

Here, we report the number of CHW visits and changes in maternal knowledge, household child care practices, care-seeking behaviour and uptake of facility-based maternal and child health interventions by mothers residing in households served by CHWs provided with additional training and supervised using a CQI mentoring approach.