Implementation research on community health workers’ provision of maternal and child health services in rural Liberia

Bull World Health Organ 2017;95:113–120 | doi: http://dx.doi.org/10.2471/BLT.16.175513 Research 113 Implementation research on community health workers’ provision of maternal and child health services in rural Liberia Peter W Luckow,a Avi Kenny,b Emily White,b Madeleine Ballard,c Lorenzo Dorr,b Kirby Erlandson,d Benjamin Grant,b Alice Johnson,b Breanna Lorenzen,e Subarna Mukherjee,b E John Ly,b Abigail McDaniel,b Netus Nowine,f Vidiya Sathananthan,b Gerald A Sechler,g John D Kraemer,h Mark J Siedneri & Rajesh Panjabig Introduction Over 95% of global maternal and child deaths occur in 75 low- and middle-income countries and remote populations within these countries often bear the greatest burden.1,2 Many countries are exploring strategies to scale up community health worker (CHW)-based programmes, which have been demonstrated to improve health in the domains of maternal and child health, access to family planning and prevention of human immuno- deficiency virus (HIV) infection, malaria and tuberculosis.3,4 In Liberia, an estimated 60% (1.2 million people) of the ru- ral population lives more than 5 km from the nearest health fa- cility and the country has among the highest maternal and child mortality rates globally, 725 deaths per 100 000 live births and 70 deaths per 1000 live births, respectively.5–7 In 2012, the health ministry partnered with Last Mile Health, a nongovernmental organization, to pilot a programme for enhanced CHW-based health care for remote populations (those living farther than 5 km or a one hour walk from the nearest health facility). The programme aimed to increase coverage of essential maternal and child health services through enhanced recruitment, train- ing, supervision and compensation of CHWs. Responsibilities of CHWs included provision of: (i) integrated community case management of childhood illnesses, including diarrhoea, acute respiratory infection and malaria; and (ii) maternal and new- born care. Here, we describe the programmatic components, implementation and an assessment of changes in maternal and child health-care use three years after implementation. Methods Setting and participants The programme took place in Konobo district in south-eastern Liberia. Konobo is one of Liberia’s most remote regions, com- prised of 2983 km2 of rainforest, with a population density of 4.1 people/km2. In 2012, approximately 12 000 residents in the district lived more than 5 km from the nearest clinic. One quarter were women of reproductive age (15–49 years) and 16% were children under five years. These two demographic groups represented the target population of the programme. All 44 re- mote communities in Konobo, located more than 5 km from the district’s only health clinic were involved with the programme. The average road distance from these communities to the clinic was approximately 25 km and the mean population of the communities was 276 people. According to the 2012 Liberian Demographic and Health Survey, Konobo had worse maternal and child health outcomes than other rural Liberian districts.8 Objective To assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme. Methods The Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation. Findings Between 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly. Conclusion We identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes. a Geisel School of Medicine at Dartmouth College, Hanover, United States of America (USA). b Last Mile Health, Monrovia, Liberia. c Department of Social Policy and Intervention, University of Oxford, Oxford, England. d Harvard Medical School, Boston, USA. e University of Minnesota Medical School, Minneapolis, USA. f Grand Gedeh County Health Team, Ministry of Health, Monrovia, Liberia. g Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA. h Department of Health Systems Administration, Georgetown School of Nursing and Health Studies, Washington, USA. i Department of Medicine, Harvard Medical School, Boston, USA. Correspondence to Rajesh Panjabi (email: raj@lastmilehealth.org). (Submitted: 31 May 2016 – Revised version received: 7 October 2016 – Accepted: 9 October 2016 ) Bull World Health Organ 2017;95:113–120| doi: http://dx.doi.org/10.2471/BLT.16.175513114 Research Maternal and child care in Liberia Peter W Luckow et al. Implementation We implemented the programme be- tween 2012 and 2015 in a stepwise fash- ion over three geographic areas within Konobo district. Integrated community case management of childhood illness was launched in February 2013, August 2013 and March 2014. Maternal and newborn care services were launched in November 2012, December 2013 and April 2015. CHW recruitment and staffing We recruited CHWs through commu- nity nomination, as recommended by the 2008 National policy and strategy on community health services.9 Our recruit- ment process added several components, including (i) completion of a literacy test; (ii) an in-person interview to assess motivation and communication skills; and (iii) training and subsequent skills’ assessment for candidates that passed the interview. After this additional three-step screening and assessment, we identified and hired the highest scoring CHWs. We also conducted a follow-up competency assessment during the first 90-days of their employment. We recruited CHWs from the communities in which they resided, and they served communities within a 30-minute walk from their home community. We also interviewed and hired two types of supervisors: clinical supervi- sors (i.e. clinic-based community health nurses and physician assistants) and peer supervisors (i.e. non-clinical supervisors who conduct process supervision and community engagement). Best perform- ing CHWs were promoted to serve as peer supervisors. Training, supervision and compensation CHWs completed an initial two-week training in the district capital. Training modules focused on community leader- ship (to promote community engage- ment), household mapping (to define his/ her catchment population) and registra- tion (to assess demographics). Subsequent modules were administered in the district capital roughly once every three months and focused on preventive and curative components of maternal, neonatal and child health services, including birth plan- ning, perinatal care, integrated community case management of malaria, acute respira- tory infection and diarrhoea, and criteria for referral of patients with warning signs to health clinics. A typical training took two weeks to complete. Physician assis- tants and registered nurses led the training sessions that focused on clinical skills, such as history-taking, physical examina- tion and specific clinical procedures, such as rapid diagnostic testing for malaria. After the start of the Ebola virus disease outbreak, we added a training module on surveillance for Ebola symptoms. CHWs received weekly supervision visits from peer supervisors who were trained in project and supply manage- ment, supportive supervision and refer- rals. Supervision visits were designed to last one hour each and consisted of form reviews, patient audits and restocking of essential commodities. High-performing CHWs were promoted to peer supervi- sors, and were equipped with a motorbike for travel during supervision visits. Ini- tially, the visits were unstructured and left to the discretion of individual supervisors, however, since May 2013, supervision visits included the use of quality assur- ance checklists and randomly-sampled patient audits led by the peer supervisors. Separately, clinical supervisors conducted monthly field supervision visits to assess adherence to clinical protocols and pro- vide formative feedback based on form reviews and direct observation of patient interactions. Although the 2008 National policy and strategy on community health ser- vices specified in-kind compensation for CHWs,9 an agreement with the health ministry allowed an additional monthly cash payment to CHWs and supervisors. CHWs were paid 60 United States dol- lars (US$) per month for an estimated 20 hours of work per week, while peer supervisors and clinical supervisors were paid US$ 150 and US$ 550 per month respectively. Programme services Initially, services were provided through passive surveillance, whereby community members visited CHW households during periods of illness or pregnancy. CHWs were trained to conduct integrated com- munity case management for diarrhoea, acute respiratory infection and malaria, along with referral of cases that presented with danger signs. They were equipped with diagnostic tools, including rapid malaria diagnostic tests, mid-upper arm circumference bands and thermometers, and therapeutics, including zinc, oral rehydration salts, amoxicillin, acetamino- phen and artemisinin-based combination therapy. Malaria was diagnosed with rapid diagnostic tests in children, with a measured fever. Additionally, CHWs con- ducted home-based antenatal care educa- tion, helped design birth plans, scheduled facility-based deliveries, screened preg- nant women and neonates for danger signs, referred cases with danger signs to the clinic and promoted exclusive breastfeeding. CHWs provided services at no cost to community members. To further promote health-care utilization, CHWs organized community health committees that partnered with trained traditional midwives to refer expectant mothers to stay at maternal waiting homes (a residence near the clinic for at-term mothers), until childbirth. Beginning in April 2013, the programme paid the midwives US$ 3–5 for clinic referrals, and mothers who delivered in the clinic were provided transport reimbursements and food stipends. We modified several elements of the programme during the Ebola virus disease outbreak. After the start of the outbreak in 2015, CHWs performed active surveil- lance through monthly household visits. While there were no confirmed cases of Ebola in the study area, use of rapid malaria diagnostic tests was suspended to ensure the safety of CHWs, and the programme adopted treatment protocols based on self-reported signs and symp- toms. Similar changes were implemented for treatment of diarrhoea and acute respiratory infection. Data collection and analysis We used data from two population-rep- resentative household surveys conducted by Last Mile Health in August 2012 and August 2015. Fundamental aspects of the survey design and execution were de- scribed previously.2 The questionnaire was adapted from the 2007 and 2012 Liberian Demographic and Health Surveys and included sections on household charac- teristics, maternal and neonatal health, re- productive health, child health and access to health care. We used a two-stage cluster design for the sampling, which provided a representative sample for assessing chang- es in maternal and child health-care use. We constructed a sampling frame using raw data from the 2008 Liberian Census. The frame was adjusted using information from household enumeration performed by Last Mile Health before each survey. Communities were the primary sampling units and were selected using probability- proportional-to-size sampling. Individual Bull World Health Organ 2017;95:113–120| doi: http://dx.doi.org/10.2471/BLT.16.175513 115 Research Maternal and child care in LiberiaPeter W Luckow et al. households served as secondary sampling units. Random selection of households within communities was done through a random walk procedure. For the 2012 baseline survey, we had a total sample of 600 households, selected from 30 clusters. Last Mile Health updated the sampling frame for the 2015 follow-up survey after a re-count of all the households in the district. The 2015 sample included 1035 households, selected from 45 clusters. We interviewed women ages 18–49 years in both surveys. We made certain changes to the sur- vey between 2012 and 2015. We added questions to the follow-up survey on asset ownership, family planning, pro- vider use, vaccination and knowledge of Ebola. Before and after implementation, comparisons were restricted to consistent items between surveys and to communi- ties common to both sampling frames. Individual weights for survey variables were adjusted post-hoc based on 2015 data. In 2012, enumerators interviewed the woman in the household who most recently completed a pregnancy, while in 2015, all women within a household were sampled and interviewed. The compara- tive analysis was therefore restricted to the household woman who in the 2015 survey responded as giving birth most recently. Surveys were done in Liberian English and Konobo Krahn by bilingual enumerators. Outcome measures We defined the child health-care use outcomes as management of childhood illnesses by a formal care provider within a two-week recall period. The childhood illnesses included were: (i) diarrhoea; (ii) acute respiratory infection (defined as the combination of fever with a rapid respiratory rate); and (iii) fever. We de- fined formal care providers as community health workers, ministry of health com- munity health volunteers (who were active in some parts of Liberia but not in our study area) and clinic staff. For maternal and neonatal health-care use, we defined outcomes as: (i) completing at least one antenatal care visit at a health facility; (ii) having a facility-based delivery; and (iii) receiving postnatal care from a clinic staff member or a CHW within 24 hours of delivery. To assess change in child health- care use, data from the 2012 survey and the 2015 survey were used as before and after programme implementation, respec- tively. To assess changes with maternal care use, the 2012 survey was used as a baseline, but assessment of programme implementation was restricted to births captured after April 2013, when all catch- ment communities had initiated at least one maternal health programme element. Data analysis We conducted descriptive analyses to summarize respondent characteristics at baseline and after programme imple- mentation. We fit logistic regression models to compare differences in each of the outcome indicators before and after implementation. The regression models for maternal health were adjusted for community type (agricultural versus gold- mining), maternal age, distance to health facility (measured by global positioning system) and presence or absence of mo- tor vehicle access to the nearest health facility. The models for child health were adjusted for these same variables as well as the child’s age. After regression, we used predictive margins, holding covari- ates at their observed values to estimate adjusted percentages of each outcome indicator before and after programme implementation, and tested before-to- after changes using contrasts of predicted percentages. Since the CHW programme had not started at the time of the base- line survey in 2012, we estimated the percentage of child health encounters for integrated community case management of childhood illnesses that were provided by a CHW only for 2015. To assess mod- erating effects of community type, we ran the same maternal and child health models with an interaction term of com- munity type and programme period. All analyses incorporated complex sampling design using inverse probability weights and finite population corrections at both stages. Standard errors were adjusted for clustering using Taylor linearization. Statistical analyses were conducted us- ing Stata version 14.2 (Statacorp, College Station, Texas, United States of America). Ethical considerations We obtained ethical approval for the sur- veys from the institutional review boards of Partners Healthcare, Georgetown University and the Liberian Institute for Biomedical Research. Respondents gave verbal informed consent. Results Implementation of programme Between October 2012 and August 2015, we recruited and trained a total of 54 CHWs and 10 supervisors, of whom 39 CHWs and 5 supervisors remained active at the end of the pilot period. By the completion of the programme, CHW-to-population ratio within the study area was 1:311, which was more than threefold higher than the ratio of 1:1 000 proposed in the Liberian health ministry’s policy.9 Respondent characteristics Table 1 summarizes the survey respon- dents’ characteristics. We used data from 364 women of the 2012 survey and 205 women, who met the inclusion criteria of the 2015 survey. The mean maternal ages were 30 and 29 years (P = 0.002), respectively. Completing secondary education was more common in the follow-up survey (P = 0.039). There were no statistically significant differences in other demographic characteristics. The number of children who met the inclusion criteria was 470 in 2012 and 452 in 2015. Child health Between 2012 and 2015, the proportion of children receiving health care for childhood illnesses from formal provid- ers significantly increased (Table 2). The adjusted percentage increased by 60.1 points (95% confidence interval, CI: 51.6 to 68.7) for diarrhoea, by 30.6 points (95% CI: 20.5 to 40.7) for fever and by 51.2 points (95% CI: 37.9 to 64.5) for acute respiratory infection. Among those children who received formal provider care in 2015, 83.5% (CI: 74.4 to 89.7) was from a CHW for diarrhoea, 78.6% (95% CI: 64.9 to 87.9) for acute respira- tory infection and 80.9% (95% CI: 73.3 to 86.7) for fever. Formal sector care for diarrhoea and fever increased more for children in agricultural than gold-mining communities, but the difference was not statistically significant for acute respira- tory infection (Table 3). Maternal health The adjusted facility-based delivery per- centage increased by 28.2 points (95% CI: 20.3 to 36.1; Table 2). The increase was 39.0 percentage points (95% CI: 29.8 to 48.2) in agricultural communities compared to 19.6 points (95% CI: 7.6 to 31.5) in mining communities. There were no significant changes in the receipt of at least one formal provider-associated antenatal care visit or receipt of postnatal care within 24 hours. Bull World Health Organ 2017;95:113–120| doi: http://dx.doi.org/10.2471/BLT.16.175513116 Research Maternal and child care in Liberia Peter W Luckow et al. Discussion Here we evaluate, over a three-year pe- riod, the implementation of a programme recruiting and training CHWs to deliver maternal and child care. Despite the Ebola virus disease outbreak, which caused sub- stantial declines in health-care utilization in other regions of the country,10–13 we show increases in health-care use from formal providers for fever, acute respira- tory infection and diarrhoea among chil- dren and facility-based delivery among pregnant women. Our three-year follow- up period is longer than many prior evalu- ations.14 While many studies do not report distance to clinic, we did not identify any studies from areas as remote as Konobo.15 Previous CHW programme evalu- ations report mixed findings, but are generally positive. CHW programmes improved care seeking for childhood illnesses, though effectiveness and effect sizes vary between interventions.3 Simi- larly, most high-quality impact evalu- ations report that CHW programmes improve child mortality, but results are mixed and individual studies are often limited because of their relatively small sample size.14,16 Systematic reviews have found substantial heterogeneity in CHW programme components and ef- fects,3,14,16,17 suggesting a need for more research on specific programme elements and across contexts. We did not detect significant im- provements in rates of antenatal or postnatal care. Antenatal care rates were already high at baseline (over 80% of pregnancies), which could explain the lack of improvement. The low rates of postnatal care could be explained by a combination of the community focus of the programme and Ebola-related effects on care seeking. However, postnatal care receipt was lower than facility-based de- liveries, which suggests missed opportu- nities at clinics. These results underscore the importance of integrating community and facility-based services throughout the continuum of care.18,19 Additionally, community-based postnatal services may be needed to increase postnatal care rates in remote locations with weak facility- based services.20,21 Programme efficacy was generally lower in gold-mining communities than agricultural communities. In Konobo, mining communities are usually larger and more transient. Limited evidence Table 1. Demographic characteristics of respondents and description of the survey site, by survey year, Konobo district, Liberia, 2012 and 2015 Characteristic Unweighteda Weightedb 2012 No. (%) (n = 364) 2015 No. (%) (n = 205) 2012 % (95% CI) (n = 364) 2015 % (95% CI) (n = 205) Maternal age 30.5 (N/A)c 28.6 (N/A)c 30.4c (29.6 to 31.1) 28.5c (27.7 to 29.4) Maternal education None 99 (27.6) 61 (27.8) 24.8 (20.4 to 29.0) 30.8 (25.5 to 36.7) Primary 211 (58.8) 117 (57.1) 54.8 (48.2 to 61.2) 57.0 (51.0 to 62.8) Secondary or higher 49 (13.7) 27 (13.2) 20.4 (14.4 to 28.8) 12.2 (9.0 to 16.4) Residents living in a gold mining community 119 (32.7) 121 (59.0) 58.1 (45.1 to 70.1) 58.2 (49.2 to 66.8) Distance to clinic 26.4 (N/A)d 26.1 (N/A)d 28.4d (26.6 to 30.2) 26.9d (24.7 to 29.1) Community accessible by vehicle 256 (70.3) 92 (44.9) 47.6 (34.3 to 61.3) 46.5 (37.8 to 55.5) CI: confidence interval; N/A: not applicable. a Unweighted counts, means and percentages describe the sample only. b Weighted values represent the population and are calculated using sampling weights. c Reported in mean years. d Reported in mean km. Table 2. Change in maternal and child health-care use, before and after programme implementation, Konobo district, Liberia, 2012 and 2015 Outcome Before 2012 Adjusted % (95% CI)a After 2015 Adjusted % (95% CI)a Percentage point difference (95% CI) Child health-care use outcomes Diarrhoea treatment from formal provider 6.1 (3.6 to 10.3) 66.3 (56.9 to 74.5) 60.1 (51.6 to 68.7) Acute respiratory infection treatment from formal provider 6.6 (3.7 to 11.4) 57.8 (44.4 to 70.1) 51.2 (37.9 to 64.5) Fever treatment from formal provider 26.2 (20.5 to 33.0) 56.8 (49.3 to 64.1) 30.6 (20.5 to 40.7) Maternal health-care use outcomes Facility-based delivery 55.8 (49.2 to 62.3) 84.0 (79.1 to 88.0) 28.2 (20.3 to 36.1) One-or-more antenatal care sessions at a health facility 81.4 (76.6 to 85.4) 82.8 (77.5 to 87.0) 1.4 (−4.7 to 7.5) Postnatal care (maternal or neonatal) within 24 hours from a clinic staff member or CHW 17.1 (13.0 to 22.1) 19.4 (15.0 to 24.6) 2.3 (−4.2 to 8.8) CI: confidence interval; CHW: community health worker. a Adjusted values were produced using predictive margins after fitting multivariable logistic regression models. Note: Formal care providers included community health workers, ministry of health community health volunteers (who were active in some parts of Liberia but not the pilot programme catchment area) and clinic staff. Bull World Health Organ 2017;95:113–120| doi: http://dx.doi.org/10.2471/BLT.16.175513 117 Research Maternal and child care in LiberiaPeter W Luckow et al. suggests that CHWs function better with high social capital,22–24 a contextual mod- erator that is likely reduced in mining communities. Additionally, mining com- munities tend to have greater availability of private-sector pharmaceutical ser- vices. Studies have shown that alternative suppliers replace formal-sector services, particularly when transportation is costly or facility-based services are perceived to be of low quality.25,26 Future investigation will need to assess the sustainability and scalability of these programmes. In addition to sus- tainable funding, pilot programmes often require alterations to remain appropriate for a wide variety of contexts as they get expanded.27–29 Practices from this pro- gramme are being scaled up to over 240 remote communities in adjacent River- cess County. Furthermore, several of the programme’s features, such as contracts and cash payments, ensuring a CHW- to-population ratio of 1:350, targeting of services to remote communities and field-based supervision, have helped to inform the design of Liberia’s National Community Health Assistant Program.5 This programme was launched in 2016 to accelerate progress towards universal health coverage for the most vulnerable populations, especially those in remote communities.5 The newly launched pro- gramme seeks to transform an existing cadre of unpaid and poorly coordinated CHWs into a more effective workforce by enhancing recruitment, supervision and compensation. The health ministry has organized a coalition of funding and implementation partners to support this new programme. Formal evaluations of both effectiveness and cost–effectiveness are planned as part of the scale-up. Our study has several limitations. First, results are uncontrolled, limit- ing causal inferences. However, we are unaware of any other programmes that occurred during implementation and our data show that by 2015 over 75% of child health services were reported to be delivered by CHWs, lending sup- port to a causal inference.30 Second, we cannot differentiate the effects of the CHW programme from the effects of the trained traditional midwives’ incen- tives, transport reimbursements and food stipends, which were simultaneously implemented. Similarly, we cannot iden- tify the independent effects of particular CHW programme sub-elements, such as supervision versus compensation. Third, our programme was done in a single dis-Ta bl e 3. Ch an ge in m at er na l a nd ch ild h ea lth -c ar e us e be fo re a nd a ft er p ro gr am m e im pl em en ta tio n, b y c om m un ity ty pe , K on ob o di st ric t, Li be ria , 2 01 2 an d 20 15 Ou tc om e Ag ric ul tu ra l c om m un iti es M in in g co m m un iti es Be fo re 2 01 2 Ad ju st ed % (9 5% CI )a Af te r 2 01 5 Ad ju st ed % (9 5% CI )a Pe rc en ta ge p oi nt di ffe re nc e (9 5% CI ) Be fo re 2 01 2 Ad ju st ed % (9 5% CI )a Af te r 2 01 5 Ad ju st ed % (9 5% CI )a Pe rc en ta ge p oi nt di ffe re nc e (9 5% CI ) Ch ild h ea lt h- ca re u se o ut co m es D ia rrh oe a tre at m en t f ro m fo rm al p ro vi de r 8. 5 (4 .0 to 1 7. 1) 88 .2 (6 6. 9 to 9 6. 5) 79 .7 (6 6. 4 to 9 3. 0) 4. 4 (1 .7 to 1 1. 3) 59 .8 (4 7. 0 to 7 1. 4) 55 .4 (4 3. 6 to 6 7. 1) Ac ut e re sp ira to ry in fe ct io n tre at m en t f ro m fo rm al p ro vi de r 16 .3 (5 .6 to 3 9. 2) 78 .0 (4 8. 7 to 9 3. 0) 61 .7 (4 1. 8 to 8 1. 7) 2. 0 (0 .3 to 1 0. 2) 48 .7 (2 8. 3 to 6 9. 6) 46 .8 (2 3. 9 to 6 9. 7) Fe ve r t re at m en t f ro m fo rm al p ro vi de r 19 .4 (1 2. 9 to 2 8. 1) 80 .6 (6 7. 4 to 8 9. 3) 61 .2 (5 0. 8 to 7 1. 5) 33 .1 (2 3. 2 to 4 4. 8) 42 .8 (3 0. 6 to 5 6. 0) 9. 7 (− 4. 6 to 2 3. 9) M at er na l h ea lt h- ca re u se o ut co m es Fa ci lit y- ba se d de liv er y 48 .8 (3 9. 7 to 5 7. 9) 87 .8 (7 9. 7. to 9 2. 9) 39 .0 (2 9. 8 to 4 8. 2) 61 .0 (5 0. 3 to 7 0. 8) 80 .6 (7 2. 6 to 8 6. 7) 19 .6 (7 .6 to 3 1. 5) O ne -o r- m or e an te na ta l c ar e se ss io ns a t a h ea lth fa ci lit y 83 .4 (7 7. 5 to 8 8. 1) 83 .5 (7 4. 3 to 8 9. 9) 0. 1 (− 7. 7 to 7 .8 ) 79 .4 (7 0. 6 to 8 6. 0) 82 .1 (7 3. 3 to 8 8. 4) 2. 7 (− 6. 6 to 1 1. 9) Po st na ta l c ar e (m at er na l o r n eo na ta l) w ith in 2 4 ho ur s b y a cl in ic st aff m em be r o r C H W 21 .0 (1 3. 9 to 3 0. 6) 25 .8 (1 6. 2 to 3 8. 7) 4. 8 (− 4. 2 to 1 3. 9) 14 .9 (9 .3 to 2 2. 9) 15 .5 (9 .9 to 2 3. 6) 0. 7 (− 7. 9 to 9 .2 ) CI : c on fid en ce in te rv al ; C HW : c om m un ity h ea lth w or ke r. a Ad ju st ed v al ue s w er e pr od uc ed u sin g pr ed ic tiv e m ar gi ns a fte r fi tti ng m ul tiv ar ia bl e lo gi st ic re gr es sio n m od el s. N ot e: F or m al c ar e pr ov id er s i nc lu de d co m m un ity h ea lth w or ke rs , m in ist ry o f h ea lth c om m un ity h ea lth v ol un te er s ( w ho w er e ac tiv e in so m e pa rts o f L ib er ia b ut n ot th e pi lo t p ro gr am m e ca tc hm en t a re a) a nd c lin ic st aff . 811315571.61.TLB/1742.01/gro.iod.xd//:ptth :iod |021–311:59;7102 nagrO htlaeH dlroW lluB hcraeseR .la te wokcuL W reteP airebiL ni erac dlihc dna lanretaM ,erofereht ,noitalupop llams a htiw tcirt lla rof elbazilareneg ton era stluser eht .snoitalupop etomer atad yranimilerp sreffo repap siTh -orp desab-WHC decnahne na woh no ekatpu eht etomorp ot desu saw emmarg htlaeh dlihc dna lanretam laitnesse fo erutuF .snoitalupop etomer ni secivres -libaniatsus eht ssessa lliw snoitagitsevni ■ .emmargorp eht fo ytilibalacs dna yti stnemegdelwonkcA ,hetaK sicnarF ,nhaD ecinreB knaht eW ,iouqauzrA K nosmaS ,elaginewG retlaW dna ,amioB abmaT ,hawsneyN trebloT ytnuoC ssecreviR ,hedeG dnarG eht fo yrtsiniM s’airebiL fo smaeT htlaeH ,kcimroCcM ahsiL ,hslaW anoiF ,htlaeH dna auozuoZ leahciM ,ebidiS yrakaB ,notsoB ni htlaeH eliM tsaL ta smaet rieht dna hedeG dnarG ,aivornoM ,kroY weN .ssecreviR desu syevrus eht rof gnidnuF :gnidnuF yb ,trap ni ,dedivorp saw atad tcelloc ot tceriD ,noitadnuoF sumitpO SBU eht ,noitadnuoF muabneerG eTh ,feileR dna dnuF doohrobhgieN labolG eht troppus deviecer PR .dnuF retseL eTh htlaeH labolG ekruB dravraH eht morf morf troppus seviecer SJM .pihswolleF HM( htlaeH fo setutitsnI lanoitaN eht rof retneC dravraH eht dna )61999032K .)453060IA03P5( hcraeseR SDIA .deralced enoN :stseretni gnitepmoC ملخص بحث حول التنفيذ العملي لبرنامج تقديم الخدمات الصحية للأمهات والأطفال من جانب الأخصائيين الصحيين للمجتمع المحلي في المناطق الريفية من ليبيريا الغرض تقييم التغييرات التي طرأت على الاستعانة بالخدمات الضرورية لصحة الأمهات والأطفال في كونوبو بليبيريا بعد تنفيذ برنامج محّسن للأخصائيين الصحيين للمجتمع المحلي. الطريقة دخلت وزارة الصحة الليبيرية في إطار من الشراكة مع منظمة “لاست مايل هيلث” الصحية غير الحكومية لتنفيذ برنامج تجريبي للأخصائيين الصحيين للمجتمع المحلي مع تطوير عمليات التعيين والتدريب والإشراف وتقديم الأجور. ولكي يتم تقييم التغييرات في مجال الاستعانة بالرعاية الصحية للأمهات والأطفال، فقد أجريت مجموعة من الاستبيانات المجمعة القطاعية المتكررة قبل تنفيذ البرنامج (في عام 2102) وبعد تنفيذه (في عام 5102). النتائج في الفترة ما بين عامّي 2102 و5102 تم تدريب 45 من الأخصائيين الصحيين للمجتمع المحلي، وسبعة مشرفين من النظراء، وثلاثة مشرفين سريريين لتقديم الخدمة لشريحة سكانية يبلغ قوامها 721،21 نسمة في 44 مجتمًعا محلًيا. وقد زادت النسبة المئوية المعّدلة وفًقا لنموذج الانحدار الإحصائي للأطفال الذين يتلقون الرعاية من مقدمي الرعاية الرسميين بمقدار 1.06 (بمستوى ثقة تبلغ نسبته 59 %: 6.15 إلى 7.86) نقطة مئوية بالنسبة للإسهال، وبمقدار 6.03 (بمستوى ثقة تبلغ نسبته 59 %: 5.02 إلى 7.04) نقطة مئوية للحمى، وبمقدار 2.15 (بمستوى ثقة تبلغ نسبته 59 %: 9.73 إلى 5.46) للعدوى التنفسية الحادة. كما تزايد إجراء عمليات الولادة في المرافق الصحية بمقدار 2.82 نقطة (بمستوى ثقة تبلغ نسبته 59 %: 3.02 إلى 1.63). وقد تحققت زيادة أكبر في نسبة عمليات الولادة في المرافق الصحية والرعاية المقدمة من جانب الجهات الرسمية لحالات العدوى الحادة في الجهاز التنفسي والإسهال في المجتمعات المحلية الزراعية بالمقارنة مع المجتمعات المحلية القائمة على تعدين الذهب. ولم تطرأ زيادة ملموسة على تلقي جلسات الرعاية لمرحلة ما قبل الولادة بمعدل جلسة واحدة أو أكثر في المرافق الصحية وخدمات الرعاية بعد الولادة خلال فترة 42 ساعة من الولادة. الاستنتاج لقد حددنا زيادات ملموسة في حجم تلقي خدمات الرعاية الصحية للأمهات والأطفال من الجهات الرسمية خلال فترة البرنامج التجريبي للأخصائيين الصحيين للمجتمع المحلي في المناطق الريفية النائية في ليبيريا. وتحتاج الخدمات المعتمدة على العيادات – مثل الرعاية في مرحلة ما بعد الولادة - والخدمات المقدمة في بيئات محددة، مثل مناطق التعدين إلى تدخلات إضافية لتحقيق أفضل النتائج. 要摘 究研施实的务服生卫幼妇供提者作工生卫区社区地村农亚里比利 计 )WHC( 者作工生卫区社的强加施实估评在旨 的目 用使务服生卫幼妇本基区地博诺科亚里比利，后以划 。化变的况情 eliM tsaL( 疗医里一后最手联部生卫亚里比利 法方 督监、训培、募招在施实，织组府政非家一，)htlaeH 试 )WHC( 者作工生卫区社的强加所有均面方酬报和 计该在们我，化变的用使健保幼妇估评了为 。划计点 横性复重了展开别分 )5102( 后之和 )2102( 前之施实划 。查调体群面断 七、者作工生卫区社名 45，间年 5102 至 2102 果结 以，训培了受接员管监床临名三和员管监伴同名 理护规 正从 。民居名 721 21 的内区社个 44 务服 分 百 整 调 归 回 的 童 儿 泻 腹 的 理 护 受 接 处 者 供 提 】7.86 至 6.15 ： )IC( 间 区 信 置 %59【1.06 了 高 提 比 6.03 了 高 提 比 分 百 童 儿 热 发 ，点 分 百 个 分百的童儿染感道吸呼性急，）7.04 至 5.02 ： IC %59（ 高提娩分院入 。）5.46 至 9.73 ： IC %59（ 2.15 了高提比 地金采与 。）1.63 至 3.02 ： IC %59（点分百个 2.82 了 性急疗治室科规正往前和娩分院入区地业农，比相区 接构机疗医在 。多更得加增况情的泻腹和染感道吸呼 的理护内时小 42 后产和程课理护前产项多或项一受 。化变著显有没况情 作工生卫区社在区地村农远偏亚里比利现发们我 论结 保幼妇受接构机疗医规正从间期点试划计 )WHC( 者 矿采和务服床临等理护泻腹 。加增著显况情的务服健 到达能才预干的外额要需，务服的下境环定特等区地 。果效的想理最 Bull World Health Organ 2017;95:113–120| doi: http://dx.doi.org/10.2471/BLT.16.175513 119 Research Maternal and child care in LiberiaPeter W Luckow et al. Résumé Recherche opérationnelle sur la prestation de services de santé maternelle et infantile par des agents de santé communautaires dans les régions rurales du Libéria Objectif Évaluer les changements dans le recours aux services essentiels de santé maternelle et infantile à Konobo, au Libéria, après la mise en œuvre d’un programme de perfectionnement des agents de santé communautaires. Méthodes Le ministère de la Santé libérien s’est associé avec Last Mile Health, une organisation non gouvernementale, afin de mettre en œuvre un programme pilote destiné à améliorer le recrutement, la formation, l’encadrement et la rémunération des agents de santé communautaires. Pour évaluer les changements au niveau des soins de santé maternelle et infantile, nous avons réalisé plusieurs sondages transversaux par grappes avant (2012) et après (2015) la mise en œuvre du programme. Résultats Entre 2012 et 2015, 54 agents de santé communautaires, sept collègues superviseurs et trois superviseurs cliniques ont été formés pour prendre en charge une population de 12 127 personnes dans 44 communautés. Le pourcentage corrigé par régression d’enfants recevant des soins de la part de prestataires de soins officiels a augmenté de 60,1 (intervalle de confiance (IC) de 95%: 51,6 à 68,7) points de pourcentage pour la diarrhée, de 30,6 (IC 95%: 20,5 à 40,7) pour la fièvre et de 51,2 (IC 95%: 37,9 à 64,5) pour les infections aiguës des voies respiratoires. Les accouchements en maternité ont augmenté de 28,2 points (IC 95%: 20,3 à 36,1). Les accouchements en maternité et la prise en charge dans le secteur formel des infections aiguës des voies respiratoires et des cas de diarrhée ont davantage augmenté dans les communautés agricoles que dans celles vivant de l’extraction de l’or. Nous n’avons pas observé de changements significatifs dans le fait de bénéficier d’une ou plusieurs séances de soins prénataux dans une structure de soins ou de soins post-partum dans les 24 heures suivant l’accouchement. Conclusion Nous avons observé une augmentation significative de la prestation de services de santé maternelle et infantile par des prestataires officiels lors du programme pilote destiné aux agents de santé communautaires dans les régions rurales isolées du Libéria. Des interventions supplémentaires sont nécessaires pour obtenir des résultats optimaux vis-à-vis de la prestation de services cliniques, comme les soins post-partum, et de services dans des zones spécifiques, comme les régions minières. Резюме Оказание услуг в сфере охраны здоровья матерей и детей местными медработниками в сельской местности Либерии: исследование в области внедрения Цель Оценить изменения в использовании основных услуг в сфере охраны здоровья матерей и детей в округе Конобо, Либерия, после внедрения усовершенствованной программы для местных медицинских работников (ММР). Методы Министерство здравоохранения Либерии вступило в партнерские отношения с неправительственной организацией Last Mile Health для внедрения пробной программы ММР, предполагающей усовершенствования в наборе кадров, обучении, надзоре и оплате труда. Чтобы оценить изменения в использовании услуг в сфере охраны здоровья матерей и детей, авторы провели несколько межсекторальных обследований с применением гнездовой выборки до (2012 год) и после (2015 год) внедрения программы. Результаты В период между 2012 и 2015 годами было подготовлено 54 ММР, семь инспекторов из партнерских организаций и три инспектора из клиник для обслуживания 12 127 человек в 44 сообществах. Скорректированная, рассчитанная с помощью модели регрессии доля детей, которые получили медицинскую помощь от официальных работников здравоохранения, увеличилась на 60,1 (95% доверительный интервал, ДИ: 51,6– 68,7) процентного пункта в случае с диареей, на 30,6 (95% ДИ: 20,5–40,7) при лихорадке и на 51,2 (95% ДИ: 37,9–64,5) при острых респираторных инфекциях. Доля родов, принятых в учреждениях, увеличилась на 28,2 пункта (95% ДИ: 20,3–36,1). Доля родов, принятых в учреждениях, и помощи, оказанной со стороны официального сектора при острых респираторных заболеваниях и диарее, увеличилась больше в сельскохозяйственных общинах, чем в золотодобывающих. Изменения в доле получивших дородовую медицинскую помощь в рамках одного или нескольких сеансов в медицинском учреждении и послеродовой уход в течение 24 часов после родов не были статистически значимы. Вывод Авторы выявили существенное увеличение в использовании услуг в сфере охраны здоровья матерей и детей, оказываемых официальными медицинскими работниками, в ходе реализации пробной программы ММР в удаленных сельских регионах Либерии. Клинические услуги, такие как послеродовой уход, и обслуживание в специфических условиях, таких как районы разработки полезных ископаемых, требуют осуществления дополнительных вмешательств для достижения оптимального результата. Resumen Investigaciones sobre la implementación en el suministro de servicios de salud materna e infantil de trabajadores comunitarios de salud en la Liberia rural Objetivo Evaluar los cambios en el uso de servicios de salud materna e infantil básicos en Konobo, Liberia, tras la implementación de un programa mejorado de trabajadores comunitarios de salud (CHW, por sus siglas en inglés). Métodos El Ministerio de Salud de Liberia se asoció con Last Mile Health, una organización no gubernamental, para implementar un programa piloto de CHW con una mejora en la contratación, formación, supervisión y compensación. Para evaluar los cambios en el uso de la atención sanitaria materna e infantil, se realizaron repetidas encuestas transversales de conglomerados antes (2012) y después (2015) de la implementación del programa. Resultados Entre 2012 y 2015, 54 CHW, 7 supervisores homólogos y 3 supervisores clínicos recibieron formación para trabajar para una población de 12 127 personas en 44 comunidades. El porcentaje ajustado a la regresión de niños que recibieron atención de profesionales sanitarios formales aumentó un 60,1% (intervalo de confianza (IC) del Bull World Health Organ 2017;95:113–120| doi: http://dx.doi.org/10.2471/BLT.16.175513120 Research Maternal and child care in Liberia Peter W Luckow et al. 95%: 51,6 a 68,7) para la diarrea, un 30,6% (IC del 95%: 20,5 a 40,7) para la fiebre y un 51,2% (IC del 95%: 37,9 a 64,5) para la infección respiratoria aguda. El suministro en centros aumentó un 28,2% (IC del 95%: 20,3 a 36,1). El suministro en centros y la atención del sector formal para la infección respiratoria aguda y la diarrea aumentaron más en comunidades agrícolas que en las de minas de oro. La recepción de una o más sesiones de atención prenatal en un centro sanitario y de atención posparto a las 24 horas del parto no experimentó cambios importantes. Conclusión Se identificaron aumentos significativos en la aceptación de los servicios de atención sanitaria materna e infantil de profesionales formales durante la versión piloto del programa de CHW en la Liberia rural remota. Los servicios clínicos, como la atención posparto y los servicios en lugares concretos, como zonas mineras, requieren intervenciones adicionales para lograr unos resultados óptimos. References 1. Bhutta ZA, Black RE. Global maternal, newborn, and child health–so near and yet so far. N Engl J Med. 2013 Dec 5;369(23):2226–35. doi: http://dx.doi. org/10.1056/NEJMra1111853 PMID: 24304052 2. Kenny A, Basu G, Ballard M, Griffiths T, Kentoffio K, Niyonzima JB, et al. Remoteness and maternal and child health service utilization in rural Liberia: A population-based survey. 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