Malawi study shows CHW programs can be expanded to address NCDs

A recently published study found that expanding an existing HIV and tuberculosis (TB) CHW program in the Neno district of Malawi to include non-communicable diseases (NCDs) and other conditions reduced the number of patients defaulting from chronic NCD care each month by approximately 20% while maintaining the already low default rate for HIV patients.

The stepped-wedge cluster randomized controlled trial evaluated expanding an existing HIV and tuberculosis (TB) CHW program to include NCDs, malnutrition and TB screening, as well as family planning and antenatal care (ANC). The trial was successful in improving antenatal care attendance and rates of default from chronic care without affecting the default rate from HIV care, which was already covered by the previous program with very strong results.

The research article published in BMJ Global Health can be read in its entirety here.

CHWs are community members outside of the formal nursing or medical profession who are trained to provide health education, screen for diseases, make referrals, and sometimes deliver basic health services. For vulnerable populations living in resource-poor settings, CHWs are a vital link to primary care.

Eliza Kazembe, left, talks with CHW Grace Mgaiwa, who supported Kazembe with antenatal care throughout her pregnancy. — Photo by Karin Schermbrucker / Slingshot Media. Copyright Partners In Health

The study evaluated a household model in which every household in the rural district of Neno received at least one visit per month from a CHW who had received five days of training to introduce the skills needed to focus on NCDs, including hypertension, diabetes, asthma, epilepsy, and mental health conditions. While many previous studies have proven that CHW programs improve health outcomes in low and middle-income countries for single health issues, such as HIV and malaria, this study evaluated the efficacy of a CHW program focused on a broad range of health areas, including NCDs. For people living with chronic health conditions, the routine access to treatment, monitoring, and counseling provided by CHWs helps ensure that patients remain in care, prevents diseases from becoming worse, and keeps patients out of the hospital.

Dr. Emily Wroe, an author of the study, explained that the CHW program was able to successfully expand to address the health needs of NCD patients while continuing to deliver excellent results for HIV care because of the way it was designed and implemented.

“On top of ensuring that each CHW was assigned a manageable caseload and had the support they needed to succeed, CHWs were chosen based on their relationship to the community,” Wroe explained. “The CHWs selected lived in the village they were serving and had the trust of their patients. Because of these relationships, the CHWs were very effective when following up with patients and checking in after missed appointments, which improved the retention of patients enrolled in NCD care.”

In addition to creating positive health outcomes for the community, the trial helped the CHWs involved and their communities by creating jobs and career pathways.