From direct engagement to technical support: a programmatic evolution to improve large community health worker...

Area of Science:

• Public Health
• Health Services Research
• Maternal and Child Health

Background:

• CARE India implemented maternal and neonatal health (MNH) programs in Bihar, evolving from the Integrated Family Health Initiative (IFHI) to a statewide Technical Support Unit (TSU).
• Frontline health worker (FHW) programs are crucial for delivering MNH services through household visits.

Purpose of the Study:

• To assess changes in FHW visit coverage, intensity, and quality between the IFHI and TSU phases.
• To determine the association between FHW outputs and key MNH practices: antenatal care, institutional delivery, and early breastfeeding initiation.

Main Methods:

• Utilized eight rounds of state-representative household surveys (N=73,093 mothers) and two facility assessments (2012-2017).
• Employed logistic regression models to analyze associations between FHW activities and MNH outcomes.
• Compared FHW visit coverage, intensity, and quality across IFHI and TSU program phases.

Main Results:

• FHW visit coverage declined from 60.2% during IFHI to 46.3% during TSU in the intervention districts.
• Despite reduced coverage and quality, MNH outcomes (antenatal care, institutional delivery, early breastfeeding) improved during the TSU phase compared to IFHI.
• Increased FHW visits, particularly in the third trimester, were significantly associated with higher odds of achieving all three MNH outcomes.
• Higher quality FHW interactions, irrespective of visit frequency, were positively associated with improved MNH outcomes.

Conclusions:

• Community-based MNH interventions require continuous strategic evaluation and adaptation for sustained impact.
• The technical support model can be effective in improving MNH outcomes, even with shifts in FHW engagement.
• Ensuring the quality of FHW interactions is as critical as visit frequency for achieving MNH goals.