Comparison of high- versus low-intensity community health worker intervention to promote newborn and child health in northern Nigeria

Authors: Sally E. Findley, Omolara T Uwemedimo, Henry V Doctor, Cathy Green, Fatima Adamu, Godwin Y. Afenyadu
Journal Title: International Journal of Women’s Health
Journal Reference: 5: 717-728
Document Type: Journal articles
Publication Date: 2013

This paper describes how infant mortality rates in northern Nigeria were two to three times higher than in the southern states, and, in 2008, the Partnership for Reviving Routine Immunisation in Northern Nigeria/ Maternal Newborn and Child Health programme (PRRINN/MNCH) was established to reduce infant and child mortality in four Northern Nigeria states. The programme intervention zones received government-supported health services plus integrated interventions at primary health care posts and development of community-based service delivery (CBSD) with a network of community volunteers and community health workers (CHWs), who focus on educating women about danger signs for themselves and their infants and promoting appropriate responses to the observation of those danger signs, consistent with the approach of the World Health Organization Integrated Management of Neonatal and Childhood Illness strategy. Before going to scale in the rest of the state, it is important to identify the relative effectiveness of the low-intensity volunteer approach versus the more intensive CBSD approach with CHWs.

Methods: We conducted stratified cluster sample household surveys at baseline (2009) and follow-up (2011) to assess changes in newborn and sick child care practices among women with births in the five prior years (baseline: n = 6,906; follow-up: n = 2,310). The follow-up respondents were grouped by level of intensity of the CHW interventions in their community, with “low” including group activities led only by a trained community volunteer and “high” including the community volunteer activities plus CBSD from a CHW providing one-on-one advice and assistance. t-tests were used to test for significant differences from baseline to follow-up, and F-statistics, which adjust for the stratified cluster design, were used to test for significant differences between the control, low-intensity, and high-intensity intervention groups at follow-up. These analyses focused on changes in newborn and sick child care practices.


    • Anti-tetanus vaccination coverage during pregnancy increased from 69.2% at baseline to 85.7% at follow-up in the intervention areas.
    • Breastfeeding within 24 hours increased from 42.9% to 59.0% in the intervention areas, and more newborns were checked by health workers within 48 hours (from 16.8% at baseline to 26.8% at follow-up in the intervention areas).
    • Newborns were more likely to be checked by trained health personnel, and they received more comprehensive newborn care.
    • Compared to the control communities, more than twice as many women in intervention communities knew to watch for specific newborn danger signs.
    • Compared to the control and low-intensity intervention communities, more mothers in the high-intensity communities learned about the care of sick children from CHWs, with a corresponding decline those seeking advice from family or friends or traditional birth attendants.
    • Significantly fewer mothers did nothing when their child was sick. High-intensity intervention communities experienced the most decline. Those who did nothing for children with fever or cough declined from 35% to 30%, and with diarrhea from 40% to 31%.
    • Use of medications, both traditional and modern, increased from baseline to follow-up, with no differentiation in use by intervention area.

Conclusion: The community-based approach to promoting improved newborn and sick child care through community volunteers and CHWs resulted in improved newborn and sick child care. The low-intensity approach with community volunteers appears to have been as effective as the higher-intensity CBSD approach with CHWs for several of the key newborn and sick child care indicators, particularly in the provision of appropriate home care for children with fever or cough.

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Tags: Nigeria, Community health workers, Immunisation, Immunization, Primary health care, Newborn health, Skilled birth attendants, Community engagement, Community mobilisation, Child health, PRRINN-MNCH, Infant mortality, Community-based service delivery, CBSD, Breastfeeding, Community volunteers, Health systems research, CHEWs, MNCH, Health systems strengthening, PRRINN, maternal danger signs, Community health systems,