Can community health worker home visiting improve care seeking and health service use in fragile states such as Afghanistan? A population based intervention study

The intervention was a standardised training and supportive supervision package aimed at improving CHW capacity to provide maternal and neonatal home visits and behaviour change communication (BCC) messages from as early as possible in the antenatal period to 28 days postpartum. It was specifically targeted to female CHWs in the study area. All (100%) 289 female CHWs in the study area received the training package. The intervention had five components. (i) Structured home visiting schedule. Each CHW was trained to provide eight home visits (four during the antenatal period and four in the postnatal period (day 1, day 3, day 7, day 28) and to provide health promotion and BCC messages at each visit. (ii) Structured and simplified MCH BCC training ‘curriculum’. This was based on the standardised World Health Organization (WHO) UNICEF CHW training package. It included topics that the CHW should provide to mothers at the home visits about: birth preparedness, care seeking for ANC, delivery care, and newborn care (including hygiene, nutrition, thermal care, danger signs for illness). As most of the CHWs in Afghanistan cannot read or write, locally appropriate tools were developed and pretested including pictorial counselling flip cards for birth preparedness, antenatal care, facility delivery, newborn greetings, postnatal care of mother and newborn, and maternal and newborn danger signs. Each training session lasted for five days and was followed by three 4-hour ‘on the job’ refresher sessions over a twelve month intervention period. (iii) Structured ‘Training of Trainers’ (ToT) program. Two female government supervisors, one per district, were trained over a five day period using the locally developed tools and training curriculum. The supervisors then provided training to the female CHWs as described above. (iv) Supportive supervision program. The female CHWs were visited once per month by the supervisors over a period of 12 months to provide advice and monitoring. These visits included both scheduled and random unscheduled visits. (v) Performance based incentive program. CHWs were provided with a family kit (consisting of cooking and eating utensils including pots, plates, spoons, towels and soap) for their own use at the beginning of the project if they mapped and registered pregnant women in their catchment areas. They were provided with an additional kit if the woman delivered at a health facility