Freelance health systems consultant, Oxford, United Kingdom.
Economics Department and The Fletcher School, Tufts University, USA.
J Glob Health. 2021 Oct 9;11:04060. doi: 10.7189/jogh.11.04060. eCollection 2021.
Home visits by community health workers are promoted to improve the coverage and uptake of evidence-based newborn services and behaviours. However, evidence on the effectiveness of these home visits delivered through government systems at scale is limited, as is evidence from the post-neonatal period. From 2013 to 2017, the Government of India piloted an intervention called Home Based Newborn Care Plus with the goal of reducing pneumonia- and diarrhoea-related morbidity and malnutrition. Village-based Accredited Social Health Activists were incentivised to make quarterly home visits to infants between three and 12 months of age. After the pilot, the intervention was adapted and scaled up nationally (with an additional visit at 15 months of age) as a new programme called Home Based Care for Young Child.
The study used a quasi-experimental, difference-in-differences method to assess the quantitative impact on key outcome indicators by comparing changes over time in treatment districts with matched control districts. This was supplemented by a quantitative health worker survey and qualitative data collected at worker and community level.
The intervention led to a significant increase in the number of home visits, and their content became more aligned with Home Based Newborn Care Plus protocols. However, absolute levels of coverage remained low. The intervention had no detectable effect on the key outcomes of feeding practices, handwashing, iron and folic acid and oral rehydration solution supplementation, growth monitoring, and immunisation.
Given the scale up of Home-Based Care for Young Child, there is a need to identify appropriate and comprehensive support for Accredited Social Health Activists to attain high coverage and quality and deliver impact. This will require reconsidering current design elements (such as incentives) and solving the underlying demand side and system level challenges (such as workload and supply chains) constraining Accredited Social Health Activists.
社区卫生工作者的家访被提倡用于提高基于证据的新生儿服务和行为的覆盖率和利用率。然而，通过政府系统大规模提供这些家访的有效性证据有限，新生儿后期的证据也有限。2013 年至 2017 年，印度政府试行一项名为“家庭新生儿护理加”的干预措施，旨在降低肺炎和腹泻相关发病率和营养不良。激励村级认证社会卫生活动家每季度对 3 至 12 个月大的婴儿进行家访。试点后，该干预措施经过改编并在全国范围内扩大规模（在 15 个月时增加一次访问），成为一项名为“幼儿家庭护理”的新计划。
本研究采用准实验、差异中的差异方法，通过比较治疗区和匹配对照组随时间变化的关键结果指标的变化，评估对关键结果指标的定量影响。这一方法得到了定量卫生工作者调查和在工作者和社区层面收集的定性数据的补充。
该干预措施导致家访次数显著增加，家访内容与“家庭新生儿护理加”方案更加一致。然而，覆盖率的绝对水平仍然较低。该干预措施对喂养行为、洗手、铁和叶酸以及口服补液盐补充、生长监测和免疫接种等关键结果没有明显影响。
鉴于“幼儿家庭护理”的扩大规模，需要为认证社会卫生活动家确定适当和全面的支持，以实现高覆盖率和高质量，并产生影响。这将需要重新考虑当前的设计要素（如激励措施），并解决限制认证社会卫生活动家的需求方和系统层面的挑战（如工作量和供应链）。
