Global Health
Community health workers, communities, and child development trajectories: A value-added approach Caitlin Hemlock* Caitlin Hemlock Ann M. Weber Emanuela Galasso Maria Dieci Lisy Ratsifandrihamanana Lia C.H. Fernald
Interventions to improve child development in low-resource settings are often delivered through home visits by community health workers (CHWs), but many have not exhibited substantial gains for young children. This analysis aimed to determine the relative effectiveness, or value-added, of CHWs on cognitive development outcomes in a home-visiting trial and to examine if any characteristics of the CHW or community were associated with effectiveness. We analyzed data from the 4 treatment arms of a cluster RCT conducted in 100 communities in rural Madagascar (2014-2016). CHWs (1 per community) and enrolled children were surveyed at baseline and two years later. Child cognitive development scores were assessed using the Ages and Stages Questionnaire-Inventory (ASQ-I) and were internally age-standardized. We estimated value-added by estimating CHW/community-level fixed effects on ASQ score change from baseline to endline, conditional on baseline score and child and household characteristics. We also assessed associations between CHW and community-level characteristics and gains in ASQ. We analyzed data from 1456 children present at baseline and endline. CHW/community value-added ranged from -1.68 SD to 1.31 SD and explained 26% ASQ change score variance. CHWs with another income-generating position were associated with a 0.54 SD (95% CI: 0.22, 0.87) increase in ASQ score from baseline to endline. Higher gains in ASQ were also associated with communities that had healthcare, education, and transportation infrastructure and were less geographically dispersed. We found positive value-added of CHWs with another income-generating activity, potentially from better intervention delivery or improved economic resources, and in communities with improved infrastructure and accessibility. Careful consideration of the contexts in which child development interventions are implemented and potential correlates of improved CHW performance are crucial for improved outcomes.