Each CHW was allocated a designated number of households and provided services in these homes. Approximately 1.7 million headcount activities on screening, tracing, referrals and linkages to care services were provided in the 280 000 households over the study period. As seen in the results for annual averages per activity, most services provided by CHWs were to identify risks and problems early. (Figs. 1–12)
As part of a broad range of health education activities, and to reduce the risk of HIV and sexually transmitted diseases, condoms were delivered to households. Figure 1 illustrates an increase in condom distribution over the given period by more than double for male condoms and a five-fold increase for female condoms over the same period.
District clinics have many clients with chronic diseases: HIV, TB, hypertension, diabetes and/or other morbidities. WBPHCOTs delivered chronic medications to identified households within their catchment areas, especially to clients who were not mobile. The number of clients who received this service grew from 3411 in 2016-17 to 9494 in 2018-19 (Fig. 2).
Screening was conducted in homes using standardized national forms; for infectious diseases (TB, HIV and STIs), non-communicable diseases/NCD (hypertension, diabetes, cervical cancer) and child health (immunization, malnutrition) issues.
During household visits, CHWs identified children under five and reviewed their immunization and nutrition status. Children were screened for malnutrition and referred to the nearest clinic if needed. CHWs used a coloured mid-upper arm circumference tape to determine if a child was malnourished or not. Figure 3 illustrated a reduction in the number of malnourished children identified in households covered by WBPHCOTs, from 1630 to 80 malnourished children, over the three-year period as the numbers of teams increased in the district and more households were reached.
CHWs conducted household screening activities across several health conditions; Fig. 4 illustrates this range. Although TB and HIV constituted much of the screening, non-communicable diseases contributed significantly too.
CHWs aim to reduce the burden of mother and child health problems through early household screening for pregnancy (at less than 20 weeks’ gestation) and identification of un-immunized children; Fig. 4 shows that pregnancy screened improved to approximately 10% of all screening activities in 2018-19. Women of childbearing age were asked if they had had a missed period or signs of pregnancy and if so CHWs conducted a rapid urine pregnancy test in the household. Over the period, there was a three-fold increase in the overall number of women tested for pregnancy in households, in an attempt to get those at less than 20 weeks gestation. An average of 90% of those testing positive for pregnancy (< 20 weeks gestation) in households reported to clinics, leading to early referrals for antenatal care; Fig. 5.
CHWs checked the health cards of children to ensure all immunizations were up to date as per national immunization schedules. In CHW supported households, as more children were screened and immunized over the years, there was less need to refer; Fig. 5 shows that in 2018-19 just 15% of children screened had to be referred for incomplete immunization, much lower than previous years. Once mothers and children were referred; 80% reported to the clinics and over 95% were given the required immunization (linked to care). This was due to the emphasis on MCH issues by CHWs in households.
Figure 4 showed that approximately 50% of those screened in households were for HIV & TB; reflecting the emphasis on the priority disease burden in poor communities. TB screening was based on symptoms of chronic cough, weight loss and night sweats; over the three years, fewer clients required referrals for TB symptoms. HIV screening was based on awareness of HIV status or not. Of those screened and referred for HIV & TB, 60–80% did report to the clinic; improving access to care in vulnerable communities.
Clients were asked if they had any genital sores or discharges, to determine if they had any sexually transmitted diseases (STIs). More than 70% of those who did, reported to clinics and were put on treatment.
To improve cervical cancer screening, women over 30 years were asked if they had had a pap smear done or not. This resulted in over 65% of referred women presenting to clinics for a pap smear, Fig. 7. Hypertension (HPT) and Diabetes (DM) screening similarly increased over the period under review; contributing to 30 to 40% of health conditions screened using clinical symptoms and/or digital BP and glucometer machines. Again, once referred; the proportion of clients who reported to clinics was high, approximately 80%.
Once CHWs refer clients to clinics and they report there, an important conclusion of the referral process is that the clients must be linked to care. If this does not happen, the hard efforts of CHWs will not improve follow up or adherence. As clients reported to clinics, the assumption was that the health service responded to their needs, either in the form of further investigations, or diagnosis and/or management of conditions. Over the three-year period, linkage to care in the clinics was good for pregnancy, immunization, STIs and cervical cancer, but less so (< 50%) for those screened for HIV, TB, DM and HPT; Fig. 6 and Fig. 8.
Tracing of clients was another important activity by WBPHCOTs. The clinic head or the OTL gave teams lists of clients who initially had attended the clinic and then did not come back for either diagnosis and/or start of treatment or for continuing care. These clients were largely defaulters but also clients who were contacts of those with newly diagnosed TB or HIV. They then had to be traced by the CHWs; many were outside of CHW allocated households. Figure 9 illustrated that over 90% of the clients were HIV and/or TB treatment defaulters.
Figure 10 illustrates the proportion of clients successfully traced by the CHWs, from the lists provided by the clinics, including clients for whom incorrect contact details were provided. For immunization, cervical cancer and non-communicable disease 70 to 80% of clients were traced on average, despite incorrect addresses and a mobile population, while for TB this was 75% and HIV 60%.
Of those clients traced, most clients returned to the clinics for further treatment, Fig. 11. For TB clients and those with chronic conditions (hypertension and diabetes) reporting back steadily improved over the period, on average over 75%; while with HIV an average of 55% of clients returned to the clinics.
The linkage to care of defaulters and contacts successfully traced was high, above 75%, across all the health conditions; Fig. 12. This showed that with clinic initiated activities staff were ready for returning defaulters and doing the needful for them, especially for HIV and TB clients.
Although quantitative data is not available, WBPHCOTs also provided psychosocial support with grants and referrals to other services as illustrated below.