Figures & Tables
Figures
- FIGURE 1.
Location of Rural Districts, Huánuco Region, Peru, Where Cluster-Randomized Controlled Trial of Community Health Worker Training Methodology Was Conducted
- FIGURE 2.
Allocation of Clusters and Study Population, Huánuco Region, Peru
- FIGURE 3.
Changes in Stunting in Children Aged 0–23 Months Before and After a Community Health Worker Training Intervention Comparing Experimental and Control Groups by Maternal Literacy, Huánuco Region, Peru
Community health worker sharing histories with mother and reviewing flip chart messages.Credit: ©2014 Lurdes Cabello/Future Generations
Community health worker asks a mother and grandmother what they see in the flip chart image. Credit: ©2013 Elie Gardner
Community supervisor meeting with small group of community health workers to reinforce training received from health personnel trainer that month. Credit: ©2013 Elie Gardner
Tables
- TABLE 1.
Comparison of CHW Training Methodology Interventions Used in a Cluster-Randomized Controlled Trial, Huánuco Region, Peru
Interventions Experimental Clusters Control Clusters Basic strengthening of primary health care services: orientation to community health strategies, interdisciplinary team building for health staff, self-assessment, and planning for community health actions Yes Yes Basic strengthening of local government to support community MNCH, to gain their commitment to provide financial and incentive support to CHWs and CSs Yes Yes Training of facilitators (health personnel trainers) on adult education methods Yes Yes Provision of a complete set of 7 flip charts to each CHW and CS Yes Yes Training of facilitators on use of facilitator manuals based on Sharing Histories as the CHW training method Yes No Training of facilitators on use of facilitator manuals based on a standard CHW training method No Yes Continuous monthly training of CHWs and CSs using Sharing Histories as the training method Yes No Continuous monthly training of CHWs and CSs using a standard CHW training method No Yes Monthly home visits conducted by CHWs, supported by CSs and health staff to educate mothers, monitor MNCH behaviors, identify danger signs, and refer to the health facility Yes Yes Monthly supervision of CHWs by CSs Yes Yes Abbreviations: CHW, community health workers; CS, community supervisors; MNCH, maternal, neonatal, and child health.
- TABLE 2.
Human Resources With Roles and Tasks for Community Promotion of Maternal, Neonatal, and Child Health, Huánuco Region, Peru
CHW CS Facilitators (Trainers) Selection process Selected preferably by other women in the community Selected by a panel of judges from the local PHC facility and municipal government Self-selected with the approval of their superior Selection criteria Respected older woman with grown children Female, literate, at least 5 years of prior CHW experience or auxiliary nurse training; ability to work half-time and travel between communities Health professional; preferably woman who has a long-term contract in PHC facility Workload 1 CHW for every 30 families (on average, 2 or 3 pregnant women and 2 or 3 children aged 0–23 months) 1 CS supports 10–15 female CHWs 1 trainer per group of 10–25 CHWs and their respective CS Key roles Attend monthly 1-day trainings at nearest PHC facility
Meet monthly in small groups with her CS for reinforcement of training and practice with flip charts and monitoring formats
Create a map of her 30 households, identifying pregnant women and children aged 0–23 months
Visit each pregnant woman and child aged 0–23 months on a monthly basis
Fill out simple monitoring checklists, referral slips, and monthly activity report checklists
Ensure that her assigned CHWs attend month training sessions in the PHC facility
Meet with her CHWs in small groups of 5–7 CHWs once or twice a month to review the training from the latest workshop in the PHC facility and to practice using flip charts to teach mothers
Accompany CHWs on home visits until the CHW feels comfortable visiting alone
Attend monthly training workshops along with CHWs in the PHC facility
Organize and hold 1 monthly workshop for CHWs in their own PHC facility
Train CHWs and CSs on how to educate and monitor mothers in the home using the flip chart series and monitoring tools, following a facilitator manual corresponding to each flip chart
Receive training in how to utilize the facilitator manual that accompanies each of 7 flip charts
Use the Sharing Histories teaching methodology as incorporated into each facilitator manual
Key tasks during monthly home visits to pregnant women and children aged 0–23 months Share histories and teach mothers using flip charts by stage of pregnancy or child age
Monitor health practices and record on pictorial checklists by stage of pregnancy or child age
Observe for danger signs using pictorial checklists by stage of pregnancy or child age
Make referrals using pictorial referral slips for maternal-child preventive care and when danger signs are detected
Incentives In-kind from the health system: certificate of recognition, training, supervision visits by CSs
In-kind from district government: clothing items identifying her as a CHW or CS with name of the district, a food basket and party for annual Health Promoters’ Day and Christmas
Monthly stipend equivalent to about one-third the salary of an auxiliary nurse (To ensure accountability, monthly payment from district government was based on demonstrated completion of the 4 key roles)
In-kind incentives from both the health sector and municipality, the same as for female CHWs
Training and recognition Abbreviations: CHW, community health workers; CS, community supervisors; PHC, primary health care.
- TABLE 3.
Demographic Characteristics of Mothers and Children, by Study Group and Survey, Cluster-Randomized Controlled Trial on Sharing Histories CHW Training Methodology, Huánuco Region, Peru
Demographic Characteristics Baseline Survey 2010 Final Survey 2014 Study Group Significance Study Group Significance Experimental (n=308) Control (N=298) Experimental (n=290) Control (n=263) Mothers Age, years, mean (SD) 26.9 (7.8) 27.2 (9.2) .62 27.1 (7.8) 26.1 (6.8) .11 Number of children, mean (SD) 2.6 (1.9) 2.8 (2.2) .18 2.7 (1.8) 2.6 (1.6) .25 Distribution of number of children, % .14 .07 1 37.5 33.0 35.9 32.5 2 22.6 27.9 22.8 28.5 3–4 26.2 21.4 22.8 27.0 5–12 13.6 17.7 18.6 12.2 Total 100.0 100.0 100.0 100.0 Education, years, mean (SD) 4.4 (3.7) 4.7 (3.6) .35 5.4 (3.9) 5.8 (3.5) .21 Distribution of maternal educational level, % (n) .60 .37 No education or cannot read (illiterate) 31.5 (97) 32.3 (96) 24.8 (72) 20.2 (53) Any primary education (literate) 46.2 (142) 42.5 (127) 40.7 (118) 45.2 (119) Any secondary or more (literate) 22.3 (69) 25.2 (75) 34.5 (100) 34.6 (91) Total 100 (308) 100 (298) 100 (290) 100 (263) Works for cash or barter, % 12.8 17.3 .25 34.1 41.8 .04 Children Age in months, mean (SD) 11.4 (6.7) 10.9 (6.8) .39 11.0 (7.0) 11.3 (6.6) .58 Sex of child, female, % 47.7 47.3 .49 50.7 47.9 .29 Birth weight (g), mean (SD) 3,045 (471) 3,042 (285) .92 3,051 (444) 3025 (481) .52 For illiterate mothers 3,063 (454) 2,953 (494) .13 2,980 (448) 3076 (475) .26 For literate mothers 3,042 (479) 3,080 (436) .41 3,074 (442) 3013 (482) .17 Low birth weight (<2,500 g) 10.2 7.2 .30 9.8 10.0 .92 For illiterate mothers 10.3 10.2 .98 9.9 8.2 .75 For literate mothers 10.2 6.7 .20 9.8 10.5 .81 Abbreviation: CHW, community health worker; SD, standard deviation.
- TABLE 4.
Home Visits From CHWs Received by Mothers at Endline Survey, 2014, by Study Group, Huánuco Region, Peru
Receipt by Mothers of CHW Home Visits Experimental (n=290) Control (n=263) Significance Mothers who received 1 or more CHW home visits, % 63.1 60.5 .29 Distribution of mothers who received 1 or more home visits by educational level, % .59 No education or cannot read (illiterate) 23.5 18.9 Any primary education and can read (literate) 46.4 49.7 Any secondary or more education (literate) 30.1 31.4 Total 100.0 100.0 Mothers who received 1 or more CHW visits received within each educational level, % No education or cannot read (illiterate) 59.7 56.6 .43 Any primary education and can read (literate) 72.0 66.4 .21 Any secondary or more education (literate) 55.0 54.9 .55 Number of CHW home visits received (range 1–27), mean (SD) 5.28 (4.6) (N=180) 5.27 (4.3) (N=159) .99 Number of CHW home visits received within each educational level (range 0–27), mean (SD) 3.28 (4.5) 3.19 (4.2) .81 No education or cannot read (illiterate) (range 0–27) 2.65 (3.9) 2.98 (4.1) .65 Any primary education and can read (literate) (range 0–27) 3.51 (4.0) 3.46 (4.3) .93 Any secondary or more education (literate) (range 0–27) 3.45 (5.3) 2.94 (4.2) .47 Distribution of number of CHW visits received by mothers, % .88 0 37.9 39.2 1 or 2 19.3 19.0 3–5 22.4 20.2 6–10 13.1 15.2 11–27 7.2 6.1 Total 100.0 100.0 Abbreviations: CHW, community health worker, SD, standard deviation.
Baseline Survey 2010 Endline Survey 2014 Baseline to Endline Differences Experimental N=308 Control N=298 Significance Experimental N=290 Control N=263 Significance Experimental Control Proportion of mothers with spontaneous correct report of at least 2 danger signs, % Danger signs in pregnancy 39.3 42.6 .28 73.8 74.5 .46 +34.5 +27.9 Danger signs during birth 11.0 7.7 .10 27.6 24.7 .25 +16.6 +17.0 Danger signs in postpartum 20.5 23.2 .24 38.3 35.7 .30 +17.8 +12.5 Danger signs in newborns 23.1 18.1 .08 61.0 61.6 .48 +37.9 +43.5 Micronutrient consumption, % Mothers consuming iron tabs 3+ months last pregnancy 51.0 46.6 .16 77.2 74.1 .41 +26.2 +27.5 Children with micronutrients added to food in past 24 hours 0.0 0.3 .49 57.9 61.2 .24 +57.9 +60.9 Children with vitamin A supplement in past 6 months 47.1 46.3 .77 21.3 19.2 .28 −25.8 −27.1 Proportion of children with nutritional pattern, % Currently breastfeeding 89.6 87.2 .36 88.3 90.1 .29 −1.3 +2.9 Early breastfeeding within 1 hour of birth 77.6 72.8 .11 69.0 66.5 .30 −8.6 −6.3 Exclusive breastfeeding, 0–5 months 71.8 (N=71) 83.5 (N=79 ) .06 86.6 (N=82) 90.2 (N=61) .35 +14.8 +6.7 Food consumption in past 24 hours for children aged 6–23 months, % (N=237) (N=219) (N=208) (N=202) Iron-rich foods 53.2 53.9 .48 93.8 93.1 .47 +40.6 +39.2 Animal protein 32.5 37.4 .16 47.1 49.0 .39 +14.6 +11.6 Minimum meal frequency 69.6 68.0 .40 94.2 89.6 .06 +24.6 +21.6 Minimum food diversity 56.1 58.4 .34 79.3 75.7 .23 +19.6 +17.3 Household water, sanitation, and hygiene practices by maternal literacy, % No animals (except pets) live inside house Illiterate 45.0 50.0 .31 52.8 64.2 .14 +7.8 +14.2 Literate 50.6 56.9 .14 65.6 58.6 .08 +15.0 +1.7 Uses correct treatment for drinking water Illiterate 80.2 89.5 .17 97.2 79.2 .00 +17.0 −10.3 Literate 86.1 85.9 .29 92.2 96.2 .06 +6.1 +10.3 Mother washes hands after defecating Illiterate 28.1 29.5 .48 23.6 34.0 .14 −4.5 +4.5 Literate 50.7 43.2 .08 50.5 39.0 .01 −0.2 −4.2 Soap is available for hand washinga Illiterate na na — 48.6 37.7 .15 — — Literate na na — 61.5 61.0 .50 — — Uses safe water source Illiterate 49.0 43.2 .26 66.7 63.5 .43 +17.7 +20.3 Literate 64.1 59.8 .21 73.0 73.1 .54 +8.9 +13.3 Improved cook stove installed in past 4 years Illiterate 51.0 60.0 .14 40.3 22.6 .03 −10.7 −37.4 Literate 50.2 43.7 .11 40.4 32.9 .07 −9.8 −10.8 Does not use wood or dried dung as cook fuel Illiterate 6.3 2.1 .14 11.1 7.5 .36 +4.8 +5.4 Literate 18.7 15.1 .20 30.7 26.2 .18 +12.0 +11.1 Receipt of government health and social services, % Infant food supplementation program 93.8 92.3 .28 0.7 1.1 .45 −93.1 −91.2 Conditional cash transfer program (Juntos) 52.6 53.0 .49 53.8 52.9 .45 +1.2 −0.1 Municipal Glass of Milk program 76.0 76.2 .52 68.6 68.1 .48 −7.4 −8.1 Child antiparasite treatment in past 6 months 12.1 15.4 .13 9.0 6.1 .13 −3.1 −9.3 Participation of mothers in women’s groups with discussion of child health and nutritiona 46.4 44.3 .60 50.0 49.4 .48 +3.6 +5.1 ↵a Not assessed at baseline.
- TABLE 6.
Changes in Prevalence of Growth Stunting in Children Aged 0–23 Months by Demographic Characteristics, Study Group, and Survey, Huánuco Region, Peru
Baseline Survey 2010 Endline Survey 2014 Experimental (N=305) Control (N=295) Significance Experimental (N=290) Control (N=263) Significance All study children 34.4 35.3 .45 30.3 35.0 .14 Mother’s educational level No education or cannot read 45.3 43.6 .47 47.2 39.6 .25 Any primary or secondary 29.0 32.0 .29 24.8 33.8 .03 Child’s age 0–11 months 22.9 22.7 .53 19.1 25.9 .10 12–23 months 46.6 48.3 .43 43.6 45.2 .45 Child’s sex Female 21.9 28.6 .12 22.4 29.4 .12 Male 45.9 41.3 .24 38.5 30.1 .43 Child birth weight ≤2,500 g 44.8 61.9 .18 50.0 46.2 .49 >2,500 g 32.6 33.0 .50 27.9 33.5 .11 - TABLE 7.
Changes in Prevalence of Growth Stunting in Children Aged 0–23 Months by Receipt of 1 or More CHW Visits, by Maternal Literacy and Study Group at Endline, Huánuco Region, Peru
Both Study Groups Significance With CHW Visit Without CHW Visit With CHWVisit Without CHW Visit Experimental Control Significance Experimental Control Significance All mothers Child stunting, % 33.3 31.3 .34 29.0 38.4 .04 37.2 29.8 .38 Maternal education in years, mean (SD) 5.3 (3.5) 6.0 (3.9) .02 5.1 (3.6) 5.6 (3.4) .20 5.9 (4.2) 6.1 (3.7) .71 N 342 211 183 159 107 104 Illiterate Child stunting, % 47.9 38.5 .19 48.8 46.7 .52 44.8 30.4 .22 Maternal education in years, mean (SD) 0.7 (1.3) 1.2 (1.4) .08 0.7 (1.3) 0.8 (1.2) .67 1.0 (1.4) 1.4 (1.4) .38 N 73 52 43 30 29 23 Literate Child stunting, % 29.4 28.9 .51 22.9 36.4 .01 28.2 29.6 .49 Maternal education in years, mean (SD) 6.5 (2.9) 7.6 (3.1) .00 6.4 (3.0) 6.7 (2.7) .49 7.8 (3.3) 7.5 (2.9) .58 N 269 159 140 129 78 81 Abbreviations: CHW, community health worker, SD, standard deviation.
- TABLE 8.
Generalized Estimating Equationsa Bivariate Associations With Child Stunting for 553 Children Aged 0–23 Months, Huánuco Region, Peru
Predictors of Child Stuntingb Estimate Beta 95% Confidence Interval Significance Experimental group 0.21 −0.31, 0.74 .43 Mother is literate 0.64 0.30, 0.98 <.00 Interaction: experimental group × maternal literacy 0.75 0.20, 1.30 <.00 Maternal characteristics No. of children born in mother’s lifetime (1–12) −0.12 −0.24, 0.01 .07 Mother has remunerated work (0, 1) 0.00 −0.34, 0.34 .99 Child characteristics Age (0–23 months) −0.08 −0.10, −0.05 <.00 Female child (0, 1) 0.63 0.26, 0.99 <.00 Low birth weight (<2,500 g) −0.75 1.32, −0.72 .01 Birth weight (g) .00 .00, .00 <.00 Child feeding variables Receives breastmilk within 1 hour of birth (0, 1) −0.19 −0.62, 0.24 .39 Meets minimum food diversity (0, 1) −0.57 −1.18, .054 .07 Meets minimum meal frequency (0, 1) −0.17 −0.86, 0.53 .64 Consumes iron-rich foods in past 24 hours (0, 1) −0.35 −1.47, 0.78 .55 Consumes animal food source past 24 hours (0, 1) 0.02 −0.55, 0.60 .94 Micronutrient consumption Mother took iron during last pregnancy (0–9 months) 0.09 −0.02, 0.17 .06 Child consumed Sprinklesc in past 24 hours (0, 1) −0.45 −0.86, −0.04 .03 Vitamin A capsule taken by child in past 6 months (0, 1) −0.04 −0.56, 0.49 .89 Water, sanitation, and hygiene practices Mother washes hands after defecation (0, 1) 0.10 −0.17, 0.36 .46 Soap, ash, or detergent used to wash hands (0, 1) 0.03 −0.19, 0.24 .80 Household has safe water source (0, 1) −0.35 −0.85, 0.15 .17 Drinking water is treated correctly (0, 1) 0.20 −0.33, 0.73 .45 Improved cook stove installed in past 4 years (0, 1) −0.44 −0.85, −0.03 .03 Non-pet animals do not live in the home (0, 1) 0.14 −0.26, 0.54 .50 Government health and social services Parasite treatment for child in past 6 months (0, 1) −0.90 −1.43, −0.37 <.01 Mother in participatory women’s group (0, 1) −0.08 −0.47, 0.31 .68 Glass of Milk daily ration for child (0, 1) −0.08 −0.48, 0.33 .72 Juntos cash transfer received by mother (0, 1) −0.10 −0.46, 0.27 .59 - TABLE 9.
DID Analysis of Mean HAZ in 533 Children Aged 0–23 Months, Baseline to Endline, for All Children and for Subgroups of Children Stratified by Maternal Literacy, Huánuco Region, Peru
Group Control Experimental Paired t-test MeanHAZ Baseline,Mean (SD) MeanHAZEndline,Mean (SD) Diff. of Means, Mean (SD) MeanHAZ Baseline,Mean (SD) MeanHAZEndline,Mean (SD) Diff. of Means, Mean (SD) Paired DID, Mean (SD) T-Statistic(df) P Value All children −1.55 (.46) −1.55 (.66) −0.0002 (0.36) −1.62 (0.47) −1.47 (0.31) 0.15 (0.46) 0.15 (0.60) 0.760 (8) .469 Stratified by literacy of mother Illiterate −1.79 (0.51) −1.57 (0.93) 0.22 (0.59) −1.77 (0.44) −1.92 (0.44) −0.16 (0.57) −0.38 (0.72) −1.561 (8) .157 Literate −0.80 (1.13) −1.53 (0.59) −0.74 (1.01) −1.60 (0.54) −1.31 (0.28) 0.29 (0.50) 1.03 (1.40) 2.202 (8) .059 Abbreviations: df, degrees of freedom; DID, difference-in-differences; HAZ, height-for-age-Z-scores, SD, standard deviation.
- TABLE 10.
Generalized Estimating Equationsa Multivariate Model for Predictors of Child Stunting With 553 Children Aged 0–23 Months, Huánuco Region, Peru
Predictors of Child Stuntingb Estimates 95% Wald Confidence Interval Hypothesis Test Beta SE Lower Upper Wald Chi-square df Significance Community health worker training intervention Experimental group (0, 1) −0.27 0.36 0.97 0.43 .58 1 .45 Mother is literate (0, 1) 0.22 0.11 0.00 0.44 3.69 1 .06 Interaction: experimental group × maternal literacy 0.77 0.27 0.23 1.31 7.91 1 <.00 Child nutrition Child consumed Sprinklesc past 24 hours (0, 1) −0.41 0.21 −0.81 .00 3.85 1 .05 Water, sanitation, and hygiene Safe water source (0, 1) −0.43 0.25 −0.92 0.07 2.87 1 .09 Improved cook stove installed past 4 years (0, 1) −0.49 0.21 −0.91 −0.07 5.26 1 .02 Government health and social services Parasite treatment for child in past 6 months (0, 1) −.85 .34 −1.52 −0.18 6.23 1 .01 Intercept 1.22 0.35 0.54 1.91 12.19 1 <.00 Goodness of fitd with corrected quasi-likelihood under independence model criterion (QICC) 672.97 - TABLE 11.
Examples of Local Beliefs Expressed by CHWs Through Sharing Histories, Huánuco Region, Peru
Topic Local Culturally Determined Knowledge, Beliefs, and/or Solutions Identified From CHWs Through Sharing Histories Standard Messages Taught to CHWs by PHC Staff Without Sharing Histories Messages Given by PHC Staff Who Are Trained to Facilitate Sharing Histories and Learning With Picture Cards Pregnancy Danger signs in pregnancy were not recognized as such. For example, female CHWs did not know that a mother could die if she is bleeding during pregnancy and may consider such bleeding as “normal.”
Did not identify pain and frequency of urination as a problem. Heavy work or lifting is continued as normal. Pregnant women eat less to have smaller baby and easier birth. Many foods are specifically avoided during pregnancy, such as fish which may “impede healing.”Danger signs not generally taught in a way to ensure understanding. Picture cards are discussed with motivational stories of pregnant women with danger signs and how they can end in death, or how they can end well if care is sought. Mothers should spare their energy by working less and eating more so the infant can have more energy. Picture cards with various images of danger signs are discussed with indications to seek care. Birth Institutional birth is not considered desirable due to fears of male health providers and horizontal birth. Women are terrorized by the idea of an episiotomy or cesarean delivery that requires transfer to a hospital distant from home and family. Care by a traditional midwife in the presence of family members is valued. Distance is a major barrier at night and holidays when no means of transport are available. Home births are illegal. Institutional births are obligatory. CHWs need to help mothers seek institutional birth with support from family and community members for transport. Newborns Newborn danger signs that were recognized as potentially fatal were infant not wanting to eat and infant being flaccid or agitated. Danger signs that were not recognized as such included an odorous umbilical stump. Newborn is placed to one side to first attend the mother immediately after a home birth, sometimes uncovered due to simple negligence. Information on birth and newborns is not discussed with CHW or mothers: CHWs and mothers “don’t need to know”. Only professional birth and checkups are allowed. Need for immediate drying and wrapping of newborn and placement with mother for warmth and immediate suckling at the breast. No bath the first day to stay warm. Picture card images of danger signs are provided and discussed with indications to seek care. Breastfeeding Insufficient breastmilk is a family trait, so a mother will expect it and nothing can be done if female family members had little milk. Breastmilk is withheld to avoid harming the infant if mother is angry, ill, or is pregnant again. Herbal tea is given frequently (for colic and infant thirst). Dozens of myths surrounding breastfeeding practice are expressed. Generally, PHC staff are not trained in local breastfeeding beliefs and practice or in correct breastfeeding techniques. Infants are taken away for immediate newborn care and not returned quickly to the mother. Free formula samples are handed out. All mothers can breastfeed if measures are taken to stimulate milk supply. Herbal tea should not be given to infants, rather the mother should drink the tea. Trainers detect local myths through CHW shared histories and use those to discuss how to avoid insufficient breastmilk and maintain exclusive breastfeeding for 6 months. Complementary feeding When a child aged over 6 months does not want to eat, mothers give only breast milk. Mothers value giving liquid soups and semiliquid foods to infants (over semisolids). Animal-source foods are acceptable to give but are not available. PHC staff recommend taking child off the breast and only give solid food. If breast milk then dries up, give milk formula or cow’s milk. Continue breastfeeding and try giving small amounts of mashed food more frequently during the day. Soups are mostly water, which fills the infant’s stomach and does not allow space for the food they need to grow. Add citrus juice to legumes to make them more nutritious (increase iron bioavailability) but animal-source foods should be given as much as possible. Diarrhea Diarrhea occurs when someone looks at the child with an “evil eye.” When diapers are damp from being hung out to dry overnight, the dampness in the diaper can “enter” the child and cause diarrhea. Traditional healers “pass a cuy (guinea pig)” or “pass an egg” over the child’s body to draw out bad energy. Dirt or lack of hygiene is not associated with diarrhea. PHC staff promote use of oral rehydration fluid and care-seeking for diarrhea. Use hygiene for prevention (without discussion of local beliefs on causation). Dirt on hands or on prepared food can cause diarrhea in some cases, aside from other believed causes. Thus, it is best to use hygiene practices to avoid such cases (i.e., handwashing, keep animals out of the home, keep the child off the ground or dirty floor, use correct treatment for drinking water, others). Abbreviations: CHW, community health worker; PHC, primary health care.
Supplemental material
- Supplement 1 -
Supplement 1
- Supplement 1 -
