Newborn screening and referral for congenital anomalies by lay health workers in Pakistan: a mixed-methods study to evaluate the effectiveness of a co-created educational intervention

Background: Globally, 8 million babies are born with a congenital anomaly annually causing 240,000 neonatal deaths, with 95% disease burden in Low- and Middle-Income Countries (LMICs). Early neonatal screening, timely referral and management can lead to reduced disability and mortality. The WHO recommends employing lay health workers (HWs) as agents to promote health due to critical shortage of health service providers worldwide. This study aims to assess the effectiveness of a learner-centered educational intervention to train lay HWs to screen neonates for external congenital anomalies and to refer affected families towards care. Methods: The CARe (Congenital Anomalies Registry) educational intervention was designed for lay HWs, with a two-week classroom component followed by two weeks of hands-on training under guided supervision at a selected hospital in Karachi. A focused curriculum was developed. Fifteen HWs underwent pre-service training. Knowledge was assessed using pre-, post- and delayed post-tests; Sign test was used to determine the effectiveness of the educational intervention by assessing if the difference between the scores was statistically significant (p-value of < 0.05). Association of median test scores with demographic factors was examined using the Kruskal Wallis test. Concordance between HWs and a helpline physician in identifying anomalies was assessed using Gwet’s AC. Skills assessment was conducted using a checklist and two focus group discussions (FGDs) were organized to capture HWs’ perspectives on the curriculum. Results: A statistically significant increase (p-value < 0.001) in knowledge of HWs was depicted by the post-test scores, not associated with any socio-demographic factors. Skills assessment scores showed that 11 out of 15 HWs were either ‘Good’ or ‘Excellent’ in clinical and communication skills. Gwet’s AC showed concordance at 0.93 with a p-value < 0.001, indicating ‘very good’ inter-rater agreement. Thematic content analysis of FGDs disclosed positive feedback on overall training, with specific emphasis on the effective strategies used by content trainers. Conclusions: This study provides preliminary evidence that the CARe educational intervention was effective. From our experience, the results could be attributed to effective training, which was reliant on meticulous planning, honest execution of the plan, teaching expertise, attitude of trainers, supportive supervision and an enabling learning environment. HWs could potentially be utilized to deliver public health interventions effectively, especially amid healthcare workforce shortages in LMICs.