{
  "abstract": "Liberia instituted a National Community Health Assistant Program (NCHAP) to increase primary healthcare access for residents living >5 km from health facilities. We evaluated the impact of this program on under-five mortality in rural Grand Bassa County as it was rolled out, between 2018 and 2022. The program was implemented in a stepped manner two districts at-a-time across Grand Bassa County from 2018 to 2022, allowing for a quasi-experimental observational stepped-wedge impact evaluation. We conducted a household census in 2022 to collect birth and death histories from all mothers in the program catchment area. We fitted mixed-effects Cox proportional hazards models to estimate the relative hazard of death among children <5 in the before- and under-intervention periods. We also compared data from the 2022 survey with a 2018 baseline household survey to estimate changes in care-seeking and healthcare service delivery coverage. We surveyed 22,315 female respondents about 32,743 children <5 who contributed person-time to the analysis. We found no difference in <5 mortality between the before- and under-intervention periods (unadjusted U5MR under intervention was higher at 62.0 versus 56.3 deaths per live births; adjusted hazard ratio 1.03 (95%CI 0.82-1.31). Care-seeking from a qualified healthcare provider for fever, diarrhea, or acute respiratory infection increased (27.0% to 53.7%; p < 0.001); and care-seeking decreased from drugstores (16.4% to 4.9%, p < 0.001) and black-market providers (42.4% to 22.7%, p < 0.001). Full vaccination among 12–23-month-olds decreased (16.2% in 2018 to 3.5% in 2022 (p < 0.001)) while facility-based delivery increased (41.0% to 57.1% (p < 0.001)). We detected no reduction in under-five mortality during initial implementation of the national CHA program in one Liberian county. Coverage of childhood treatment for high-priority conditions improved, and we observed a shift in care-seeking to trained providers. These results suggest potential program benefits, but additional interventions, some of which are already underway, will be needed to reduce under-five mortality.",
  "abstract_shown": true,
  "affiliations": [
    "Last Mile Health, Monrovia, Liberia",
    "Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany",
    "Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America",
    "Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America",
    "Spatial Sciences Institute, Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, California, United States of America",
    "Grand Bassa County Health Team, Buchanan, Liberia",
    "Ministry of Health, Monrovia, Liberia",
    "Ryan Center for Global Primary Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America",
    "Harvard Medical School, Boston, Massachusetts, United States of America",
    "Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America",
    "Department of Health Management and Policy, Georgetown University School of Health, Washington, District of Columbia, United States of America"
  ],
  "article_type": "Research Article",
  "arxiv": null,
  "author_total": 20,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Hawa I. Obaje"
    },
    {
      "affs": [
        1
      ],
      "name": "Emily E. White"
    },
    {
      "affs": [
        2
      ],
      "name": "Mardieh Dennis"
    },
    {
      "affs": [
        3
      ],
      "name": "Dominik Jockers"
    },
    {
      "affs": [
        4
      ],
      "name": "Till Bärnighausen"
    },
    {
      "affs": [
        5
      ],
      "name": "Avi Kenny"
    },
    {
      "affs": [
        6
      ],
      "name": "Jeffrey W. Rozelle"
    },
    {
      "affs": [
        7
      ],
      "name": "Robert G. Karlay Jr."
    },
    {
      "affs": [
        8
      ],
      "name": "Savior F. Mendin"
    },
    {
      "affs": [
        9
      ],
      "name": "Lekilay G. Tehmeh"
    },
    {
      "affs": [
        10
      ],
      "name": "Brittney Varpilah"
    },
    {
      "name": "Ben Grant"
    },
    {
      "name": "Marion Subah"
    },
    {
      "name": "Richard Harris"
    },
    {
      "name": "S. Olasford Wiah"
    },
    {
      "name": "Nelson Dunbar"
    },
    {
      "name": "C. Sanford Wesseh"
    },
    {
      "name": "Lisa R. Hirschhorn"
    },
    {
      "name": "Mark J. Siedner"
    },
    {
      "name": "John D. Kraemer"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/0vg7qd19zzh2w.bib",
  "cited_by": 0,
  "doi": "10.1371/journal.pgph.0005681",
  "fulltext_url": "https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005681",
  "id": "0vg7qd19zzh2w",
  "issns": [
    "2767-3375"
  ],
  "landing_url": "https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005681",
  "language": null,
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
  "licence_source": "journal",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "openalex",
      "2735|Global Maternal and Child Health"
    ],
    [
      "plos",
      "/Biology and life sciences/Immunology/Vaccination and immunization"
    ],
    [
      "plos",
      "/Biology and life sciences/Population biology/Population metrics/Death rates"
    ],
    [
      "plos",
      "/Medicine and health sciences/Clinical medicine/Signs and symptoms/Diarrhea"
    ],
    [
      "plos",
      "/Medicine and health sciences/Clinical medicine/Signs and symptoms/Fevers"
    ],
    [
      "plos",
      "/Medicine and health sciences/Gastroenterology and hepatology/Diarrhea"
    ],
    [
      "plos",
      "/Medicine and health sciences/Health care/Health care facilities"
    ],
    [
      "plos",
      "/Medicine and health sciences/Immunology/Vaccination and immunization"
    ],
    [
      "plos",
      "/Medicine and health sciences/Pediatrics/Child health"
    ],
    [
      "plos",
      "/Medicine and health sciences/Public and occupational health/Child health"
    ],
    [
      "plos",
      "/Medicine and health sciences/Public and occupational health/Preventive medicine/Vaccination and immunization"
    ],
    [
      "plos",
      "/People and places/Geographical locations/Africa/Liberia"
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    [
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      "/Research and analysis methods/Research design/Survey research/Surveys"
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  "openalex": "W7214614526",
  "pdf_url": "https://journals.plos.org/globalpublichealth/article/file?id=10.1371/journal.pgph.0005681&type=printable",
  "pmcid": null,
  "pmid": null,
  "published": "2026-09-28",
  "publisher": "Public Library of Science",
  "ris": "https://research.draconitic.com/paper/0vg7qd19zzh2w.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:17:37Z",
      "native_id": "10.1371/journal.pgph.0005681",
      "source": "plos",
      "url": "https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005681"
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  "subjects": [
    {
      "field": "biology",
      "origin": "plos:immunology",
      "subfield": "immunology"
    },
    {
      "field": "medicine",
      "origin": "plos:public and occupational health",
      "subfield": "epidemiology-public-health"
    },
    {
      "field": "medicine",
      "origin": "plos:pediatrics",
      "subfield": "reproductive-child"
    }
  ],
  "title": "Early impact of the Liberian National Community Health Assistant Program on under-five mortality in Grand Bassa County: A non-randomized stepped wedge evaluation",
  "title_text": "Early impact of the Liberian National Community Health Assistant Program on under-five mortality in Grand Bassa County: A non-randomized stepped wedge evaluation",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T12:17:37Z",
  "url": "https://research.draconitic.com/paper/0vg7qd19zzh2w",
  "venue": "PLOS Global Public Health",
  "versions": []
}