Early impact of the Liberian National Community Health Assistant Program on under-five mortality in Grand Bassa County: A non-randomized stepped wedge evaluation

@article{obaje2026early,
  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}},
  author = {Hawa I. Obaje and Emily E. White and Mardieh Dennis and Dominik Jockers and Till Bärnighausen and Avi Kenny and Jeffrey W. Rozelle and Robert G. Karlay Jr. and Savior F. Mendin and Lekilay G. Tehmeh and Brittney Varpilah and Ben Grant and Marion Subah and Richard Harris and S. Olasford Wiah and Nelson Dunbar and C. Sanford Wesseh and Lisa R. Hirschhorn and Mark J. Siedner and John D. Kraemer},
  journal = {PLOS Global Public Health},
  year = {2026},
  month = sep,
  doi = {10.1371/journal.pgph.0005681},
  url = {https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005681},
  note = {CC BY 4.0},
}

TY  - JOUR
TI  - Early impact of the Liberian National Community Health Assistant Program on under-five mortality in Grand Bassa County: A non-randomized stepped wedge evaluation
AU  - Hawa I. Obaje
AU  - Emily E. White
AU  - Mardieh Dennis
AU  - Dominik Jockers
AU  - Till Bärnighausen
AU  - Avi Kenny
AU  - Jeffrey W. Rozelle
AU  - Robert G. Karlay Jr.
AU  - Savior F. Mendin
AU  - Lekilay G. Tehmeh
AU  - Brittney Varpilah
AU  - Ben Grant
AU  - Marion Subah
AU  - Richard Harris
AU  - S. Olasford Wiah
AU  - Nelson Dunbar
AU  - C. Sanford Wesseh
AU  - Lisa R. Hirschhorn
AU  - Mark J. Siedner
AU  - John D. Kraemer
PY  - 2026
DA  - 2026/09/28
JO  - PLOS Global Public Health
DO  - 10.1371/journal.pgph.0005681
UR  - https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005681
AB  - 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.
SN  - 2767-3375
ER  -