Abstract
BACKGROUND: In Pakistan’s high child mortality context, a large-scale Lady Health Worker (LHW) Program raises the need to look at whether LHWs are delivering their key mandate as agents of change for child health. This study examines the quantity and quality of LHW interactions with mothers for child health and their impact on mothers' knowledge and child health practices.
 
 METHODS: 1,968 mothers of children <2 years (n=1,968) were interviewed through a cross-sectional survey in two rural districts of Pakistan focusing on immunization, nutrition, and early child illness. Data on frequency of LHW’s visits; services provided, specific services related to routine immunization (RI), nutrition and child illness, and maternal knowledge and practices were analyzed using median values for continuous variables and counts and percentages for categorical data. 
 
 RESULTS: Monthly visits by LHW were reported by only 63% of LHW covered households. During LHW monthly encounters, Oral Polio drops administration was most frequently reported (77%), followed by RI (59%), breastfeeding counseling (20%), child illness management advice (18%), growth monitoring (9.5%), while none reported receiving hygiene counseling. Although LHWs were reported to be the main information source for child health; limited impact of LHW-mother interaction was seen on maternal knowledge and practices: 76% mothers reported receiving ORS packets from LHWs but only 27% knew of correct usage, only 34% washed hands before feeding children, less than a third could correctly recall early signs of pneumonia and awareness of Vaccine Preventable Diseases other than Polio ranged from 42%-9% only. 
 
 CONCLUSION: Although LHWs are main information source for child health services but infrequent, poor quality household encounters indicate ineffective delivery on the key mandate of community-based child health. Policy debate instead of focusing on scaling up or downsizing the program, should prioritize quality and supervision to improve value for money of a critical community resource.
Highlights
In several Low Middle Income Countries (LMICs), community health workers (CHWs) are the first point of contact for the community to access health services
Lady Health Worker (LHW) were reported to be the main information source for child health; limited impact of LHW-mother interaction was seen on maternal knowledge and practices: 76% mothers reported receiving Oral Rehydration Solution (ORS) packets from LHWs but only 27% knew of correct usage, only 34% washed hands before feeding children, less than a third could correctly recall early signs of pneumonia and awareness of Vaccine Preventable Diseases other than Polio ranged from 42%-9% only
Data was collected on frequency of LHW visits to household, child health services provided during LHW visits, mothers’ recognition and handling of pneumonia and diarrhea, maternal knowledge and practices related to essential preventive services of routine immunization, infant feeding, and hygiene
Summary
In several Low Middle Income Countries (LMICs), community health workers (CHWs) are the first point of contact for the community to access health services. Their foremost purpose has been the provision of frontline advice, treatment and referral for childhood illness, under-nutrition, maternal care, malaria and HIV treatment (Gilmore & McAuliffe, 2013; Brenner et al, 2011; Mambulu‐Chikankheni, Eyles, & Ditlopo, 2018; Uganda, 2016). Within the area of child health, the pivotal role of CHWs is for increasing community uptake of evidence based preventive and promotive practices to reduce child mortality as well as contribute to early recognition and referral so that childhood diseases can be dealt with timely at health facilities. This study examines the quantity and quality of LHW interactions with mothers for child health and their impact on mothers' knowledge and child health practices
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