Factors associated with utilization of community health workers in improving access to malaria treatment among children in Kenya

Engaging Community Health Workers (CHWs) in Africa: Lessons from the Canadian Red Cross supported programs

Universal Health Coverage (UHC) will not be achieved if health care worker shortages, estimated to increase to 18 million by 2030, are not addressed rapidly. Community-based health systems, which pivot to effective engagement of community health workers (CHW), may have an essential role in linking communities with health care facilities and reducing unmet health services needs caused by these shortages. The Canadian Red Cross (CRC) has partnered with different National Red Cross/Red Crescent Societies and Ministries of Health in Africa in the implementation of programs where CHWs contributed to the provision of various health services. This study reports on key findings (i.e., beneficiaries reached, CHWs engaged, programs implemented, intervention outcomes) and lessons learned from CRC supported CHW programs in Africa over the last 15 years (2007-2022). Qualitative methodology was employed to conduct document analysis on 17 sets of reports from each CRC-supported community health worker project in Africa over the past 15 years. Focus was on identifying challenges, facilitators, and lessons learned. CRC supported projects have trained over 9000 CHWs, benefiting nearly 7.5 million people across Africa. Key success factors include adaptability and agility in programming and project management, and considering contextual factors (political, social, and cultural systems). Investing in essential training for CHWs, staff, and volunteers is crucial, alongside employing an evidence-based approach to inform all aspects of programming and implementation. Additionally, projects prioritizing protection, gender and inclusion (PGI) while leveraging existing community structures and partnerships important for successful implementation. Despite challenges (i.e., weak health systems, lack of political commitment, insufficient funding, inadequate training) CHWs are recognized as crucial in promoting community-based health, improving access to care, addressing disparities, and contributing to achieving (UHC). Their unique position within communities enables them to provide culturally appropriate and localized primary health care- particularly in remote, resource limited and poverty-stricken regions.

Factors influencing patients' adherence to malaria artemisinin-based combination therapy in Kamuli District, Uganda

BACKGROUND

Patients' adherence to artemisinin-based combination therapy (ACT) is a malaria control strategy. Studies report varied experiences regarding patients' adherence to ACT. The study aimed at determining factors influencing patients' adherence to ACT for malaria in Kamuli, Uganda.

METHODS

In a longitudinal study, 1266 participants at 8 public health facilities were enrolled. Equal numbers (422) were assigned to the three arms (no follow-up, day 2 and day 4). To establish the mean difference between groups, Student t-test was used and a chi-square test was used for proportionality. A multivariate logistic regression analysis was used to establish the influence of predictor variables on the dependent variable. Statistical significance was established at p < 0.05.

RESULTS

A total of 844 patients were analysed. The median age was 20 years, majority (64.3%) were females. Overall patients' adherence was 588/844 (69.7%). At bivariate level, age (t-test = 2.258, p = 0.024), household head (χ2 = 14.484, p = 0.002), employment status (χ2 = 35.886, p < 0.0001), patients' preference of ACT to other anti-malarials (χ2 = 15.981, p < 0.0001), giving a patient/caregiver instructions on how to take the medication (χ2 = 7.134, p = 0.011), being satisfied with getting ACT at facility (χ2 = 48.261, p < 0.0001), patient/caregiver knowing the drug prescribed (χ2 = 5.483, p = 0.019), patient history of saving ACT medicines (χ2 = 39.242, p < 0.0001), and patient ever shared ACT medicines (χ2 = 30.893, p < 0.0001) were all associated with patients' adherence to ACT. Multivariate analysis demonstrated that adhering to ACT is 3.063 times higher for someone satisfied with getting ACT at the facility (OR = 3.063; p < 0.0001), 4.088 times for someone with history of saving ACT medicines (OR = 4.088; p < 0.0001), 2.134 times for someone who shared ACT (OR = 2.134; p = 0.03), and 2.817 times for someone with a household head (OR = 2.817; p = 0.008).

CONCLUSION

Patients' adherence to ACT is generally good in the studied population. However, patients' tendencies to save ACT for future use and sharing among family members is a threat, amidst the benefits associated with adherence. There is a need to educate all about adherence to medicines as prescribed, and tighten government medicine supply chain to avoid stock-outs.

Supply-side and demand-side factors influencing uptake of malaria testing services in the community: lessons for scale-up from a post-hoc analysis of a cluster randomised, community-based trial in western Kenya

OBJECTIVES

Maximising the impact of community-based programmes requires understanding how supply of, and demand for, the intervention interact at the point of delivery.

DESIGN

Post-hoc analysis from a large-scale community health worker (CHW) study designed to increase the uptake of malaria diagnostic testing.

SETTING

Respondents were identified during a household survey in western Kenya between July 2016 and April 2017.

PARTICIPANTS

Household members with fever in the last 4 weeks were interviewed at 12 and 18 months post-implementation. We collected monthly testing data from 244 participating CHWs and conducted semistructured interviews with a random sample of 70 CHWs.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was diagnostic testing before treatment for a recent fever. The secondary outcomes were receiving a test from a CHW and tests done per month by each CHW.

RESULTS

55% (n=948 of 1738) reported having a malaria diagnostic test for their recent illness, of which 38.4% were tested by a CHW. Being aware of a local CHW (adjusted OR=1.50, 95% CI: 1.10 to 2.04) and belonging to the wealthiest households (vs least wealthy) were associated with higher testing (adjusted OR=1.53, 95% CI: 1.14 to 2.06). Wealthier households were less likely to receive their test from a CHW compared with poorer households (adjusted OR=0.32, 95% CI: 0.17 to 0.62). Confidence in artemether-lumefantrine to cure malaria (adjusted OR=2.75, 95% CI: 1.54 to 4.92) and perceived accuracy of a malaria rapid diagnostic test (adjusted OR=2.43, 95% CI: 1.12 to 5.27) were positively associated with testing by a CHW. Specific CHW attributes were associated with performing a higher monthly number of tests including formal employment, serving more than 50 households (vs <50) and serving areas with a higher test positivity. On demand side, confidence of the respondent in a test performed by a CHW was strongly associated with seeking a test from a CHW.

CONCLUSION

Scale-up of community-based malaria testing is feasible and effective in increasing uptake among the poorest households. To maximise impact, it is important to recognise factors that may restrict delivery and demand for such services.

TRIAL REGISTRATION NUMBER

NCT02461628; Post-results.

Community case management of malaria in Western Kenya: performance of community health volunteers in active malaria case surveillance

BACKGROUND

In western Kenya, not all malaria cases are reported as stipulated in the community case management of malaria (CCMm) strategy. This underreporting affects the equity distribution of malaria commodities and the evaluation of interventions. The current study aimed to evaluate the effectiveness of community health volunteers' active case detection and management of malaria in western Kenya.

METHODS

Cross-sectional active case detection (ACD) of malaria survey was carried out between May and August 2021 in three eco-epidemiologically distinct zones in Kisumu, western Kenya: Kano Plains, Lowland lakeshore and Highland Plateau. The CHVs conducted biweekly ACD of malaria household visits to interview and examine residents for febrile illness. The Community Health Volunteers (CHVs) performance during the ACD of malaria was observed and interviews done using structured questionnaires.

RESULTS

Of the total 28,800 surveyed, 2597 (9%) had fever and associated malaria symptoms. Eco-epidemiological zones, gender, age group, axillary body temperature, bed net use, travel history, and survey month all had a significant association with malaria febrile illness (p < 0.05). The qualification of the CHV had a significant influence on the quality of their service. The number of health trainings received by the CHVs was significantly related to the correctness of using job aid (χ2 = 6.261, df = 1, p = 0.012) and safety procedures during the ACD activity (χ2 = 4.114, df = 1, p = 0.043). Male CHVs were more likely than female CHVs to correctly refer RDT-negative febrile residents to a health facility for further treatment (OR = 3.94, 95% CI = 1.85-5.44, p < 0.0001). Most of RDT-negative febrile residents who were correctly referred to the health facility came from the clusters with a CHV having 10 years of experience or more (OR = 1.29, 95% CI = 1.05-1.57, p = 0.016). Febrile residents in clusters managed by CHVs with more than 10 years of experience (OR = 1.82, 95% CI = 1.43-2.31, p < 0.0001), who had a secondary education (OR = 1.53, 95% CI = 1.27-1.85, p < 0.0001), and were over the age of 50 (OR = 1.44, 95% CI = 1.18-1.76, p < 0.0001), were more likely to seek malaria treatment in public hospitals. All RDT positive febrile residents were given anti-malarial by the CHVs, and RDT negatives were referred to the nearest health facility for further treatment.

CONCLUSIONS

The CHV's years of experience, education level, and age had a significant influence on their service quality. Understanding the qualifications of CHVs can assist healthcare systems and policymakers in designing effective interventions that assist CHVs in providing high-quality services to their communities.

Utilization of integrated community case management service of childhood illness (ICCM) and associated factors among under-five children in Shashogo district, Hadiya zone, south Ethiopia

Background

Integrated community case management (ICCM) service is provision of concurrent clinical and preventive care by trained community health workers for common childhood illnesses in the community. In Ethiopia, integrated community case management (ICCM) service utilization is low and its magnitude is unknown as well as no adequate evidence on its associated factors. This study aimed to investigate use of integrated community case management service of childhood illness and factors associated with it.

Methods

A community-based cross-sectional study was conducted in Shashogo district. A total of 422 mothers who have under-five children were selected using simple random sampling method. Structured interviewer administered pre-tested in 5% of the sample; questionnaire was used to collect data. Descriptive statistics, binary and multivariable logistic regression analyses were used.

Results

The proportion of integrated community case management (ICCM) service utilization among sick under-five children in past six months at Shashogo district was found was 199(47.2%, with 95%CI:(43.2, 51.2)). Receiving training on health extension packages as model family AOR = 2.07(1.05, 4.08), experiencing frequent childhood illness AOR = 1.92(1.11, 3.33), having information about ICCM service AOR = 3.73(1.42, 9.76), and having a postnatal care visit in recent child AOR = 13(7.37, 23.06) were associated with utilization of integrated community case management service.

Conclusion

ICCM service was not used as planned though there is offer of free of charge service nearby. ICCM service is affected by maternal and child health utilization. Hence, collaborative activities of information, education, and communication activities are needed.

Utilization of Integrated Community Case Management and Its Factors in Southern Ethiopia: Facility Based-Cross-Sectional Study

Background. An integrated community case management (ICCM) program fosters child health care seeking and access to appropriate treatment for illnesses in children at the community level in Ethiopia. There is paucity of evidence to the utilization of ICCM services by mothers/child caregivers in rural Sothern Ethiopia. Hence, the aim of this study was to determine the utilization of integrated community case management (ICCM) and its factors among mothers/child caregivers in rural Southern Ethiopia. Methods. A multistage sampling technique was used to select study participants in health care facilities offering child health care services. An exit interview was conducted on 574 mothers/child caregivers in randomly selected public health centres. Data were entered using Epi Info and transported to SPSS version 20 for analysis. Results. Only less than a quarter of participants visited health posts for ICCM services during the study period. Those study participants who have not heard about ICCM service before the survey were about 6.53 times more likely not to use the services as compared to those who have heard about the service. Participants who were not members of the women’s development team were about 2.23 times more likely not to utilize ICCM services when compared to their counterparts. Conclusion. The study shows low utilization of ICCM service by children less than five years. Prior information about ICCM services and membership in the health development army was significantly associated with ICCM use. Therefore, our finding may suggest the need for advocacy to increase participation in the health development army and information education to increase the level of awareness and formal education efforts.

Predictors of Health Seeking Behaviours for Common Childhood Illnesses in Poor Resource Settings in Zambia, A Community Cross Sectional Study

Background: Developing countries, including Zambia, account for larger share of child morbidities and mortalities due to common childhood illnesses. Studies on wider determinants of behaviour pertaining to treatment seeking for childhood febrile illnesses in poor resource settings are limited. This study investigated health seeking behaviours of mothers in poor resource settings of Zambia and identified associated factors.

Methods: Secondary data from a community cross sectional study design from the Health for the Poorest Population (HPP) Project was analysed between March and May 2019. Data was collected between May and August, 2013. It was collected by means of administering a structured questionnaire from the mothers of under-five children. The survey took place in Samfya and Chiengi of Luapula province while in Northern Province, Luwingu and Mungwi were settled for. A total of 1 653 mothers of under 5 years who had an episode of diarrhoea, malaria, pneumonia or a combination of any of them not more than 14 days before the interview were included in the study. A sample size was arrived at using A Lot Quality Assurance Sampling (LQAS) method. In order to determine the associations between respondent's demographic characteristics and health seeking behaviour, chi square test of independence was carried out. Multivariable logistic regression was also done to identify predictors of health seeking behaviours for common childhood illnesses in children aged <5 years old in poor resource settings.

Results: Among the mothers interviewed, 64.6% were married while 35.4% were unmarried. Their mean age was 32 years. Mothers who took their sick children to the health facilities for the purpose of seeking health care for their child for either of the illnesses accounted for 75.2%, [95% CI: 0.62–0.96], while 24.8% did not seek health care for their sick child. Factors typically associated with health seeking behaviours were mothers' marital status [aOR = 0.74; 95% CI: 0.58–0.94], and mothers ‘education level [aOR = 1.47; 95% CI: 1.13–1.92].

Conclusion: It was established in this study that health care seeking behaviours for these common childhood illnesses in poor resource settings was relatively high and could be predicted by mother's education level and mothers' marital status. Integrating interventions targeted at increasing utilisation of maternal and child health services with basic education to women and moral support counselling to families may potentially maximise health seeking behaviours in marginalised communities.

Needs assessment of community health workers to enhance efficient delivery of their services for community case management of malaria in Kenya

Background

Malaria continues to be the leading cause of morbidity and mortality in Africa. Community Case Management of malaria (CCMm) which is undertaken by engaging Community Health Workers (CHWs) to effectively address management of malaria cases in some endemic communities was explored in this study. The aim was to assess the needs of CHWs that would help sustain and retain their services to enhance the efficient delivery of CCMm.

Methods

Using semi-structured questionnaires, data on the needs of CHWs was gathered through a qualitative study consisting of in-depth interviews and focus group discussions (FGDs) conducted among study participants in five districts in western Kenya. The study participants comprised of 100 CHWs, 100 mothers of children under five years and 25 key informants made up of public health officers and clinicians involved in the CCMm. The interviews were conducted in English and Swahili or Dholuo, the local language. The recorded audio interviews were transcribed later. The analysis was done using NVivo version 7 software and transcripts were coded after which themes related to the objectives of the study were identified.

Results

All the study participants recognized the need to train and update CHWs on their work as well as remunerating them for their services to enhance efficient delivery of services. The CHWs on their part perceived the provision of gloves, rapid diagnostic test kits (RDTs), lancets, cotton wool and ethanol, bins (to dispose of RDTs and lancets), together with drugs for treating clients as the essential needs to undertake CCMm in the communities. Other logistical needs and incentives mentioned by CHWs and key informants for the successful delivery of CCMm included: gumboots, raincoats, torch lights, mobile phones, means of transportation (bicycles and motorbikes), uniforms and ID cards for identification.

Conclusions

CHWs would perform tasks better and their services retained for a sustainable CCMm if: properly incentivized; offered refresher trainings (and updates) on malaria; and equipped with the requisite tools identified in this study.

From "4Rs and 2Ss" to "Amaka Amasanyufu" (Happy Families): Adapting a U.S.-based Evidence-Based Intervention to the Uganda Context

In Uganda, one in five children presents mental health challenges, including disruptive behavior disorders (DBDs). DBDs can persist through adulthood and result in negative outcomes. Effective interventions for DBDs have been developed and tested in high-poverty communities in developed countries. Yet, most African countries, such as Uganda, lack such interventions. This paper describes the adaptation process of an evidence-based intervention of U.S. origin to optimize fit to context with intervention fidelity, as part of a randomized trial conducted with youth that exhibit behavioral challenges and their caregivers in 30 schools in Uganda. The process involved: initial meetings with headteachers and teachers to introduce the study and the main concepts of the intervention; initial manual review focusing on 4Rs and 2Ss content by the Uganda team; engagement of community stakeholders for additional feedback on content and cultural relevance; final revision of the manual; and collection of children's drawings for the illustration of the manual. This paper describes both similarities and differences between the original and adapted intervention content and methods of delivery. The findings also highlight the importance of involving community stakeholders in the adaptation process.

Utilization of Integrated Community Case Management of Childhood Illnesses at Health Posts in Southern Ethiopia

PURPOSE

Even if strategic actions were undertaken to tackle common childhood illnesses, Ethiopia still stood as one of the six countries accounting for half of the global under-five deaths. So this study aimed to assess the utilization of integrated community case management during childhood illness at health posts in the study area.

METHODS

A community-based cross-sectional study was conducted using a multistage sampling technique that includes 633 sick under-five children with common childhood illnesses. The data was entered into EpiData 3.1 and exported to SPSS 20 for further analysis. Descriptive statistics, bivariate and multivariate logistic regression analyses were computed and adjusted odds ratio within 95% confidence interval was used to measure the statistical association between variables.

RESULTS

Out of the planned 633 participant, 624 caregivers underwent all the study components making the response rate 98.6%. The study indicated that only 10.6% of the sick children sought care from health posts. Income (AOR = 2.99, 95% CI: 1.37-6.53), previous service utilization (AOR = 6.66, 95% CI: 1.81-24.04), awareness of service availability (AOR = 4.74, 95% CI: 1.39-12.10), ownership of health insurance (AOR = 2.63, 95% CI: 1.45-4.76), distance (AOR = 5.23, 95% CI: 1.69-10.19) and type of illness (AOR = 2.97, 95% CI: 1.41-6.25) were the associated factors.

CONCLUSION

The low utilization of integrated community case management insights to focus on availing additional well-equipped health posts, creating community awareness on services at health posts and at what time the services are given to address the problem of the majority.

Coverage of community case management for malaria through CHWs: a quantitative assessment using primary household surveys of high-burden areas in Chhattisgarh state of India

BACKGROUND

Community Case Management of Malaria (CCMM) has been implemented through community health workers (CHWs) in many countries. Existing studies have shown that CHWs can be viable means of implementing CCMM. However, not many studies have examined the coverage under large-scale CCMM programmes. India is a big contributor to global malaria burden. Chhattisgarh is a leading state in India in terms of malaria incidence and mortality. CCMM was implemented on a large scale through the 'mitanin' CHWs in rural Chhattisgarh from 2015. Under CCMM, 37,696 CHWs in 84 high-burden administrative blocks of the state were trained and equipped with rapid diagnostic tests (RDT), artemisinin-based combination therapy (ACT) and chloroquine.

METHODS

This descriptive quantitative study assesses coverage of CCMM in detection and treatment of Malaria over three rounds of household surveys-2015, 2016 and 2018. Household-interviews covered more than 15,000 individuals in each round, using multi-stage random sampling across the 84 blocks. The main objectives were to find out the coverage in identification and treatment of malaria and the share of CHWs in them. A 15-days recall was used to find out cases of fever and healthcare sought by them.

RESULTS

In 2018, 62% of febrile cases in rural population contacted CHWs. RDT, ACT and chloroquine were available with 96%, 80% and 95% of CHWs, respectively. From 2015 to 2018, the share of CHWs in testing of febrile cases increased from 34 to 70%, while it increased from 28 to 69% in treatment of malaria cases. CHWs performed better than other providers in treatment-completion and administered medication under direct observation to 72% of cases they treated.

CONCLUSION

This study adds to one of the most crucial but relatively less reported area of CCMM programmes, i.e. the extent of coverage of the total febrile population by CHWs, which subsequently determines the actual coverage of case-management in malaria. Mitanin-CHWs achieved high coverage and treatment-completion rates that were rarely reported in context of large-scale CCMM elsewhere. Close to community, well-trained CHWs with sufficient supplies of rapid tests and anti-malarial drugs can play a key role in achieving the desired coverage in malaria-management.

Routine data for malaria morbidity estimation in Africa: challenges and prospects

BACKGROUND

The burden of malaria in sub-Saharan Africa remains challenging to measure relying on epidemiological modelling to evaluate the impact of investments and providing an in-depth analysis of progress and trends in malaria response globally. In malaria-endemic countries of Africa, there is increasing use of routine surveillance data to define national strategic targets, estimate malaria case burdens and measure control progress to identify financing priorities. Existing research focuses mainly on the strengths of these data with less emphasis on existing challenges and opportunities presented.

CONCLUSION

Here we define the current imperfections common to routine malaria morbidity data at national levels and offer prospects into their future use to reflect changing disease burdens.

Implementation science in global health settings: Collaborating with governmental & community partners in Uganda

Approximately 450 million people, many of whom live in poverty and are from low and middle-income countries (LMICs), experience serious mental health challenges. Children in sub-Saharan Africa comprise half of the total regional population, yet existing mental health services are severely under-equipped to meet their needs and evidence-based practices (EBPs) are scarce. In Uganda, one in five children present mental health challenges, including disruptive behavior disorders. Guided by the Practical, Robust Implementation and Sustainability (PRISM) framework, this paper describes the strategies by which we have engaged community and government partners to invest in a collaborative, longitudinal study in Uganda aimed at improving youth behavioral health outcomes by testing a collaboratively adapted EBP. We emphasize that implementation scientists should be prepared and willing to invest time and effort engaging key stakeholders and sustain relationships through a full range of collaborative activities; ensure that their science meets a felt need among the stakeholders; and translate their research findings rapidly into accessible and actionable policy recommendations. Finally, we highlight that collaboration with global communities and governments plays a critical role in the adaptation, uptake, scalability, and sustainability of EBPs, and that the process of engagement and collaboration can be guided by conceptual frameworks.

Characterizing the Spatial Determinants and Prevention of Malaria in Kenya

The United Nations' Sustainable Development Goal 3 is to ensure health and well-being for all at all ages with a specific target to end malaria by 2030. Aligned with this goal, the primary objective of this study is to determine the effectiveness of utilizing local spatial variations to uncover the statistical relationships between malaria incidence rate and environmental and behavioral factors across the counties of Kenya. Two data sources are used-Kenya Demographic and Health Surveys of 2000, 2005, 2010, and 2015, and the national Malaria Indicator Survey of 2015. The spatial analysis shows clustering of counties with high malaria incidence rate, or hot spots, in the Lake Victoria region and the east coastal area around Mombasa; there are significant clusters of counties with low incidence rate, or cold spot areas in Nairobi. We apply an analysis technique, geographically weighted regression, that helps to better model how environmental and social determinants are related to malaria incidence rate while accounting for the confounding effects of spatial non-stationarity. Some general patterns persist over the four years of observation. We establish that variables including rainfall, proximity to water, vegetation, and population density, show differential impacts on the incidence of malaria in Kenya. The El-Nino-southern oscillation (ENSO) event in 2015 was significant in driving up malaria in the southern region of Lake Victoria compared with prior time-periods. The applied spatial multivariate clustering analysis indicates the significance of social and behavioral survey responses. This study can help build a better spatially explicit predictive model for malaria in Kenya capturing the role and spatial distribution of environmental, social, behavioral, and other characteristics of the households.

Utilization of health services in Tenali Mandal, Andhra Pradesh- A cross-sectional study

Introduction

India has a plurality of health care with different systems of medicine delivered by government and local bodies in hospitals and clinics. Public hospitals provide 60% of all hospitalizations, while the private sector provides 75% of all routine care. Utilization is the actual attendance by the members of the public at health care facilities, which measures the number of visits per year or the number of people with at least one visit during the previous year, serves as an important tool and acts as a guiding path in understanding disease profile and also helps resource allocation.

Materials and Methods

A cross-sectional study was done using the National Pathfinder survey (stratified cluster random sampling) to know the health care utilization, profile, and pattern in Tenali Mandal, Guntur, Andhra Pradesh.

Results

The study sample comprised of 1,500 subjects who were equally divided among 5 age groups. Out of 1,500 participants, 52.8% were females and 47.2% were males. In total, 71.7% of the study participants have utilized health services, with majority of them (44.5%) had availed services within the last 6 months with prime reason of fevers (15.8%), while the main barrier for not seeking care was distance (17.03%), almost an equal proportion of the population sought care for their problems through home remedies and over-the-counter.

Conclusion

There is an utmost need to minimize barriers of utilizing by making them aware of the health problems, so that they develop a positive attitude toward health care utilization. Therefore, knowledge of utilization of health services and associated factors is important in planning and delivery of interventions by the primary care physicians to improve health services coverage.

Proximity to a community health worker is associated with utilization of malaria treatment services in the community among under-five children: a cross-sectional study in rural Uganda

BACKGROUND

In rural areas of sub-Saharan Africa, health facilities are difficult to access for prompt treatment of malaria. Community health workers (CHWs) have been trained and equipped to treat malaria. Utilization of their service has not been adequately evaluated. The aim of this study was to determine the level of utilization of CHWs, and whether distance and other factors influence the utilization.

METHODS

The authors conducted a cross-sectional study among households with a child below 5 y of age and interviewed caregivers in Sheema district, rural western Uganda. Logistic regression was used to calculate adjusted ORs (aOR) for factors associated with use of CHW services.

RESULTS

Among 547 households, 64% (338/528) reported using CHWs as the first point of consultation for their febrile children. Factors associated with the use of CHWs services were lower asset index (aOR=1.9, p=0.02), mother being the decision maker for site of first consultation (aOR=1.9, p=0.01), distance to nearest CHW of <3 km (aOR=2.1, p=0.03) compared to >3 km, and trust for CHWs services (aOR=7.8, p<0.001).

CONCLUSION

Proximal location to a CHW is associated with use of CHW services. Programs should ensure that CHW are well located to enable easy access.

Analysis of the quality of seasonal malaria chemoprevention provided by community health Workers in Boulsa health district, Burkina Faso

Background

Since 2014, the Burkina Faso government has made Seasonal Malaria Chemoprevention (SMC) a priority in its strategic plan to fight against malaria among children aged from 3 to 59 months. Very few studies have examined the care provided by community health workers in the framework of this strategy. The purpose of this study was to evaluate the level of quality of care provided by the latter.

Methods

This was a mixed study. The quantitative component consisted of a non-participant observation of community health workers during the administration of care. The qualitative component consisted of one-on-one interviews with community health workers, child caregivers and head nurses. Five dimensions (organizational accessibility, interpersonal relationship, technical competence, safety of care and satisfaction of child caregivers) adapted from the Donabedian quality of care model were used to assess the quality level of care. The Corlien et al. Health Systems Research Program Implementation Scale was used to establish quality scores for each of the five dimensions. The study sites were the health centers located in the administrative centers of the 4 communes of the health district of Boulsa. The data were collected during the first cycle of the 2017 SMC campaign.

Results

A total of 14 active pairs (28 CHWs) were observed and 40 in-depth interviews with community health workers, Head nurses in duty and community leaders were conducted. The results show that community health workers worked in pairs. They had all received SMC training and possessed equipment to do their job. The dimensions of organizational accessibility and satisfaction of the caregivers were rated as good. The dimensions of interpersonal relationship and technical competence were judged to be of an acceptable score. Safety of care was judged to be of a low-level score. The overall quality of care was considered acceptable.

Conclusion

The results of this study have shown that despite the difficulties faced by community health workers, they manage to deliver acceptable quality of care. Their use would be an asset for SMC in particular and for the health system in general.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4299-3) contains supplementary material, which is available to authorized users.

Exploring communities' and health workers' perceptions of indicators and drivers of malaria decline in Malindi, Kenya

BACKGROUND

Since 2000, a decrease in malaria burden has been observed in most endemic countries. Declining infection rates and disease burden and reduction in asymptomatic carriers are the outcome of improved quality of care and related health system factors. These include improved case management through better diagnosis, implementation of highly effective antimalarial drugs and increased use of bednets. We studied communities' and health workers' perceptions of indicators and drivers in the context of decreasing malaria transmission in Malindi, Kenya.

MATERIALS AND METHODS

A variety of qualitative methods that included participatory rural appraisal (PRA) tools such as community river of life and trend lines, focus group discussions (FGDs) and key informant interviews were used. Studies took place between November 2013 and April 2014.

RESULTS

Providing residents with bednets contributed to malaria reduction, and increasing community awareness on the causes and symptoms of malaria and improved malaria treatment were also perceived to contribute to the decline of malaria. The study identified three perceived drivers to the reported decline in malaria: a) community health workers' enhanced awareness creation towards household owners regarding malaria-related activities through visitations and awareness sessions, b) Women involvement in Savings Internal Lending Community was perceived to have increased their financial base, thereby improving their decision-making power towards the care of their sick child(ren), c) Non Governmental Organizations (NGOs) and partners played a promoter part in health and general economic development initiatives.

CONCLUSIONS

To achieve the goal of malaria elimination, collaboration between governmental and NGOs will be crucial when improving the financial base of women and enhancing participation of community health workers.

Strengthening mental health and research training in Sub-Saharan Africa (SMART Africa): Uganda study protocol

BACKGROUND

Children in Sub-Saharan Africa (SSA) comprise half of the total regional population, yet existing mental health services are severely under-equipped to meet their needs. Although effective interventions for the treatment of disruptive behavioral disorders (DBDs) in youth have been tested in high-poverty and high-stress communities in developed countries, and are relevant for widespread dissemination in low- and middle-income countries (LMICs), most of these evidence-based practices (EBPs) have not been utilized in SSA, a region heavily impacted by poverty, diseases including HIV/AIDS, and violence. Thus, this paper presents a protocol for a scale-up longitudinal experimental study that uses a mixed-methods, hybrid type II, effectiveness implementation design to test the effectiveness of an EBP, called Multiple Family Group (MFG) aimed at improving child behavioral challenges in Uganda while concurrently examining the multi-level factors that influence uptake, implementation, sustainment, and youth outcomes.

METHODS

The MFG intervention will be implemented and tested via a longitudinal experimental study conducted across 30 public primary schools located in both semi-urban and rural communities. The schools will be randomly assigned to three study conditions (n = 10 per study condition): (1) MFG delivered by trained family peers; (2) MFG delivered by community health workers; or; (3) comparison: usual care comprising mental health care support materials, bolstered with school support materials. A total of 3000 children (ages 8 to 13 years; grades 2 to 7) and their caregivers (N = 3000 dyads); 60 parent peers, and 60 community health workers will be recruited. Each study condition will comprise of 1000 child-caregiver dyads. Data will be collected at baseline, 8 and 16 weeks, and 6-month follow-up.

DISCUSSION

This project is the first to test the effectiveness of the MFG intervention while concurrently examining multi-level factors that influence overall implementation of a family-based intervention provided in schools and aimed at reaching the large child population with mental health service needs in Uganda. Moreover, the study draws upon an EBP that has already been tested for delivery by parent peers and community facilitators, and hence will take advantage of the advancing science behind task-shifting. If successful, the project has great potential to address global child mental health needs.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03081195 . Registered on 16 March 2017.

Factors associated with retention of community health workers in maternal, newborn and child health programme in Simiyu Region, Tanzania

Background

Attrition of community health workers (CHWs) continues to threaten the full realisation and sustainability of community-based health programmes globally.

Aim

This study aimed to understand factors associated with CHWs’ recruitment and their retention.

Setting

This study was conducted in five districts of the Simiyu Region, namely, Bariadi, Busega, Itilima, Maswa and Meatu in north-western Tanzania.

Methods

In this cross-sectional study design, 341 CHWs who were working with the maternal health programme were randomly selected. Semi-structured questionnaires were administered to all participants. Data were descriptively and inferentially analysed using SPSS version 20.

Results

Majority (58.0%) of CHWs were below 35 years. Over half (53.1%) had completed primary education only. Motivation factors for being CHW were aspiration to serve the community and desire for further training to become a qualified medical practitioner. Community recognition and financial incentives were among the key retention reasons for the CHWs. Being married (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.7–20.1) having prior volunteer experience (OR 10.5 95% CI 12.7–40.5) and prior employment OR 21.8 (CI 12.2–38.9) were positively associated with retention of CHWs, while being a female was negatively associated with retention OR 0.4 (CI 0.2–0.8).

Conclusions

Both financial and non-financial incentives were critical in contributing to the retention of CHWs. Thus, health programmes should carefully select CHWs by understanding their motives beforehand, and provide them with incentives.

Towards a framework for analyzing determinants of performance of community health workers in malaria prevention and control: a systematic review

BACKGROUND

Community health workers (CHWs) are an important human resource in improving coverage of and success to interventions aimed at reducing malaria incidence. Evidence suggests that the performance of CHWs in malaria programs varies in different contexts. However, comprehensive frameworks, based on systematic reviews, to guide the analysis of determinants of performance of CHWs in malaria prevention and control programs are lacking.

METHODS

We systematically searched Google Scholar, Science Direct, and PubMed including reference lists that had English language publications. We included 16 full text articles that evaluated CHW performance in malaria control. Search terms were used and studies that had performance as an outcome of interest attributed to community-based interventions done by CHWs were included.

RESULTS

Sixteen studies were included in the final review and were mostly on malaria Rapid Diagnosis and Treatment, as well as adherence to referral guidelines. Factors determining performance and effective implementation of CHW malaria programs included health system factors such as nature of training of CHWs; type of supervision including feedback process; availability of stocks, supplies, and job aids; nature of work environment and reporting systems; availability of financial resources and transport systems; types of remuneration; health staff confidence in CHWs; and workload. In addition, community dynamics such as nature of community connectedness and support from the community and utilization of services by the community also influenced performance. Furthermore, community health worker characteristics such marital status, sex, and CHW confidence levels also shaped CHW performance.

CONCLUSIONS

Effectively analyzing and promoting the performance of CHWs in malaria prevention and control programs may require adopting a framework that considers health systems and community factors as well as community health worker characteristics.

Temporal variation in confirmed diagnosis of fever-related malarial cases among children under-5 years by community health workers and in health facilities between years 2013 and 2015 in Siaya County, Kenya

BACKGROUND

Malaria case management continues to experience dynamic changes. Building community capacity is instrumental in both prevention and treatment of malaria. The World Health Organization (WHO) recommends utilization of well-trained and supervised community health workers (CHWs) to reduce the burden of malaria deaths among children under-5 years of age in Africa. Longitudinally-tracked information on utilization of CHWs by communities in terms of trends in diagnosis of malaria in children under-5 years of age is essential in influencing national and local malaria control policies and strategies.

METHODS

A desktop review was carried out of a database consisting of confirmed uncomplicated malaria cases in 10 villages using CHWs and out-patient departments of 10 health facilities in children under-five for the period of 3 years between January 2013 and December 2015. Analyses of association between the diagnosed cases and satellite-based rainfall, village and time (months and years) were carried out using a Poisson regression model.

RESULTS

Analysis of malaria diagnoses made by CHWs showed the following trends: (i) the incidence of reported documented malaria-positive fever cases increased with time (2013-2015) and the difference over the years was statistically significant (P < 0.001), (ii) specific village was significantly associated (P < 0.001) with reporting malaria-positive fever cases, (iii) the long-term monthly sequence starting from highest to lowest incidence of reported malaria-positive fever cases was July, May and June, March, August, April, September, November, and February, October and, finally, January, and the difference in reported malaria-positives between the months was statistically significant (P = 0.001) and (iv) none of the tested rainfall regimes (current, lagged or cumulative) was associated with reported malaria-positive fever cases during the 3-year period (P > 0.1). Looking at the number of diagnoses made at the health facilities, (i) The number of reported malaria-positive fever cases decreased with time (2013-2015) and the difference among the years was not statistically significant (P = 0.399), (ii) The long-term monthly sequence starting from highest to lowest number of reported malaria-positive fever cases was July, June, May, April, January, August, March, February, September, November, October and December, and the difference between the months was statistically significant (P < 0.001).

CONCLUSIONS

CHWs have the potential to play a major role in diagnosing and treating malaria, thereby decreasing under-five children mortality. Temporally, the risk of diagnosing malaria seems predictable and this may present opportunities for policy-targeted malaria preparedness and control. The findings are expected to support policy actions that may scale-up community health services in remote rural settings.

Cost effectiveness of pre-referral antimalarial treatment in severe malaria among children in sub-Saharan Africa

BACKGROUND

In 2013, 78% of malaria deaths occurred in children aged 5 years and below, in sub-Saharan Africa. Treatment of severe malaria requires a health facility with inpatient care. However, in most sub-Sahara African countries, access to health facilities is a major problem. Pre-referral antimalarial treatments aim to delay the progress of severe malaria as patients seek to access health facilities. Rectal artesunate can be administered in the community as a pre-referral treatment in rural hard-to-reach areas. In Kenya, though pre-referral rectal artesunate has been included in the National Guidelines for pre-referral treatment, it is yet to be implemented in the public healthcare system. It is important, therefore, to establish its cost-utility compared to current parenteral treatments. This study evaluated the cost-utility of provision of pre-referral treatments by community health workers compared to similar services at a primary health facility.

METHODS

This was a decision model-based cost-utility analysis, comparing pre-referral antimalarial treatments provided by: community health workers (CHWs), primary health facility, direct access to a tertiary health facility and no access to treatment. A theoretical cohort, of 1000 children, who were below 5 years old; residing in rural hard-to-reach areas, was taken as the reference population. Data was collected through key informant interviews, to assess the costs, while key measures of effectiveness, were obtained from existing studies. The key measure of outcomes was Disability Adjusted Life Years (DALYS) averted. Probabilistic sensitivity analysis was carried out to assess the robustness of the model.

RESULTS

Provision of rectal pre-referral treatment by community health workers was estimated to avert 13,276 DALYs, at a cost of $68,428 for a cohort of 1000 children. Provision of rectal pre-referral treatment at a primary health facility was estimated to avert 9993 DALYs, at a cost of $73,826 for a cohort of 1000 children, while going directly to a tertiary health facility was estimated to avert 15,801 DALYs, at a cost of $114,903 for a cohort of 1000 children. The incremental cost effectiveness ratios for provision of pre-referral treatment by community health care and primary health workers were $5.11 and $7.30 per DALYs averted respectively.

CONCLUSION

Use of CHWs was more cost effective than provision of pre-referral treatments at a primary health facility especially, with high referral compliance. Rectal artesunate can easily be administered by community health workers, unlike parenteral pre-referral interventions.

Community perceptions and attitudes on malaria case management and the role of community health workers

Background

Community Case Management of malaria (CCMm) is one of the new approaches adopted by the World Health Organization for malaria endemic countries to reduce the burden of malaria for vulnerable populations. It is based on the evidence that well-trained and supervised community health workers (CHWs) can provide prompt and adequate treatment to fever cases within 24 h to help reduce morbidity and mortality associated with malaria among under-five children. The perception and attitudes of the community members on the CHWs’ role is of greater importance for acceptance of their services. The aim of the study was to assess community’s perception and attitude towards CCMm and on CHWs who undertake it.

Methods

This study was conducted in five districts in western Kenya where Community Case Management was being undertaken. This was a qualitative cross-sectional study in which in-depth interviews and focus group discussions were conducted with mothers of under-five children and key stakeholders.

Results

Overall, there were more positive expressions of perceptions and attitudes of the community members towards the CCMm programme and the role of CHWs. The positive perceptions included among others; recognition and appreciation of services of CHWs, bringing health services to close proximity to the community, avoiding long queues in the health facilities, provision of health education that encourages good health practices, and promotion of positive health-seeking behaviour from within the communities. This programme is not without challenges as some of the negative perceptions expressed by the community members included the fact that some clinicians doubt the capacity of CHWs on dispensing drugs in the community, some CHWs do not keep client’s secrets and mistrust of CHWs due to conflicting information by government.

Conclusions

It was evident that the community had more positive perceptions and attitudes towards the role of CHWs in CCMm than negative ones. There should however, be deliberate efforts towards sustaining the positive aspects and addressing the negative concerns raised by the community and the health care practitioners.

Integrated community case management for childhood illnesses: explaining policy resistance in Kenya

BACKGROUND

There has been a re-emphasis recently on community health workers to provide child health care services including integrated community case management for childhood illness (iCCM). This research analysed iCCM policy development in Kenya and in particular the types of decision-making criteria used by Kenyan policy-makers in considering whether to advance iCCM policy.

METHOD

Data were collected through document reviews (n = 41) and semi-structured interviews (n = 19) with key stakeholders in iCCM policy including government officials, development partners, bilateral donors, and civil society organizations. Initial analysis was guided by the policy triangle with further analysis of factors affecting policy decision-making drawing upon a simple framework developed by Grindle and Thomas (Policy makers, policy choices and policy outcomes: the political economy of reform in developing countries. 1989; Policy Sci 22: :213-48.).

FINDINGS

Policy development for iCCM has been slow in Kenya, compared with other Sub-Saharan African countries. At the time of the study, the Government had just completed the Community Health Training Manual which incorporated iCCM as a module, but this was the only formal expression of iCCM in Kenya. We found technical considerations, notably concerns about community health workers dispensing antibiotics to be a key factor slowing iCCM policy development, but this also overlapped with bureaucratic considerations, such as how the development of community health worker cadres may affect clinicians, as well as initial concerns about how an integrated approach might affect vertically oriented programs. International actors through agreements such as the Millennium Development Goals helped to get child survival onto the national policy agenda and such actors were active promoters of iCCM policy change. However international funders had not committed funding to scale-up iCCM policy, and this probably constrained their influence over iCCM policy debate.

CONCLUSION

Kenyan actors' concerns about iCCM underline the importance of adapting global policies to local conditions, and also generating local evidence to inform decision-making.

Determinants of Utilization and Community Experiences with Community Health Volunteers for Treatment of Childhood Illnesses in Rural Sierra Leone

In 2010, at the same time as the national roll out of the Free Health Care Initiative (FHCI), which removed user fees for facility based health care, trained community health volunteers (CHVs) were deployed to provide integrated community case management of diarrhea, malaria and pneumonia to children under 5 years of age (U5) in Kambia and Pujehun districts, Sierra Leone. After 2 years of implementation and in the context of FHCI, CHV utilization rate was 14.0 %. In this study, we examine the factors associated with this level of CHV utilization. A cross-sectional household-cluster survey of 1590 caregivers of 2279 children U5 was conducted in 2012; with CHV utilization assessed using a multiple logistic regression model. Focus groups and in-depth interviews were also conducted to understand communities' experiences with CHVs. Children with diarrhea (OR = 3.17, 95 % CI: 1.17-8.60), from female-headed households (OR = 4.55, 95 % CI: 1.88-11.00), and whose caregivers reported poor quality of care as a barrier to facility care-seeking (OR = 8.53, 95 % CI: 3.13-23.16) were more likely to receive treatment from a CHV. Despite low utilization, caregivers were highly familiar and appreciative of CHVs, but were concerned about the lack of financial remuneration for CHVs. CHVs remained an important source of care for children from female-headed households and whose caregivers reported poor quality of care at health facilities. CHVs are an important strategy for certain populations even when facility utilization is high or when facility services are compromised, as has happened with the recent Ebola epidemic in Sierra Leone.

Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review

BACKGROUND

Human resource for health crisis has impaired global efforts against malaria in highly endemic countries. To address this, the World Health Organization (WHO) recommended scaling-up of community health workers (CHWs) and related cadres owing to their documented success in malaria and other disease prevention and management. Evidence is inconsistent on the roles and challenges they encounter in malaria interventions. This systematic review aims to summarize evidence on roles and challenges of CHWs and related cadres in integrated community case management for malaria (iCCM).

METHODS

This systematic review retrieved evidence from PubMed, CINAHL, ISI Web of Knowledge, and WHO regional databases. Terms extracted from the Boolean phrase used for PubMed were also used in other databases. The review included studies with Randomized Control Trial, Quasi-experimental, Pre-post interventional, Longitudinal and cohort, Cross-sectional, Case study, and Secondary data analysis. Because of heterogeneity, only narrative synthesis was conducted for this review.

RESULTS

A total of 66 articles were eligible for analysis out of 1380 studies retrieved. CHWs and related cadre roles in malaria interventions included: malaria case management, prevention including health surveillance and health promotion specific to malaria. Despite their documented success, CHWs and related cadres succumb to health system challenges. These are poor and unsustainable finance for iCCM, workforce related challenges, lack of and unsustainable supply of medicines and diagnostics, lack of information and research, service delivery and leadership challenges.

CONCLUSIONS

Community health workers and related cadres had important preventive, case management and promotive roles in malaria interventions. To enable their effective integration into the health systems, the identified challenges should be addressed. They include: introducing sustainable financing on iCCM programmes, tailoring their training to address the identified gaps, improving sustainable supply chain management of malaria drugs and diagnostics, and addressing regulatory challenges in the local contexts.

How equitable are community health worker programmes and which programme features influence equity of community health worker services? A systematic review

BACKGROUND

Community health workers (CHWs) are uniquely placed to link communities with the health system, playing a role in improving the reach of health systems and bringing health services closer to hard-to-reach and marginalised groups. A systematic review was conducted to determine the extent of equity of CHW programmes and to identify intervention design factors which influence equity of health outcomes.

METHODS

In accordance with our published protocol, we systematically searched eight databases from 2004 to 2014 for quantitative and qualitative studies which assessed access, utilisation, quality or community empowerment following introduction of a CHW programme according to equity stratifiers (place of residence, gender, socio-economic position and disability). Thirty four papers met inclusion criteria. A thematic framework was applied and data extracted and managed, prior to charting and thematic analysis.

RESULTS

To our knowledge this is the first systematic review that describes the extent of equity within CHW programmes and identifies CHW intervention design features which influence equity. CHW programmes were found to promote equity of access and utilisation for community health by reducing inequities relating to place of residence, gender, education and socio-economic position. CHWs can also contribute towards more equitable uptake of referrals at health facility level. There was no clear evidence for equitable quality of services provided by CHWs and limited information regarding the role of the CHW in generating community empowerment to respond to social determinants of health. Factors promoting greater equity of CHW services include recruitment of most poor community members as CHWs, close proximity of services to households, pre-existing social relationship with CHW, provision of home-based services, free service delivery, targeting of poor households, strengthened referral to facility, sensitisation and mobilisation of community. However, if CHW programmes are not well planned some of the barriers faced by clients at health facility level can replicate at community level.

CONCLUSIONS

CHWs promote equitable access to health promotion, disease prevention and use of curative services at household level. However, care must be taken by policymakers and implementers to take into account factors which can influence the equity of services during planning and implementation of CHW programmes.

Experiences engaging community health workers to provide maternal and newborn health services: implementation of four programs

A paucity of skilled health providers is a considerable impediment to reducing maternal, infant, and under-five mortality for many low-resource countries. Although evidence supports the effectiveness of community health workers (CHWs) in delivering primary healthcare services, shifting tasks to this cadre from providers with advanced training has been pursued with overall caution-both because of difficulties determining an appropriate package of CHW services and to avoid overburdening the cadre. We reviewed programs in Rwanda, Afghanistan, Nigeria, and Nepal where tasks in delivery of health promotion information and distribution of commodities were transitioned to CHWs to reach underserved populations. The community-based interventions were complementary to facility-based interventions as part of a comprehensive approach to increase access to basic health services. Drawing on these experiences, we illuminate commonalities, lessons learned, and factors contributing to the programs' implementation strategies to help inform practical application in other settings.

First Steps in Initiating an Effective Maternal, Neonatal, and Child Health Program in Urban Slums: the BRAC Manoshi Project's Experience with Community Engagement, Social Mapping, and Census Taking in Bangladesh

The processes for implementing effective programs at scale in low-income countries have not been well-documented in the peer-reviewed literature. This article describes the initial steps taken by one such program--the BRAC Manoshi Project, which now reaches a population of 6.9 million. The project has achieved notable increases in facility births and reductions in maternal and neonatal mortality. The focus of the paper is on the initial steps--community engagement, social mapping, and census taking. Community engagement began with (1) engaging local leaders, (2) creating Maternal, Neonatal, and Child Health Committees for populations of approximately 10,000 people, (3) responding to advice from the community, (4) social mapping of the community, and (5) census taking. Social mapping involved community members working with BRAC staff to map all important physical features that affect how the community carries out its daily functions--such as alleys, lanes and roads, schools, mosques, markets, pharmacies, health facilities, latrine sites, and ponds. As the social mapping progressed, it became possible to conduct household censuses with maps identifying every household and listing family members by household. Again, this was a process of collaboration between BRAC staff and community members. Thus, social mapping and census taking were also instrumental for advancing community engagement. These three processes-community engagement, social mapping, and census taking--can be valuable strategies for strengthening health programs in urban slum settings of low-income countries.

Access to integrated community case management of childhood illnesses services in rural Ethiopia: a qualitative study of the perspectives and experiences of caregivers

BACKGROUND

In 2010, Ethiopia began scaling up the integrated community case management (iCCM) of childhood illness strategy throughout the country allowing health extension workers (HEWs) to treat children in rural health posts. After 2 years of iCCM scale up, utilization of HEWs remains low. Little is known about factors related to the use of health services in this setting. This research aimed to elicit perceptions and experiences of caregivers to better understand reasons for low utilization of iCCM services.

METHODS

A rapid ethnographic assessment was conducted in eight rural health post catchment areas in two zones: Jimma and West Hararghe. In total, 16 focus group discussions and 78 in-depth interviews were completed with mothers, fathers, HEWs and community health volunteers.

RESULTS

In spite of the HEW being a core component of iCCM, we found that the lack of availability of HEWs at the health post was one of the most common barriers to the utilization of iCCM services mentioned by caregivers. Financial and geographic challenges continue to influence caregiver decisions despite extension of free child health services in communities. Acceptability of HEWs was often low due to a perceived lack of sensitivity of HEWs and concerns about medicines given at the health post. Social networks acted both to facilitate and hinder use of HEWs. Many mothers stated a preference for using the health post, but some were unable to do so due to objections or alternative care-seeking preferences of gatekeepers, often mothers-in-law and husbands.

CONCLUSION

Caregivers in Ethiopia face many challenges in using HEWs at the health post, potentially resulting in low demand for iCCM services. Efforts to minimize barriers to care seeking and to improve demand should be incorporated into the iCCM strategy in order to achieve reductions in child mortality and promote equity in access and child health outcomes.

Reduction in symptomatic malaria prevalence through proactive community treatment in rural Senegal

OBJECTIVES

We piloted a community-based proactive malaria case detection model in rural Senegal to evaluate whether this model can increase testing and treatment and reduce prevalence of symptomatic malaria in target communities.

METHODS

Home care providers conducted weekly sweeps of every household in their village throughout the transmission season to identify patients with symptoms of malaria, perform rapid diagnostic tests (RDT) on symptomatic patients and provide treatment for positive cases. The model was implemented in 15 villages from July to November 2013, the high transmission season. Fifteen comparison villages were chosen from those implementing Senegal's original, passive model of community case management of malaria. Three sweeps were conducted in the comparison villages to compare prevalence of symptomatic malaria using difference in differences analysis.

RESULTS

At baseline, prevalence of symptomatic malaria confirmed by RDT for all symptomatic individuals found during sweeps was similar in both sets of villages (P = 0.79). At end line, prevalence was 16 times higher in the comparison villages than in the intervention villages (P = 0.003). Adjusting for potential confounders, the intervention was associated with a 30-fold reduction in odds of symptomatic malaria in the intervention villages (AOR = 0.033; 95% CI: 0.017, 0.065). Treatment seeking also increased in the intervention villages, with 57% of consultations by home care providers conducted between sweeps through routine community case management.

CONCLUSIONS

This pilot study suggests that community-based proactive case detection reduces symptomatic malaria prevalence, likely through more timely case management and improved care seeking behaviour. A randomised controlled trial is needed to further evaluate the impact of this model.

Determinants of Utilization of Health Extension Workers in the Context of Scale-Up of Integrated Community Case Management of Childhood Illnesses in Ethiopia

Ethiopia has invested significant resources in integrated community case management (iCCM) of childhood illness. In Oromia Region, iCCM scale-up was phased in, allowing for comparisons between districts providing iCCM and routine services. We assessed the determinants of utilization of health extension workers (HEWs) delivering iCCM services at rural health posts by caregivers of sick, under-five children in a cross-sectional survey. We found low utilization of HEWs with only 9.3% of caregivers of a child sick with diarrhea, fever, and/or pneumonia in the previous 2 weeks taking their child to HEWs in both iCCM and routine areas. There was a higher likelihood of utilization of HEWs in iCCM areas (OR: 1.44; 95% CI: 0.97–2.12; P = 0.07), but this effect disappeared after accounting for confounders. In iCCM areas, maternal education, illness type, and distance were associated with utilization. Perceptions of illness severity and service quality were the primary reasons given for not utilizing the health post. Our findings suggest that though iCCM is reaching some vulnerable populations, there remain significant barriers to use of HEWs delivering iCCM services. Efforts for demand generation and minimization of remaining barriers are urgently needed for the sustained success of the iCCM strategy in Ethiopia.

Utilization of community health workers for malaria treatment: results from a three-year panel study in the districts of Kaya and Zorgho, Burkina Faso

Background

Malaria is holo-endemic in Burkina Faso and causes approximately 40,000 deaths every year. In 2010, health authorities scaled up community case management of malaria with artemisinin-based combination therapy. Previous trials and pilot project evaluations have shown that this strategy may be feasible, acceptable, and effective under controlled implementation conditions. However, little is known about its effectiveness or feasibility/acceptability under real-world conditions of implementation at national scale.

Methods

A panel study was conducted in two health districts of Burkina Faso, Kaya and Zorgho. Three rounds of surveys were conducted during the peak malaria-transmission season (in August 2011, 2012 and 2013) in a panel of 2,232 randomly selected households. All sickness episodes in children under five and associated health-seeking practices were documented. Community health worker (CHW) treatment coverage was evaluated and the determinants of consulting a CHW were analysed using multi-level logistic regression.

Results

In urban areas, less than 1% of sick children consulted a CHW, compared to 1%–9% in rural areas. Gaps remained between intentions and actual practices in treatment-seeking behaviour. In 2013, the most frequent reasons for not consulting the CHW were: the fact of not knowing him/her (78% in urban areas; 33% in rural areas); preferring the health centre (23% and 45%, respectively); and drug stock-outs (2% and 12%, respectively). The odds of visiting a CHW in rural areas significantly increased with the distance to the nearest health centre and if the household had been visited by a CHW during the previous three months.

Conclusions

This study shows that CHWs are rarely used in Burkina Faso to treat malaria in children. Issues of implementation fidelity, a lack of adaptation to the local context and problems of acceptability/feasibility might have undermined the effectiveness of community case management of malaria. While some suggest extending this strategy in urban areas, total absence of CHW services uptake in these areas suggest that caution is required. Even in rural areas, treatment coverage by CHWs was considerably less than that reported by previous trials and pilot projects. This study confirms the necessity of evaluating public health interventions under real-world conditions of implementation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0591-9) contains supplementary material, which is available to authorized users.

Implementing an early childhood school-based mental health promotion intervention in low-resource Ugandan schools: study protocol for a cluster randomized controlled trial

Background

Children in Sub-Saharan Africa (SSA) are burdened by significant unmet mental health needs, but this region has limited access to mental health workers and resources to address these needs. Despite the successes of numerous school-based interventions for promoting child mental health, most evidence-based interventions are not available in SSA. This study will investigate the transportability of an evidence-based program from a developed country (United States) to a SSA country (Uganda). The approach includes task-shifting to early childhood teachers and consists of professional development (five days) to introduce strategies for effective behavior management and positive teacher-student interactions, and group-based consultation (14 sessions) to support adoption of effective practices and tailoring to meet the needs of individual students.

Methods/Design

The design of this study is guided by two implementation frameworks, the Consolidated Framework for Implementation Research and the Teacher Training Implementation Model, that consider multidimensional aspects of intervention fidelity and contextual predictors that may influence implementation and teacher outcomes. Using a cluster randomized design, 10 schools in Uganda will be randomized to either the intervention group (five schools) or the waitlist control group (five schools). A total of 80 to 100 early childhood teachers will be enrolled in the study. Teacher utilization of evidence-based strategies and practices will be assessed at baseline, immediate post-intervention (six months after baseline), and at seven months post-intervention (during a new academic year). Fidelity measures will be assessed throughout the program implementation period (during professional development and consultation sessions). Individual teacher and contextual factors will be assessed at baseline. Data will be collected from multiple sources. Linear mixed-effect modeling, adjusting for school nesting, will be applied to address study questions.

Discussion

The study will produce important information regarding the value of an evidence-based early intervention, and a theory-guided implementation process and tools designed for use in implementing early childhood evidence-based programs in SSA countries or resource-constrained community settings.

Trial registration

This trial was registered with ClinicalTrials.gov (registration number: NCT097115) on 15 May 2013.

Influence of community health volunteers on care seeking and treatment coverage for common childhood illnesses in the context of free health care in rural Sierra Leone

OBJECTIVE

To examine whether community health volunteers induced significant changes in care seeking and treatment of ill children under five 2 years after their deployment in two underserved districts of Sierra Leone.

METHODS

A pre-test-post-test study with intervention and comparison groups was used. A household cluster survey was conducted among caregivers of 5643 children at baseline and of 5259 children at endline.

RESULTS

In the intervention districts, treatments provided by community health volunteers increased from 0 to 14.3% for all three conditions combined (P < 0.001). Care seeking from an appropriate provider was not statistically significant (OR = 1.50, 95% CI: 0.88-2.54) between intervention and comparison districts and coverage of appropriate treatment increased in both study groups for all three illnesses. However, the presence of community health volunteers was associated with a 105% increase in appropriate treatment for pneumonia (OR = 2.05, 95% CI: 1.22-3.42) and a 55% drop in traditional treatment for diarrhoea (OR = 0.45, 95% CI: 0.21-0.96). Community health volunteers were also associated with fewer facility treatments for malaria (OR = 0.21, 95% CI: 0.07-0.62).

CONCLUSION

After implementing free care, coverage for treatment for all three illnesses in both study groups improved. Deployment of community health volunteers was associated with a reduced treatment burden at facilities and less reliance on traditional treatments.

Lay perceptions of malaria and therapeutic itinerary of resettled pregnant women in South Sudan

BACKGROUND

Approximately 95% of South Sudan is malaria-endemic and transmission is high throughout the year. Annually, 2.3 million people are at risk of malarial infection, but children under 5 years, pregnant women and their unborn children are particularly at high risk. Appropriate policies for malarial prevention and control require a better understanding of the populations' malarial perceptions and treatment itinerary.

METHODS

A qualitative study was carried out to explore malarial lay perceptions and therapeutic itinerary among 30 resettled pregnant women in Unity State, South Sudan.

RESULTS

The study showed that the therapeutic itinerary was prompted by fever and composed of five steps that were simultaneously or successively explored. The household and community constitute the first-line treatment options for fever. Interviewees relied on homemade remedies and concoctions, traditional healers' cures, magician's rituals and private formal and informal medicine vendors at the local market before seeking malarial diagnosis and treatment at the health centre.

CONCLUSIONS

Improving capacities for proper identification and management of malarial fever at household and community level is a priority for reducing the delay in seeking timely and proper treatment. The formal health system may, in time, aspire to address the economic and cultural barriers within the system that contribute to delaying effective treatment-seeking.

Rural-urban disparities in maternal immunization knowledge and childhood health-seeking behavior in Nigeria: a mixed method study

BACKGROUND

Immunization and appropriate health-seeking behavior are effective strategies to reduce child deaths.

OBJECTIVES

To compare maternal knowledge about immunization, use of growth chart and childhood health-seeking behavior in rural and urban areas.

METHODS

A cross-sectional comparative study done in Lagos, Nigeria. Questionnaire survey and focus group discussions were done. 300 respondents were selected by multi-stage sampling while discussants were purposively selected.

RESULTS

Awareness of immunization was high but knowledge of vaccine preventable diseases (VPDs) was poor in both areas. Urban women utilized preventive services more; growth monitoring (p<0.001) and immunization (p<0.001) while higher proportions of rural women utilized nutritional counseling (p=0.005) and treatment of illness (p<0.001). Growth chart utilization was better in the urban areas (p<0.001). Increasing maternal education increased use of growth chart in both areas. Both groups of women use multiple treatment sources for children (more in urban), determined by cost, time, perceived severity of illness and type of ailment (urban) and peculiarity of illness (rural). There is a preference for orthodox care in the rural area.

CONCLUSIONS

Knowledge of VPDs was poor and multiple treatment sources were common among rural and urban women. Education is vital to improve immunization knowledge and health-seeking behavior in both areas.

Validity and reliability of data collected by community health workers in rural and peri-urban contexts in Kenya

Background

Reliability and validity of measurements are important for the interpretation and generalisation of research findings. Valid, reliable and comparable measures of health status of individuals are critical components of the evidence base for health policy. The need for sound information is especially urgent in the case of emerging diseases and other acute health threats, where rapid awareness, investigation and response can save lives and prevent broader national outbreaks and even global pandemics.

Several successfully implemented health interventions have involved community health workers (CHWs) in reaching out to the community, and the Community Health Strategy is one such an intervention. The government of Kenya, through the Ministry of Public Health and Sanitation has rolled out the strategy as a way of improving health care at the household level. It involves CHWs collecting health status data at the household level, which is presented at community meetings in which the community discusses the results, identifies action areas, and plans activities for improving their health status.

Methods

Ten percent of all households visited by CHWs for data collection in different sites (rural and peri-urban) were systematically selected and visited a second time by technically trained research team members. The test-retest method was applied to establish reliability. The Kappa score was used to measure reliability, while sensitivity, specificity, and positive predictive values were used to measure validity.

Results

Inter-observer agreement between the two sets of data in both sites was good; most indicators measured slight agreement. However, some indicators demonstrated greater discrepancies between the two data sets (e.g. measles immunization). Specificity measures were more stable in Butere (rural), which had more than 90% in all the indicators tested, compared to Nyalenda (peri-urban), which fluctuated between 50% and 90%. There were variable reliability results in the peri-urban site for the indicators measured, while the rural site presented more stable results. This is also depicted in the validity measures in both sites.

Conclusions

The paper concludes that there are convincing results that CHWs can accurately and reliably collect certain types of community data which has cost-saving implications, especially for resource poor settings.

Overcoming the perceived barriers to health care access among single mothers in coastal Kenya

OBJECTIVES

This study assesses the effects of a comprehensive empowerment intervention on barriers to health care access for single mothers in coastal Kenya.

METHODS

We surveyed 41 single mothers who completed a pilot empowerment program and 60 single mothers who had not yet initiated the program. Comparisons were made using bivariate tests of association and logistic regression.

RESULTS

Women in the pilot program were less likely to report transportation costs (OR = 0.26; 95 % CI [0.11-0.59], p = 0.001) and hospital fees (OR = 0.22 [0.10-0.49], p < 0.001) as barriers. Pilot program mothers were more likely to visit a public hospital for their children (OR = 4.38; [1.58-12.1], p = 0.004) and self (OR = 4.70; [1.54-14.4], p = 0.007) when ill.

CONCLUSIONS

Empowerment programs can alleviate perceived barriers to health care among vulnerable populations.

Scaling-up malaria treatment: a review of the performance of different providers

Background

Despite great progress towards malaria control, the disease continues to be a major public health problem in many developing countries, especially for poor women and children in remote areas. Resistance to artemisinin combination therapy (ACT) emerged in East Asia. Its spread would threaten the only effective malaria treatment currently available. Improvement in availability of diagnosis as part of malaria control has highlighted the fact that many fevers are not due to malaria. These fevers also need to be promptly diagnosed and adequately treated in order to improve public health outcomes in developing countries.

Methods

This review looked for evidence for the most effective approach to deliver malaria treatment in developing countries, by public sector, formal and informal private sector, and community health workers (CHWs). The authors analysed 31 studies to assess providers based on six parameters: knowledge and practice of provider, diagnosis, referral practices, price of medicine, availability of ACT, and treatment coverage and impact on morbidity and mortality.

Results

The public sector has made progress in prevention and treatment in many countries, but facilities are inaccessible to some communities, and the sector suffers shortages of health workers and stock-outs of medicines. Despite wide outreach, the private sector, especially informal facilities, presents public health risks. This is due to an inability to diagnose and treat non-malarial fevers, and an innate motive to over-prescribe malaria treatment. The need to pay for treatment is a major factor in deterring poor women and children from accessing the medicines they need. A system that depends on ability to pay risks a repeat of the chloroquine story, where an effective and cheap anti-malarial drug was rendered useless partly due to under-treatment. CHWs have proved to be effective agents in providing correct diagnosis and treatment of malaria and other common fevers, even in remote areas.

Conclusions

The evidence shows that there is no short-cut to investing in training and supervision of providers, or in treating malaria within a public health context rather than as a separate disease. The studies highlighted that all outlets face challenges in delivering their services, but that CHWs scored highly in almost all parameters. CHWs have proved to be effective agents in providing correct diagnosis and treatment of malaria and other common fevers, even in remote areas. Their role should be recognized and expanded.