Evaluating fidelity of community health worker roles in malaria prevention and control programs in Livingstone District, Zambia-A bottleneck analysis.

BACKGROUND: Community Health Workers (CHWs) are an important human resource in improving community malaria intervention coverages and success in reducing malaria incidence has been attributed to them. However, despite this attribution, malaria resurgence cases have been reported in various countries including Zambia. This study aims to evaluate the implementation fidelity of CHW roles in malaria prevention and control programs in Livingstone through performance and service quality assessment. METHODS: A mixed method concurrent cross-sectional study based on quantitative and qualitative approaches was used to evaluate performance and service quality of the CHW roles for selected catchments areas in Livingstone district. For the quantitative approach, (34) CHWs were interviewed and a community survey was also done with 464 community participants. For qualitative approach, two focused group discussions with CHWs and three key informant interviews from the CHW supervisors were done. RESULTS: Overall implementation fidelity to the CHW roles was low with only 5(14.7%) of the CHWs having good performance and least good quality service while 29 (85.3%) performed poorly with substandard service. About 30% of house-holds reported having experienced malaria cases but CHWs had low coverage in testing with RDT (27%) for malaria index case service response with treatment at 14% coverage and provision of health education at 23%. For other households without malaria cases, only 27% had received malaria health education and 15% were screened for malaria. However, ITN distribution, sensitization for IRS were among other CHW services received by the community but were not documented in CHW registers for evaluation. Factors that shaped fidelity were being married, record for reports, supervision, and work experience as significant factors associated with performance. Lack of supplies, insufficient remuneration and lack of ownership by the supervising district were reported to hinder ideal implementation of the CHW strategy. CONCLUSION: Fidelity to the malaria CHW roles was low as performance and quality of service was poor. A systems approach for malaria CHW facilitation considering supervision, stock supply and recruiting more CHWs on a more standardized level of recognition and remuneration would render an effective quality implementation of the CHW roles in malaria.

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.

Uptake of intermittent preventive treatment for malaria during pregnancy with Sulphadoxine-Pyrimethamine (IPTp-SP) among postpartum women in Zomba District, Malawi: a cross-sectional study.

BACKGROUND: Malaria in pregnancy causes adverse birth outcomes. Intermittent preventive treatment of malaria during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) is recommended as a chemoprevention therapy. Zomba district IPTp uptake falls far below the national average. The study was conducted to assess determinants of IPTp-SP uptake during pregnancy among postpartum women in Zomba district after adoption of new IPTp-SP policy in 2014. METHODS: This was a cross-sectional survey. Two public health facilities (HFs) were randomly selected from urban and rural areas in Zomba district. Study participants were postpartum women selected by using exit poll method from HFs. A total of 463 postpartum women were interviewed using structured questionnaire. Bivariate and multiple logistic regression was used in data analysis. RESULTS: Out of all the enrolled participants (n = 463), 92% women had complete information for analysis. Of these, (n = 426) women, 127 (29.8%, 95% CI: 25.6%-34.3%) received three or more doses of SP, 299 (70.2%, 95% CI: 65.7%-74.4%) received two or less doses. Women receiving SP from rural HF were less likely to get at least three doses of SP than urban women, (AOR = 0.31, 95% CI 0.13-0.70); Others less likely were those with three or few antenatal care (ANC) visits versus four or more visits (AOR = 0.29, 95% CI 0.18-0.48); not taking SP under direct observation therapy (DOT) (AOR = 0.18, 95% CI (0.05-0.63). CONCLUSIONS: There is low utilisation of at least three doses of SP in this population and this seems to be associated with the number of ANC visits and use of DOTs. These determinants may therefore be important in shaping interventions aimed at increasing the uptake of IPTp in this district. In addition, the rural urban differential suggests the need for further research to understand the barriers and enablers of uptake in each context in order to improve the health of the community.