Using the RE-AIM framework to evaluate the implementation of integrated community case management in Kenya.

AIM: To evaluate an integrated community case management programme for sick children aged 2 to 59 months in western Kenya using the Research, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. METHODS: This was a prospective observational research project conducted between December 2013 and February 2016. Outcome variables were measured before, during and at end of implementation using a series of surveys as well as by looking at routine service statistics. RESULTS: A total of 2604 community health workers were trained in 245 community units. The average post-training knowledge level (73.5%) and retention rates (89.7) of trained community health workers was high. At the end of study, there was an increase in the proportion of children who received appropriate treatment for diarrhoea (49.2%), pneumonia (19.5%), malaria (16.4%) and vitamin A (51.5%) from baseline. Community health workers were able to assess, classify and treat sick children with a similar quality as that provided by facility-based healthcare workers (>85% concordance). CONCLUSION: Based on the RE-AIM metrics, our results demonstrate promising practical approaches and outcomes of a large-scale implementation of integrated community case management in western Kenya. The findings have important implications for future design and expansion of the programme in Kenya.

Community case management of lower chest indrawing pneumonia with oral amoxicillin in children in Kenya.

AIM: To determine the accuracy and effectiveness of community health workers (CHWs) when compared to trained nurses for management of pneumonia in Kenyan children. METHODS: In Homabay County in western Kenya, children 2-59 months of age with lower chest indrawing pneumonia were identified, classified and treated by CHWs with oral amoxicillin (90 mg/kg per day) for five days at home. Trained nurses visited the child within 24 hours to verify diagnosis; and on day 4 and 14 to assess treatment outcomes. RESULTS: CHWs identified 1906 children with lower chest indrawing pneumonia. There was an 88.7% concordance in classification and treatment for lower chest indrawing pneumonia by CHWs compared to nurses. Children with moderate malnutrition (OR 1.68; 95% CI: 1.22-2.30), comorbidities such as diarrhoea or malaria (OR 1.55; 95% CI: 1.32-1.81) or an additional day of delay in care seeking (OR 1.06; 95% CI: 1.02-1.10) were more likely to have an incorrect classification of lower chest indrawing by the CHW. Comorbidity (OR 1.66; 95% CI: 1.12-2.48) and fast breathing (OR 4.66; 95% CI: 1.26-17.27) were significantly associated with treatment failure on day 14. CONCLUSION: CHWs can correctly manage lower chest indrawing pneumonia even in high-mortality settings, such as western Kenya, in sub-Saharan Africa.

Perceived Quality of Care of Community Health Worker and Facility-Based Health Worker Management of Pneumonia in Children Under 5 Years in Western Kenya: A Cross-Sectional Multidimensional Study.

Integrated community case management (iCCM) programs that train lay community health workers (CHWs) in the diagnosis and treatment of diarrhea, malaria, and pneumonia have been increasingly adopted throughout sub-Saharan Africa to provide services in areas where accessibility to formal public sector health services is low. One important aspect of successful iCCM programs is the acceptability and utilization of services provided by CHWs. To understand community perceptions of the quality of care in an iCCM intervention in western Kenya, we used the Primary Care Assessment Survey to compare caregiver attitudes about the diagnosis and treatment of childhood pneumonia as provided by CHWs and facility-based health workers (FBHWs). Overall, caregivers rated CHWs more highly than FBHWs across a set of 10 domains that capture multiple dimensions of the care process. Caregivers perceived CHWs to provide higher quality care in terms of accessibility and patient relationship and equal quality care on clinical aspects. These results argue for the continued implementation and scale-up of iCCM programs as an acceptable intervention for increasing access to treatment of childhood pneumonia.