Assessment of pre-referral treatment for malaria, diarrhea, and pneumonia by rural community health workers in Southwestern Uganda: a cross-sectional study.

BACKGROUND: Pre-referral treatment aims to stabilize the child's condition before transferring them to a higher level of healthcare. This study explored pre-referral treatment for diarrhea, malaria and pneumonia in children U5. The study aims to assess pre-referral treatment practices among community health workers (CHWs) for children aged 2 to 59 months diagnosed with malaria, diarrhea, and pneumonia. METHODS: Conducted in 2023, this study employed a quantitative retrospective analysis of secondary data gathered from March 2014 to December 2018. Among the subjects, 171 patients received pre-referral treatment, serving as the foundation for categorical data analysis, presenting proportions and 95% confidence intervals across different categories. RESULTS: In this cohort, 90 (53%) of the 177 children U5 were male, and age distribution showed 39 (23%), 70 (41%), and 62 (36%) in the 2-11 months, 12-35 months, and 36-60 months categories, respectively. Rapid Diagnostic Test (RDT) malaria results indicated a negative outcome in 83(60%) and positive in 55 (40%) of cases. Symptomatically, 45 (26%) had diarrhea, 52 (30%) exhibited fast breathing, and 109 (63%) presented with fever. Furthermore, 59 (35%) displayed danger signs, while 104 (61%) sought medical attention within 24 h. CONCLUSION: The study analyzed a sample of 171 children under 5 years old to assess various characteristics and variables related to pre-referral treatment. The findings reveal notable proportions in gender distribution, age categories, RDT results, presence of diarrhea, fast breathing, fever, danger signs, and timely medical visits. The results highlight the need to strengthen pre-referral treatment interventions and enhance iCCM programs.

Management of children with danger signs in integrated community case management care in rural southwestern Uganda (2014-2018).

BACKGROUND: In integrated community case management (iCCM) care, community health workers (CHWs) provide home-based management of fever, diarrhea and fast breathing for children aged <5 y. The iCCM protocol recommends that children with danger signs for severe illness are referred by CHWs to health facilities within their catchment area. This study examines the management of danger signs by CHWs implementing iCCM in a rural context. METHODS: A retrospective observational study that examined clinical records for all patients with danger signs evaluated by CHWs from March 2014 to December 2018 was conducted. RESULTS: In total, 229 children aged <5 y had been recorded as having a danger sign during 2014-2018. Of these children, 56% were males with a mean age of 25 (SD 16.9) mo, among whom 78% were referred by the CHWs as per the iCCM protocol. The age category of 12 to 35 mo had the highest numbers of prereferred and referred cases (54% and 46%, respectively). CONCLUSIONS: CHWs play a key role in early symptomatic detection, prereferral treatment and early referral of children aged <5 y. Danger signs among children aged <5 y, if left untreated, can result in death. A high proportion of the children with danger signs were referred as per the iCCM protocol. Continuous CHW training is emphasized to reduce the number of referral cases that are missed. More studies need to focus on children aged 12-35 mo and why they are the most referred category. Policymakers should occasionally revise iCCM guidelines to detail the types of danger signs and how CHWs can address these.

Promptness in seeking treatment from Village Health workers for children under five years with malaria, diarrhoea and pneumonia in rural southwestern Uganda.

BACKGROUND: Village Health Workers (VHWs) in Uganda provide treatment for the childhood illness of malaria, pneumonia, and diarrhoea through the integrated community case management (iCCM) strategy. Under the strategy children under five years receive treatment for these illnesses within 24 h of onset of illness. This study examined promptness in seeking treatment from VHWs by children under five years with malaria, pneumonia, and diarrhoea in rural southwestern Uganda. METHODS: In August 2022, a database containing information from the VHWs patient registers over a 5-year study period was reviewed (2014-2018). A total of 18,430 child records drawn from 8 villages of Bugoye sub-county, Kasese district were included in the study. Promptness was defined a caregiver seeking treatment for a child from a VHW within 24 h of onset of illness. RESULTS: Sixty-four percent (64%) of the children included in the study sought treatment promptly. Children with fever had the highest likelihood of seeking prompt treatment (aOR = 1.93, 95% CI 1.80-2.06, p < 0.001) as compared to those with diarrhoea (aOR = 1.43, 95% CI 1.32-1.52, p < 0.001) and pneumonia (aOR = 1.33, 95% CI 1.24-1.42, p < 0.001). CONCLUSION: The findings provide further evidence that VHWs play a critical role in the treatment of childhood illness in rural contexts. However, the proportion of children seeking prompt treatment remains below the target set at the inception of the iCCM strategy, in Uganda. There is a need to continually engage rural communities to promote modification of health-seeking behaviour, particularly for children with danger signs. Evidence to inform the design of services and behaviour change communication, can be provided through undertaking qualitative studies to understand the underlying reasons for decisions about care-seeking in rural settings. Co-design with communities in these settings may increase the acceptability of these services.

Contribution of community health workers to the treatment of common illnesses among under 5-year-olds in rural Uganda.

BACKGROUND: The control of malaria, pneumonia, and diarrhoea is important for the reduction in morbidity and mortality among children under 5 years. Uganda has adopted the Integrated Community Case Management strategy using Community Health Workers (CHWs) to address this challenge. The extent and trend of these three conditions managed by the CHWs are not well documented. This study was done to describe the epidemiology and trends of the three common illnesses treated by the CHWs in Bugoye Sub-County in rural Uganda. METHODS: A retrospective review of monthly morbidity data for children less than 5 years of age for the period April 2014-December 2018 for CHWs in rural Bugoye Sub-County in Kasese district, Uganda was done. The total number reviewed was 18,430 records. The data were analysed using STATA version 14. RESULTS: In total male were 50.2% of the sample, pneumonia was the highest cause of illness among the infants (< 1 year), while malaria was the highest among the children 1 year-59 months. Infection with a single illness was the commonest recorded cause of presentation but there were some children recorded with multiple illnesses. All the CHWs were managing the three common illnesses among children under 5 years. The trend of the three common illnesses was changing from malaria to pneumonia being the commonest. Children aged 12-24 months and 25-59 months were at 2.1 times (95% CI 1.7-2.4) and 5.2 times (95% CI 4.6-5.9), respectively, more likely to get malaria but less likely to get pneumonia and diarrhoea. CONCLUSION: Community Health Workers in rural Uganda are contributing significantly to the management of all the three commonest illnesses among under-5 years-old children. The trend of the commonest illness is changing from malaria to pneumonia. Children under 1 year are at a higher risk of getting pneumonia and diarrhoea and at a lower risk of getting malaria.

Long-term quality of integrated community case management care for children in Bugoye Subcounty, Uganda: a retrospective observational study.

OBJECTIVE: Integrated community case management (iCCM) of childhood illness in Uganda involves protocol-based care of malaria, pneumonia and diarrhoea for children under 5 years old. This study assessed volunteer village health workers' (VHW) ability to provide correct iCCM care according to the national protocol and change in their performance over time since initial training. SETTING: VHWs affiliated with the Ugandan national programme provide community-based care in eight villages in Bugoye Subcounty, a rural area in Kasese District. The first cohort of VHWs began providing iCCM care in March 2013, the second cohort in July 2016. PARTICIPANTS: All children receiving iCCM care in 18 430 clinical encounters occurring between April 2014 and December 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: The descriptive primary outcome measure was the proportion of patients receiving overall correct care, defined as adherence to the iCCM protocol for the presenting condition (hereafter quality of care). The analytic primary outcome was change in the odds of receiving correct care over time, assessed using logistic regression models with generalised estimating equations. Secondary outcome measures included a set of binary measures of adherence to specific elements of the iCCM protocol. Preplanned and final measures were the same. RESULTS: Overall, VHWs provided correct care in 74% of clinical encounters. For the first cohort of VHWs, regression modelling demonstrated a modest increase in quality of care until approximately 3 years after their initial iCCM training (OR 1.022 per month elapsed, 95% CI 1.005 to 1.038), followed by a modest decrease thereafter (OR 0.978 per month, 95% CI 0.970 to 0.986). For the second cohort, quality of care was essentially constant over time (OR 1.007 per month, 95% CI 0.989 to 1.025). CONCLUSION: Quality of care was relatively constant over time, though the trend towards decreasing quality of care after 3 years of providing iCCM care requires further monitoring.

Usage of and satisfaction with Integrated Community Case Management care in western Uganda: a cross-sectional survey.

BACKGROUND: In some areas of Uganda, village health workers (VHW) deliver Integrated Community Case Management (iCCM) care, providing initial assessment of children under 5 years of age as well as protocol-based treatment of malaria, pneumonia, and diarrhoea for eligible patients. Little is known about community perspectives on or satisfaction with iCCM care. This study examines usage of and satisfaction with iCCM care as well as potential associations between these outcomes and time required to travel to the household's preferred health facility. METHODS: A cross-sectional household survey was administered in a rural subcounty in western Uganda during December 2016, using a stratified random sampling approach in villages where iCCM care was available. Households were eligible if the household contained one or more children under 5 years of age. RESULTS: A total of 271 households across 8 villages were included in the final sample. Of these, 39% reported that it took over an hour to reach their preferred health facility, and 73% reported walking to the health facility; 92% stated they had seen a VHW for iCCM care in the past, and 55% had seen a VHW in the month prior to the survey. Of respondents whose households had sought iCCM care, 60% rated their overall experience as "very good" or "excellent," 97% stated they would seek iCCM care in the future, and 92% stated they were "confident" or "very confident" in the VHW's overall abilities. Longer travel time to the household's preferred health facility did not appear to be associated with higher propensity to seek iCCM care or higher overall satisfaction with iCCM care. CONCLUSIONS: In this setting, community usage of and satisfaction with iCCM care for malaria, pneumonia, and diarrhoea appears high overall. Ease of access to facility-based care did not appear to impact the choice to access iCCM care or satisfaction with iCCM care.

A cross-sectional study comparing case scenarios and record review to measure quality of Integrated Community Case Management care in western Uganda.

BACKGROUND: In Integrated Community Case Management (iCCM), village health workers (VHW) assess and treat malaria, pneumonia and diarrhea using a clinical algorithm. Study objectives included: 1) Compare VHWs' performance on case scenario exercises to record review data; 2) assess impact of formal education on performance in the case scenario exercises. METHODS: 36 VHWs in Bugoye Subcounty, Uganda completed the case scenarios exercise, which included video case scenarios and brief oral case vignettes, between July 2017 and February 2018. We obtained clinical records for all iCCM encounters in the same time period. RESULTS: In the video case scenarios, 45% of mock patients received all correct management steps (including all recommended education), while 94% received all critical management steps. Based on the level of data available from record review, 74% of patients in the record review dataset received overall correct management compared to 94% in the video case scenarios. In the case scenarios, VHWs with primary school education performed similarly to those with some or all secondary school education. CONCLUSIONS: The case scenarios produced higher estimates of quality of care than record review. VHWs often omitted recommended health education topics in the case scenarios. Level of formal education did not appear to influence performance in the case scenarios.

Assessing Village Health Workers' Ability to Perform and Interpret Rapid Diagnostic Tests for Malaria 4 Years after Initial Training: A Cross-Sectional Study.

Village health workers (VHWs) in Bugoye subcounty, Uganda, provide integrated community case management (iCCM) care to children younger than 5 years for malaria, pneumonia, and diarrhea. We assessed the longevity of VHWs' skills in performing and reading malaria rapid diagnostic tests (RDTs) 4 years after initial training, comparing VHWs who had completed initial iCCM training 1 year before the study with VHWs who had completed training 4 years before the study. Both groups received quarterly refresher trainings. Trained interviewers observed 36 VHWs reading six mock RDTs each and performing an RDT as part of a larger skills assessment exercise. VHWs read 97% of mock RDTs correctly; of the 36 VHWs, 86% read all six mock RDTs correctly. Most VHWs scored either 12/13 or 13/13 on the RDT checklist (39% and 36%, respectively), with 25% scoring 11/13 or lower. For reading mock RDTs, VHWs in the first group (initial training 4 years before study) read 97% of mock RDTs correctly, whereas those in the second group (initial training 1 year before study) read 96% of mock RDTs correctly; the first group had a mean of 5.83 RDTs read correctly, compared with 5.77 RDTs read correctly in the second group (P = 0.83). For performing an RDT, the first group completed a mean of 12.0 steps correctly, compared with a mean of 12.2 correct steps in the second group (P = 0.60). Overall, VHWs demonstrated proficiency in reading RDTs accurately and performing RDTs according to protocol at least 4 years after initial iCCM training.

Completion of community health worker initiated patient referrals in integrated community case management in rural Uganda.

BACKGROUND: Uganda has sought to address leading causes of childhood mortality: malaria, pneumonia and diarrhoea, through integrated community case management (iCCM). The success of this approach relies on community health worker (CHW) assessment and referral of sick children to a nearby health centre. This study aimed to determine rates of referral completion in an iCCM programme in rural Uganda. METHODS: This was a prospective observational study of referrals made by CHWs in 8 villages in rural western Uganda. All patient referrals by CHWs were tracked and health centre registers were reviewed for documentation of completed referrals. Caregivers of referred patients were invited to complete a survey 2-3 weeks after the referral with questions on the CHW visit, referral completion, and the patient's clinical condition. RESULTS: Among 143 total referrals, 136 (94%) caregivers completed the follow-up survey. Reasons for visiting the CHW were fever/malaria in 111 (82%) cases, cough in 61 (45%) cases, and fast/difficult breathing in 25 (18%) cases. Overall, 121 (89%) caregivers reported taking the referred child for further medical evaluation, of whom 102 (75% overall) were taken to the local public health centre. Ninety per cent of reported referral visits were confirmed in health centre documentation. For the 34 caregivers who did not complete referral at the local health centre, the most common reasons were improvement in child's health, lack of time, ease of going elsewhere, and needing to care for other children. Referrals were slightly more likely to be completed on weekdays versus weekends (p = 0.0377); referral completion was otherwise not associated with child's age or gender, caregiver age, or caregiver relationship to child. One village had a lower rate of referral completion than the others. Improvement in the child's health was not associated with completed referral or timing of the referral visit. CONCLUSIONS: A high percentage of children referred to the health centre through iCCM in rural Uganda completed the referral. Barriers to referral completion included improvement in the child's health, time and distance. Interestingly, referral completion at the health centre was not associated with improvement in the child's health. Barriers to referral completion and clinical management at all stages of referral linkages warrant further study.

Quality of care in integrated community case management services in Bugoye, Uganda: a retrospective observational study.

BACKGROUND: Village health workers (VHWs) in five villages in Bugoye subcounty (Kasese District, Uganda) provide integrated community case management (iCCM) services, in which VHWs evaluate and treat malaria, pneumonia, and diarrhoea in children under 5 years of age. VHWs use a "Sick Child Job Aid" that guides them through the evaluation and treatment of these illnesses. A retrospective observational study was conducted to measure the quality of iCCM care provided by 23 VHWs in 5 villages in Bugoye subcounty over a 2-year period. METHODS: Patient characteristics and clinical services were summarized using existing aggregate programme data. Lot quality assurance sampling of individual patient records was used to estimate adherence to the iCCM algorithm, VHW-level quality (based on adherence to the iCCM protocol), and change over time in quality of care (using generalized estimating equations regression modelling). RESULTS: For each of 23 VHWs, 25 patient visits were randomly selected from a 2-year period after iCCM care initiation. In these visits, 97% (150) of patients with diarrhoea were treated with oral rehydration and zinc, 95% (216) of patients with pneumonia were treated with amoxicillin, and 94% (240) of patients with malaria were treated with artemisinin-based combination therapy or rectal artesunate. However, only 44% (44) of patients with a negative rapid test for malaria were appropriately referred to a health facility. Overall, 75% (434) of patients received all the correct evaluation and management steps. Only 9 (39%) of the 23 VHWs met the pre-determined LQAS threshold for high-quality care over the 2-year observation period. Quality of care increased significantly in the first 6 months after initiation of iCCM services (p = 0.003), and then plateaued during months 7-24. CONCLUSIONS: Quality of care was high for uncomplicated malaria, pneumonia and diarrhoea. Overall quality of care was lower, in part because VHWs often did not follow the guidelines to refer patients with fever who tested negative for malaria. Quality of care appears to improve in the initial months after iCCM implementation, as VHWs gain initial experience in iCCM care.

Monitoring iCCM referral systems: Bugoye Integrated Community Case Management Initiative (BIMI) in Uganda.

BACKGROUND: In Uganda, over half of under-five child mortality is attributed to three infectious diseases: malaria, pneumonia and diarrhoea. Integrated community case management (iCCM) trains village health workers (VHWs) to provide in-home diagnosis and treatment of these common childhood illnesses. For severely ill children, iCCM relies on a functioning referral system to ensure timely treatment at a health facility. However, referral completion rates vary widely among iCCM programmes and are difficult to monitor. The Bugoye Integrated Community Case Management Initiative (BIMI) is an iCCM programme operating in Bugoye sub-county, Uganda. This case study describes BIMI's experience with monitoring referral completion at Bugoye Health Centre III (BHC), and outlines improvements to be made within iCCM referral systems. METHODS: This study triangulated multiple data sources to evaluate the strengths and gaps in the BIMI referral system. Three quantitative data sources were reviewed: (1) VHW report of referred patients, (2) referral forms found at BHC, and (3) BHC patient records. These data sources were collated and triangulated from January-December 2014. The goal was to determine if patients were completing their referrals and if referrals were adequately documented using routine data sources. RESULTS: From January-December 2014, there were 268 patients referred to BHC, as documented by VHWs. However, only 52 of these patients had referral forms stored at BHC. Of the 52 referral forms found, 22 of these patients were also found in BHC register books recorded by clinic staff. Thus, the study found a mismatch between VHW reports of patient referrals and the referral visits documented at BHC. This discrepancy may indicate several gaps: (1) referred patients may not be completing their referral, (2) referral forms may be getting lost at BHC, and, (3) referred patients may be going to other health facilities or drug shops, rather than BHC, for their referral. CONCLUSIONS: This study demonstrates the challenges of effectively monitoring iCCM referral completion, given identified limitations such as discordant data sources, incomplete record keeping and lack of unique identifiers. There is a need to innovate and improve the ways by which referral compliance is monitored using routine data, in order to improve the percentage of referrals completed. Through research and field experience, this study proposes programmatic and technological solutions to rectify these gaps within iCCM programmes facing similar challenges. With improved monitoring, VHWs will be empowered to increase referral completion, allowing critically ill children to access needed health services.