Performance of Community Health Workers in Community Case Management: Uganda

Author(s) Agnes Nanyonjo1, Edmound Kertho2, Seyi Soremekun3, Frida Kastenge 4, Guus TenAsbroek 5, James Tibenderana6, Karin Kallander7
Affiliation(s) 1Technical, Uganda Country Office, Malaria Consortium, Kampala, Uganda, 2Technical, Uganda Country Oficce, Malaria Consortium, Kampala, Uganda, 3Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom, 4Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom, 5Population Health, London School of Hygiene and Tropical Medicine, Amsterdam, Netherlands, 6Technical, Africa Region Ofiice, Malaria Consortium, Kampala, Uganda, 7Technical, Africa Region Office, Malaria Consortium, Kampala, Uganda.
Country - ies of focus Uganda
Relevant to the conference tracks Health Workforce
Summary Integrated community case management is key child survival strategy in resource poor settings. There is paucity of data on performance of community health workers in this strategy and how this performance can be measured. We report on a study that evaluated the performance of community health workers using case vignettes. Overall community health workers perform well with respect to treatment. However omissions in terms of probing for danger signs and other illness symptoms and provision of general health education required by the treatment guidelines deter community health worker performance.
Background Integrated community case management for malaria, pneumonia and diarrhoea (iCCM) is one of the key interventions tailored towards curbing child mortality in low income countries. In iCCM lay community health workers (CHWs) use a given algorithm provided in a job aid to ask about illness symptoms, assess signs, classify and treat disease or refer severely ill children. They treat malaria with artemether lumefantrine combination, pneumonia with amoxycillin and diarrhoea with oral rehydration salts (ORS) and zinc. They are also required to offer health education regarding disease prevention. Although measurement of performance in itself poses key challenges in terms of choice of method used, assessment and understanding of the performance of CHWs is crucial to ensure high quality care of the sick children.
Objectives The objective of the study was to assess the performance of CHWs while managing children with solitary disease such as malaria alone or mixed infections such as malaria and pneumonia by using case vignettes.
Methodology The study was conducted among a sample of 360 CHWs who had been practicing iCCM for at least three to eight months in eight districts in Midwestern Uganda. CHWs were given four case vignettes; one after the other. Using probing questions the CHWs were asked to describe the actions they would take from the time they encountered the sick child and his/her caregiver to the time they finished the consultation. The CHWs were allowed to use their job aid during the evaluation. One case vignette emulated a 6 months old child with an uncomplicated malaria classification presenting with fever, poor appetite and no danger signs; requiring a malaria rapid diagnostic test, malaria treatment and health education. Another vignette depicted a 3 year old child with diarrhoea and no blood in stool; requiring zinc, ORS and health education. The third vignette was about a child with both cough fast breathing and fever and a history of stiff feet early that morning depicting a child with pneumonia and complicated malaria requiring referral and pre-referral treatment due to the danger sign. The last case was about a child with fever and cough, essentially with uncomplicated malaria but no pneumonia. Each appropriate action, i.e. questions the CHW should have asked, test CHW should have performed and treatment and health education CHW should have given basing on the guidelines, was assigned a weight of one. The average performance score for each CHW was generated on a scale of 0-100. Scores were also sub-analyzed per case managed as well as association with socio-demographic factors, such as sex, literacy and district of the CHWs.
Results Out of all actions that should have been taken for each case, the overall mean performance score of the CHWs was 41.5 (SD 8.6). The mean performance score based on case scenarios was 46.6 (SD 16.3) for the uncomplicated malaria case, 59.3 (SD 15.6) for the case of uncomplicated malaria with cough, 36.5 (SD 13.6) for the diarrhoea case, and 23.5 (SD 14.4) for the case with pneumonia and complicated malaria and. Overall, CHWs ability to state the correct treatment and dose for the simulated case was high, with 93.3% sating the correct treatment for a child case with malaria alone; 94.4% stating the appropriate treatment for a child case with diarrhoea, and 84.4% being able to suggest referral for a child case with a history of a danger sign. However, the problematic areas in the management algorithm that appeared to decrease the overall mean performance score included: a) failure to ask about dangers signs and symptoms that are not mentioned by the caregiver. Overall only 1% of the CHWs remembered to probe for the presence of any danger signs and other symptoms not automatically volunteered by the care taker in at least one of the case scenarios; b) Failure to assess for key illness symptoms. In the pneumonia and complicated malaria case only 22.7% of CHWs mentioned that they would assess the respiratory rate of the child; c) Failure to give pre-referral treatment. Only 28.1% and 9.7% CHWs mentioned that they would give pre-referral treatment for malaria and pneumonia, respectively; d) Failure to give instructions on how to administer the drug, especially in the diarrhoea case scenario where only 40% mentioned at least one instruction they would give to the caretaker regarding how to mix and give ORS; e) Failure to provide general health education and information on when to take the child to the health facility for further treatment. Twenty percent of CHWs did not give caretakers any of the recommended advice. Performance levels were positively associated with the district of the CHWs (p<0.001) and to the increasing number of patients the CHW had seen in the last week (p=0.015).
Conclusion If the case scenarios where a reflection of a real life situation our data suggest that majority of children seen by CHWs would get the appropriate curative treatment or action required. However they would not be able to benefit optimally from their visit to the CHWs due to omitted actions, such as provision of pre-referral treatment, health education and counseling, and demonstration to caregivers on how to give the first dose. Supportive supervision and refresher training of CHWs should which emphasizes strict adherence to treatment algorithms, and which offers strengthening of interpersonal communication skills should be implemented.

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