Abstract
BackgroundUganda 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.MethodsThis 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.ResultsAmong 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.ConclusionsA 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.
Highlights
Uganda has sought to address leading causes of childhood mortality: malaria, pneumonia and diar‐ rhoea, through integrated community case management
For integrated community case management (iCCM), community health worker (CHW) use an algorithmic protocol for assessment of a sick child, including a targeted physical examination, history and a rapid diagnostic test (RDT) for malaria for children presenting with fever based on history or examination
The Bugoye Integrated Community Case Management Initiative (BIMI) iCCM programme operates in an area of high malaria incidence; since programme inception, 73.4% of children evaluated by BIMI CHWs for fever have had a positive RDT result
Summary
Uganda has sought to address leading causes of childhood mortality: malaria, pneumonia and diar‐ rhoea, 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. In 2012, the WHO and UNICEF formally endorsed Integrated Community Case Management (iCCM), an evidence-based algorithmic management approach employed by CHWs, to jointly address the leading causes of under-5 mortality (malaria, pneumonia, diarrhoea [11]), and by 2013, 28 sub-Saharan African (SSA) countries had implemented iCCM [12]. CHWs provide treatment in the community or, for particular conditions or danger signs, refer the patient to a nearby public health facility
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