Abstract
BackgroundIntegrated community case management (iCCM) strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age. Community health workers, known as Village Health Teams (VHTs) in Uganda, have been shown to be effective in hard-to-reach, underserved areas, but there is little evidence to support iCCM as an appropriate strategy in non-rural contexts. This study aimed to inform future iCCM implementation by exploring caregiver and VHT member perceptions of the value and effectiveness of iCCM in peri-urban settings in Uganda.MethodsA qualitative evaluation was conducted in seven villages in Wakiso district, a rapidly urbanising area in central Uganda. Villages were purposively selected, spanning a range of peri-urban settlements experiencing rapid population change. In each village, rapid appraisal activities were undertaken separately with purposively selected caregivers (n = 85) and all iCCM-trained VHT members (n = 14), providing platforms for group discussions. Fifteen key informant interviews were also conducted with community leaders and VHT members. Thematic analysis was based on the ‘Health Access Livelihoods Framework’.ResultsiCCM was perceived to facilitate timely treatment access and improve child health in peri-urban settings, often supplanting private clinics and traditional healers as first point of care. Relative to other health service providers, caregivers valued VHTs’ free, proximal services, caring attitudes, perceived treatment quality, perceived competency and protocol use, and follow-up and referral services. VHT effectiveness was perceived to be restricted by inadequate diagnostics, limited newborn care, drug stockouts and VHT member absence – factors which drove utilisation of alternative providers. Low community engagement in VHT selection, lack of referral transport and poor availability of referral services also diminished perceived effectiveness. The iCCM strategy was widely perceived to result in economic savings and other livelihood benefits.ConclusionsIn peri-urban areas, iCCM was perceived as an effective, well-utilised strategy, reflecting both VHT attributes and gaps in existing health services. Depending on health system resources and organisation, iCCM may be a useful transitional service delivery approach. Implementation in peri-urban areas should consider tailored community engagement strategies, adapted selection criteria, and assessment of population density to ensure sufficient coverage.
Highlights
Integrated community case management strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age
Mixed results from rural-urban comparative studies of community case management interventions for malaria and pneumonia have been reported, with treatment coverage by Community health worker (CHW) in urban areas ranging from less than 1% to an average of 40%, and consistently lower uptake of CHW services observed in urban areas than in rural [10,11,12,13]
The happiness of a father is children in the homes. (Caregiver, Village 4). In this qualitative evaluation, Integrated community case management (iCCM) was perceived to be effective in facilitating treatment access in a rapidly urbanising setting that differed from the hard to reach, rural settings traditionally targeted for iCCM implementation. These qualitative findings complement a recent evaluation of iCCM in central Uganda that was conducted under the same programme of implementation, but covering a wider geographic area, which found that iCCM increased treatment coverage for diarrhoea and fever, and health care seeking for all three diseases [26]
Summary
Integrated community case management (iCCM) strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age. ICCM implementation strategies have primarily targeted hard to reach, rural areas, which tend to be underserved by facility-based care [1] In these contexts, evidence from a number of countries has shown iCCM to be an effective and feasible strategy for improving equitable access to treatment [3,4,5,6,7,8,9]. Lower uptake in urban areas has been attributed in part to low awareness or low acceptability of CHW services, or a preference for health centres [10] It appears a few countries have introduced iCCM or other community case management programmes (for pneumonia or malaria) in peri-urban areas [14], this has not been well-documented. Community-based delivery strategies have been effectively implemented for preventive health, outreach and referral interventions in periurban settings [15,16,17,18], it seems there has been no explicit study exploring whether iCCM is an appropriate strategy for meeting the treatment needs of peri-urban communities
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