Abstract
BackgroundVillage 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.MethodsPatient 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).ResultsFor 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.ConclusionsQuality 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.
Highlights
Village health workers (VHWs) in five villages in Bugoye subcounty (Kasese District, Uganda) provide integrated community case management services, in which VHWs evaluate and treat malaria, pneumonia, and diarrhoea in children under 5 years of age
VHWs use the integrated community case management (iCCM) protocol, called the “Sick Child Job Aid”, to determine the proper care for each patient (Additional file 1). They are equipped with rapid diagnostic tests (RDT) for malaria diagnosis in patients presenting with subjective fever; pneumonia is diagnosed based on age-based respiratory rate cut-offs, and diarrhoea is diagnosed by clinical history
This study shows much lower adherence to referral guidelines for patients with fever who had negative RDTs; this was the single most common error made by VHWs, comprising nearly 40% of the patient visits with incorrect management
Summary
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. 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. Interest has increased in equipping VHWs to provide assessment and curative treatment for young children, using variants of integrated community case management (iCCM). A retrospective observational study was conducted to assess the quality of iCCM care provided by 23 VHWs in five villages over a 2-year period from March 2013– February 2015 in a pilot iCCM programme in Bugoye subcounty, a rural part of Kasese district in Western Uganda
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