Integrated Community Case Management Research Articles

Utilization of integrated community-based case management of childhood illness and associated factors in Ethiopia: a systematic review and meta-analysis

BackgroundDespite significant progress being made in reducing under-five mortality, three-fourths of under-five deaths are still caused by preventable conditions such as pneumonia, diarrhea, malaria, and newborn issues. Integrated community case management of childhood illnesses (ICCM) could serve as a means to reduce preventable child mortality in Low- and Middle-Income countries. Our aim was to assess the overall level of ICCM utilization and its associated factors in Ethiopia.MethodsCandidate studies for inclusion in this review were identified through searches across various databases, including PubMed, EMBASE, Google Scholar, and university repositories online databases, spanning from February 1, 2024, to March 18, 2024. The quality assessment of the studies included in this systematic review and meta-analysis was conducted using the Newcastle-Ottawa Quality Assessment Scale (NOS). Data extraction and analysis were carried out using Microsoft Excel and Stata 17 software, respectively. Heterogeneity among the studies was assessed using Cochran’s Q test and I2 statistics, while the presence of publication bias was evaluated through funnel plots and Egger’s regression asymmetry test. Subgroup analysis was performed based on sample size and study site.ResultsIn this study, the pooled level of ICCM utilization was found to be 42.73 (95%, CI 27.65%, 57.80%) based on the evidence obtained from ten primary studies. In this review, parents’ awareness about illness (OR = 2.77, 95%, CI 2.06, 3.74), awareness about ICCM service (OR = 3.64, 95%, CI 2.16, 6.14), perceived severity of the disease (OR = 3.14, 95%, CI 2.33, 4.23), secondary/above level of education (OR = 2.57, 95%, CI 1.39, 4.77), and live within 30 min distance to the health post (OR = 3.93, 95%, CI 2.30, 6.74) were variables significantly associated with utilization of ICCM in Ethiopia.ConclusionThe utilization of ICCM was found to be low in Ethiopia. Factors such as parents’ awareness about the illness, knowledge of ICCM services, perceived severity of the disease, attending a secondary or more level of education, and living within 30 min distance to the health post were significantly associated with the utilization of ICCM. Therefore, it is crucial to focus on creating awareness and improving access to high-quality ICCM services to reduce child morbidity and mortality from preventable causes.

Integration of Acute Malnutrition Treatment Into Integrated Community Case Management in Three Districts in Southern Mali: An Economic Evaluation.

Enabling community health workers (CHWs) to treat acute malnutrition improves treatment access and coverage. However, data on the cost and cost-effectiveness of this approach is limited. We aimed to cost the treatment at scale and determine the cost-effectiveness of different levels of supervision and technical support. This economic evaluation was part of a prospective nonrandomized community intervention study in 3 districts in Mali examining the impact of different levels of CHW and health center supervision and support on treatment outcomes for children with severe acute malnutrition. Treatment admission and outcome data were extracted from the records of 120 participating health centers and 169 CHW sites. Cost data were collected from accountancy records and through key informant interviews. Results were presented as cost per child treated and cured. Modeled scenario sensitivity analyses were conducted to determine how cost-efficiency and cost-effectiveness estimates change in an equal scale scenario and/or if the supervision had been done by government staff. In the observed scenario, with an unequal number of children, the average cost per child treated was US$203.40 in Bafoulabé where a basic level of supervision and support was provided, US$279.90 in Kayes with a medium level of supervision, and US$253.9 in Kita with the highest level of supervision. Costs per child cured were US$303.90 in Bafoulabé, US$324.90 in Kayes, and US$311.80 in Kita, with overlapping uncertainty ranges. Additional supervision has the potential to be a cost-effective strategy if supervision costs are reduced without compromising the quality of supervision. Further research should aim to better adapt the supervision model and associated tools to the context and investigate where efficiencies can be made in its delivery.

The impacts of task shifting on the management and treatment of malnourished children in Northern Kenya: a cluster-randomized controlled trial.

Treating children with acute malnutrition can be challenging, particularly regarding access to healthcare facilities during treatment. Task shifting, a strategy of transferring specific tasks to health workers with shorter training and fewer qualifications, is being considered as an effective approach to enhancing health outcomes in primary healthcare. This study aimed to assess the effectiveness of integrating the treatment of acute malnutrition by community health volunteers into integrated community case management in two sub-counties in northern Kenya (Loima and Isiolo). We conducted a two-arm non-inferiority cluster-randomized controlled trial across 20 community health units. Participants were children aged 6-59 months with uncomplicated acute malnutrition. In the intervention group, community health volunteers used simplified tools and protocols to identify and treat eligible children at home and provided the usual integrated community case management package. In the control group, community health volunteers provided the usual integrated community case management package only (screening and referral of the malnourished children to the health facilities). The primary outcome was recovery (MUAC ≥12.5 cm for 2 consecutive weeks). Results show that children in the intervention group were more likely to recover than those in the control group [73 vs 50; risk difference (RD) = 26% (95% CI 12 to 40) and risk ratio (RR) = 2 (95% CI 1.2 to 1.9)]. The probability of defaulting was lower in the intervention group than in the control group: RD = -21% (95% CI -31 to -10) and RR = 0.3 (95% CI 0.2 to 0.5). The intervention reduced the length of stay by about 13 days, although this was not statistically significant and varied substantially by sub-county. Integrating the treatment of acute malnutrition by community health volunteers into the integrated community case management programme led to better malnutrition treatment outcomes. There is a need to integrate acute malnutrition treatment into integrated community case management and review policies to allow community health volunteers to treat uncomplicated acute malnutrition.

Barriers and benefits of mHealth for community health workers in integrated community case management of childhood diseases in Banda Parish, Kampala, Uganda: a cross-sectional study

BackgroundLow-quality data presents a significant challenge for community health workers (CHWs) in low and middle-income countries (LMICs). Mobile health (mHealth) applications offer a solution by enabling CHWs to record and submit data electronically. However, the barriers and benefits of mHealth usage among CHWs in informal urban settlements remain poorly understood. This study sought to determine the barriers and benefits of mHealth among CHWs in Banda parish, Kampala.MethodsThis qualitative study involved 12 key informant interviews (KIIs) among focal persons from Kampala City Council Authority (KCCA) and NGOs involved in data collected by CHWs, and officials from the Ministry of Health (MOH) and two mixed-sex Focused Group Discussions (FGDs) of CHWs from Banda parish, Kampala district. Data analysis utilised Atlas Ti Version 7.5.7. Thematic analysis was conducted, and themes were aligned with the social-ecological model.ResultsThree themes of institutional and policy, community and interpersonal, and individual aligning to the Social ecological model highlighted the factors contributing to barriers and the benefits of mHealth among CHWs for iCCM. The key barriers to usability, acceptability and sustainability included high training costs, CHW demotivation, infrastructure limitations, data security concerns, community awareness deficits, and skill deficiencies. Conversely, mHealth offers benefits such as timely data submission, enhanced data quality, geo-mapping capabilities, improved CHW performance monitoring, community health surveillance, cost-effective reporting, and CHW empowering with technology.ConclusionDespite limited mHealth experience, CHWs expressed enthusiasm for its potential. Implementation was viewed as a solution to multiple challenges, facilitating access to health information, efficient data reporting, and administrative processes, particularly in resource-constrained settings. Successful mHealth implementation requires addressing CHWs’ demotivation, ensuring reliable power and network connectivity, and enhancing capacity for digital data ethics and management. By overcoming these barriers, mHealth can significantly enhance healthcare delivery at the community level, leveraging technology to optimize resource utilization and improve health outcomes. mHealth holds promise for transforming CHW practices, yet its effective integration necessitates targeted interventions to address systemic challenges and ensure sustainable implementation in LMIC contexts.

Cost-effectiveness of village health worker-led integrated community case management (iCCM) versus health facility based management for childhood illnesses in rural southwestern Uganda

BackgroundIn Uganda, village health workers (VHWs) manage childhood illness under the integrated community case management (iCCM) strategy. Care is provided for malaria, pneumonia, and diarrhoea in a community setting. Currently, there is limited evidence on the cost-effectiveness of iCCM in comparison to health facility-based management for childhood illnesses. This study examined the cost-effectiveness of the management of childhood illness using the VHW-led iCCM against health facility-based services in rural south-western Uganda.MethodsData on the costs and effectiveness of VHW-led iCCM versus health facility-based services for the management of childhood illness was collected in one sub-county in rural southwestern Uganda. Costing was performed using the ingredients approach. Effectiveness was measured as the number of under-five children appropriately treated. The Incremental Cost-Effectiveness Ratio (ICER) was calculated from the provider perspective.ResultsBased on the decision model for this study, the cost for 100 children treated was US$628.27 under the VHW led iCCM and US$87.19 for the health facility based services, while the effectiveness was 77 and 71 children treated for VHW led iCCM and health facility-based services, respectively. An ICER of US$6.67 per under five-year child treated appropriately for malaria, pneumonia and diarrhoea was derived for the provider perspective.ConclusionThe health facility based services are less costly when compared to the VHW led iCCM per child treated appropriately. The VHW led iCCM was however more effective with regard to the number of children treated appropriately for malaria, pneumonia and diarrhoea. Considering the public health expenditure per capita for Uganda as the willingness to pay threshold, VHW led iCCM is a cost-effective strategy. VHW led iCCM should, therefore, be enhanced and sustained as an option to complement the health facility-based services for treatment of childhood illness in rural contexts.

Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design

BackgroundIntegrated Community Case Management (ICCM) of common childhood illness is one of the global initiatives to reduce mortality among under-five children by two-thirds. It is also implemented in Ethiopia to improve community access and coverage of health services. However, as per our best knowledge the implementation status of integrated community case management in the study area is not well evaluated. Therefore, this study aimed to evaluate the implementation status of the integrated community case management program in Gondar City, Northwest Ethiopia.MethodsA single case study design with mixed methods was employed to evaluate the process of integrated community case management for common childhood illness in Gondar town from March 17 to April 17, 2022. The availability, compliance, and acceptability dimensions of the program implementation were evaluated using 49 indicators. In this evaluation, 484 mothers or caregivers participated in exit interviews; 230 records were reviewed, 21 key informants were interviewed; and 42 observations were included. To identify the predictor variables associated with acceptability, we used a multivariable logistic regression analysis. Statistically significant variables were identified based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value. The qualitative data was recorded, transcribed, and translated into English, and thematic analysis was carried out.ResultsThe overall implementation of integrated community case management was 81.5%, of which availability (84.2%), compliance (83.1%), and acceptability (75.3%) contributed. Some drugs and medical equipment, like Cotrimoxazole, vitamin K, a timer, and a resuscitation bag, were stocked out. Health care providers complained that lack of refreshment training and continuous supportive supervision was the common challenges that led to a skill gap for effective program delivery. Educational status (primary AOR = 0.27, 95% CI:0.11–0.52), secondary AOR = 0.16, 95% CI:0.07–0.39), and college and above AOR = 0.08, 95% CI:0.07–0.39), prescribed drug availability (AOR = 2.17, 95% CI:1.14–4.10), travel time to the to the ICCM site (AOR = 3.8, 95% CI:1.99–7.35), and waiting time (AOR = 2.80, 95% CI:1.16–6.79) were factors associated with the acceptability of the program by caregivers.Conclusion and recommendationThe overall implementation status of the integrated community case management program was judged as good. However, there were gaps observed in the assessment, classification, and treatment of diseases. Educational status, availability of the prescribed drugs, waiting time and travel time to integrated community case management sites were factors associated with the program acceptability. Continuous supportive supervision for health facilities, refreshment training for HEW’s to maximize compliance, construction clean water sources for HPs, and conducting longitudinal studies for the future are the forwarded recommendation.

Infant Mortality Decline in Zambia: To What Extent Did Maternal Education Influence Infant Mortality Rate Decline for the Period 1992 to 2018?

Purpose: In Zambia, infant mortality has reduced from 107 per 1000 live births in 1992, to 42 per 1000 live births during the 2018 period. Across the Globe, it is argued that maternal education (ME) contributes to the reduction in infant mortality (IM). However, the extent to which maternal education influenced the decline in infant mortality in Zambia for the period 1992 to 2018 was not clear. Therefore, this study sought to investigate the extent to which ME influenced the decline in IM in Zambia from 1992 to 2018. Materials and Methods: This study was a secondary data analysis (Trend Analysis). Zambia Demographic and Health Survey (ZDHS) data sets: 1992 to 2018 were used in the analyses. The unit of analysis was IM with sample sizes: 6169, 7066, 6526, 6025,12916 and 9959 respective to the ZDHS years. All analyses were done using SPSS version 25.0. Univariate analysis was done for descriptive statistics. Bivariate analysis, Chi-square was used at 5% level of significance for associations. Point Bi-serial Correction was done between ME and IM at 1% and/or 5% levels of significance. Binary logistic regression at 5% level of significance was used to determine the influence of predictors on IM. Findings: It was found that ME was (negatively) related to IM from 1992 to 2001-2. The correlation coefficients were smaller negatives indicating a very weak negative relationship between ME and IM. In multivariate analysis ME was found to be negatively associated with IM, from 1992 to 2001-2 only. Among the interactions, only the interactions between ME and contraceptive use; ME and preceding birth interval; ME and breast feeding; and ME and antenatal care (visits) significantly influenced the decline in IM from 1992 to 2018. Singularly, ME influenced the decline in IM rate to a lesser extent (only marginally). When interacted with contraceptive use, preceding birth interval, breast feeding and antenatal care, ME influenced the decline in IM to a larger extent. Implications to Theory, Practice and Policy: in order to come up with more robust interventions to further reduce IM in the country, these interactions should be considered in the planning and implementation of child health programs such as the child health nutrition, national partnership for maternal, new-born and child health, child health week, Integrated Community Case Management of Childhood Illnesses (ICCM), and the Support to Safe motherhood and New-born Health among others.

Factors influencing fever care-seeking for children under five years of age in The Gambia: a secondary analysis of 2019–20 DHS data

BackgroundMalaria contributes to excess child mortality in The Gambia. Children under five are at risk of severe malaria and death if not treated promptly and appropriately. It is crucial that a child with fever receive appropriate care from a trained provider. The aim was to identify influences on child fever care-seeking in The Gambia to inform malaria control strategies.MethodsThis cross-sectional analysis of The Gambia 2019–20 Demographic and Health Survey used logistic regression analysis to identify associations between source of care for a child with fever (public or private healthcare provider, other, or no treatment) and mother, child, and household characteristics.ResultsOnly 52.0% of mothers sought care from a trained healthcare provider for a child with fever—45.1% from a public facility and 7.0% from the private sector. 35.2% of mothers did not seek treatment. Mothers in urban households were 2.67 times as likely (aOR, 95% CI 1.504–4.736) as mothers in rural households to seek care from an informal source (e.g., pharmacy) versus not seeking treatment, and 0.29 times as likely (aOR, 95% CI 0.165–0.515) as mothers in rural households to seek care from a public provider versus informal source. Mothers in wealthier households were 2.30 times as likely (aOR, 95% CI 1.274–4.164) as mothers in poorer households to seek care from an informal source versus no treatment and half as likely as mothers in poorer households to seek care from a public provider versus informal source (aOR 0.53, 95% CI 0.291–0.959).ConclusionsMaintaining The Gambia’s malaria control achievements will require the active engagement and oversight of private pharmacies along with continued integrated community case management to reach mothers who do not seek care for a child with fever, and remove challenges to seeking appropriate care from trained providers. Whether influenced by convenience, costs, perceived urgency, or other factors, given the likelihood of urban mothers and mothers in wealthier households to seek care from private pharmacies, it will be necessary to incorporate private pharmacies into malaria control strategies while building public sector capacity and workforce, and initiating more effective attitude and behavioural change among mothers and households.

Systems Thinking for Supply Chains: Identifying Bottlenecks Using Process Mapping of a Child Health Intervention in the Democratic Republic of the Congo (DRC)

The quality of supply chains in public health interventions in low- and middle-income countries can determine how effectively a program is able to treat its intended population group and subsequently achieve its health targets. We aimed to disentangle where challenges exist hierarchically and administratively through the application of process mapping to the supply chain of an integrated community case management (iCCM) intervention in the Democratic Republic of the Congo (DRC). We conducted a document review, semi-structured key informant interviews, and focus group discussions with program agents involved in supply chain processes of the child health intervention. Enterprise architecture was used to map the intervention’s supply chain and its participatory actors, and detailed bottlenecks of the chain through the application of a health systems framework. The results of this study will be used to inform a system dynamics model of the supply chain of iCCM in DRC. The greatest bottlenecks leading to stockouts at the community level occurred upstream (from national to province and from zone to health facility). While the use of local procurement processes was partially attempted to strengthen systems, parallel supply chain activities compromised sustainable system integration and development. Initial delays in stock dispensation were due to international procurement at the supplier, inducing a trickle-down effect. Inadequate quantification of supply needs and subsequent insufficient product procuration were the single most important steps that led to stockouts. This study demonstrated that the community health supply chain would be most impacted by improvements made in processes at the highest administrative strata, while exposing its delicate dependence on activities at the lowest levels. Visibility of inventory at all levels and improved data quality and use through a transparent tracking system have the potential to significantly reduce stockouts. Future interventions should take care to not develop parallel processes or exclude local health system agents to avoid disruption and ensure sustainable health outcome gains. Causal loop studies and system dynamics can further identify the systems interactions and relationships and their underlying causal mechanisms in need of intervention.

Optimizing integration of community-based management of possible serious bacterial infection (PSBI) in young infants into primary healthcare systems in Ethiopia and Kenya: successes and challenges

BackgroundEthiopia and Kenya have adopted the community-based integrated community case management (iCCM) of common childhood illnesses and newborn care strategy to improve access to treatment of infections in newborns and young infants since 2012 and 2018, respectively. However, the iCCM strategy implementation has not been fully integrated into the health system in both countries. This paper describes the extent of integration of iCCM program at the district/county health system level, related barriers to optimal integration and implementation of strategies.MethodsFrom November 2020 to August 2021, Ethiopia and Kenya implemented the community-based treatment of possible serious bacterial infection (PSBI) when referral to a higher facility is not possible using embedded implementation research (eIR) to mitigate the impact of COVID-19 on the delivery of this life-saving intervention. Both projects conducted mixed methods research from April-May 2021 to identify barriers and facilitators and inform strategies and summative evaluations from June-July 2022 to monitor the effectiveness of implementation outcomes including integration of strategies.ResultsStrategies identified as needed for successful implementation and sustainability of the management of PSBI integrated at the primary care level included continued coaching and support systems for frontline health workers, technical oversight from the district/county health system, and ensuring adequate supply of commodities. As a result, support and technical oversight capacity and collaborative learning were strengthened between primary care facilities and community health workers, resulting in improved bidirectional linkages. Improvement of PSBI treatment was seen with over 85% and 81% of estimated sick young infants identified and treated in Ethiopia and Kenya, respectively. However, perceived low quality of service, lack of community trust, and shortage of supplies remained barriers impeding optimal PSBI services access and delivery.ConclusionPragmatic eIR identified shared and unique contextual challenges between and across the two countries which informed the design and implementation of strategies to optimize the integration of PSBI management into the health system during the COVID-19 pandemic. The eIR participatory design also strengthened ownership to operationalize the implementation of identified strategies needed to improve the health system’s capacity for PSBI treatment.

Reducing the equity gap in under-5 mortality through an innovative community health program in Ethiopia: an implementation research study

BackgroundThe Ethiopian government implemented a national community health program, the Health Extension Program (HEP), to provide community-based health services to address persisting access-related barriers to care using health extension workers (HEWs). We used implementation research to understand how Ethiopia leveraged the HEP to widely implement evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M) and address health inequities.MethodsThis study was part of a six-country case study series using implementation research to understand how countries implemented EBIs between 2000–2015. Our mixed-methods research was informed by a hybrid implementation science framework using desk review of published and gray literature, analysis of existing data sources, and 11 key informant interviews. We used implementation of pneumococcal conjugate vaccine (PCV-10) and integrated community case management (iCCM) to illustrate Ethiopia’s ability to rapidly integrate interventions into existing systems at a national level through leveraging the HEP and other implementation strategies and contextual factors which influenced implementation outcomes.ResultsEthiopia implemented numerous EBIs known to address leading causes of U5M, leveraging the HEP as a platform for delivery to successfully introduce and scale new EBIs nationally. By 2014/15, estimated coverage of three doses of PCV-10 was at 76%, with high acceptability (nearly 100%) of vaccines in the community. Between 2000 and 2015, we found evidence of improved care-seeking; coverage of oral rehydration solution for treatment of diarrhea, a service included in iCCM, doubled over this period. HEWs made health services more accessible to rural and pastoralist communities, which account for over 80% of the population, with previously low access, a contextual factor that had been a barrier to high coverage of interventions.ConclusionsLeveraging the HEP as a platform for service delivery allowed Ethiopia to successfully introduce and scale existing and new EBIs nationally, improving feasibility and reach of introduction and scale-up of interventions. Additional efforts are required to reduce the equity gap in coverage of EBIs including PCV-10 and iCCM among pastoralist and rural communities. As other countries continue to work towards reducing U5M, Ethiopia’s experience provides important lessons in effectively delivering key EBIs in the presence of challenging contextual factors.

Availability of antimalarial medicines and inventory management at the community level: a case study of Bugesera district in Rwanda

BackgroundMalaria is a public health hazard globally, with Sub-Saharan Africa accounting for more than 90% of malaria deaths, primarily affecting children under the age of five. In Rwanda, malaria interventions include the availability of antimalarial medications, notably Artemisinin-based combination treatments (ACTs) and quick diagnostic test kits (RDTs). However, the availability of antimalarial medicines and its related inventory management at community level in Rwanda has yet to be identified.MethodsThe study was conducted using a descriptive cross-sectional research design. The study involved the Community Health Workers (CHWs) in Bugesera District, working as a team of one male-female pair called Binômes. CHWs provide Integrated Community Case Management (iCCM) and treatment of Malaria in the villages. The sample size was 295 and respondents were selected using convenient random sampling from 15 sectors of Bugesera District, each cell being represented. A structured research questionnaire was used to collect data. The questionnaires were filled by CHWs who were available for this study at the time of data collection. Collected data were exported to SPSS version 26 for coding and analysis.ResultsThe CHWs reported to be actively involved in managing the antimalarial medicines inventory. Overall, 64.1% of CHWs indicated that the population could easily obtain antimalarial medicines from community health workers and 31.2% attested that people could also obtain antimalarial medicines from the health centers. Majority of respondents 78% confirmed that the CHWs had the appropriate storage conditions for antimalarial medicines, while the overall stock out recorded was 3.20%. Furthermore, CHWs described some challenges, including but not limited to, lack of appropriate or dependable transportation and inappropriate medicines storage. Transportation was reported as a critical barrier for accessing antimalarial medicines. The majority, 70,85% travel on foot while 25.4% reported that CHWs walk for a distance between 1 and 2 h for resupply of antimalarial medicines.ConclusionThis study investigated the availability of antimalarial medicines and inventory management challenges at community level in Rwanda. Addressing these challenges will reduce the rate of stockout and increase the availability of antimalarial medicine at community level. Appropriate storage, and reduction of stock out rate, will serve to strengthen the current CHWs system, and provide critical guidance for the evolution of CHWs’ systems in Rwanda.

Improving malaria case management with artemisinin-based combination therapies and malaria rapid diagnostic tests in private medicine retail outlets in sub-Saharan Africa: A systematic review.

Private medicine retailers (PMRs) such as pharmacies and drug stores account for a substantial share of treatment-seeking for fever and malaria, but there are widespread concerns about quality of care, including inadequate access to malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapies (ACTs). This review synthesizes evidence on the effectiveness of interventions to improve malaria case management in PMRs in sub-Saharan Africa (PROSPERO #2021:CRD42021253564). We included quantitative studies evaluating interventions supporting RDT and/or ACT sales by PMR staff, with a historical or contemporaneous control group, and outcomes related to care received. We searched Medline Ovid, Embase Ovid, Global Health Ovid, Econlit Ovid and the Cochrane Library; unpublished studies were identified by contacting key informants. We conducted a narrative synthesis by intervention category. We included 41 papers, relating to 34 studies. There was strong evidence that small and large-scale ACT subsidy programmes (without RDTs) increased the market share of quality-assured ACT in PMRs, including among rural and poorer groups, with increases of over 30 percentage points in most settings. Interventions to introduce or enhance RDT use in PMRs led to RDT uptake among febrile clients of over two-thirds and dispensing according to RDT result of over three quarters, though some studies had much poorer results. Introducing Integrated Community Case Management (iCCM) was also effective in improving malaria case management. However, there were no eligible studies on RDT or iCCM implementation at large scale. There was limited evidence that PMR accreditation (without RDTs) increased ACT uptake. Key evidence gaps include evaluations of RDTs and iCCM at large scale, evaluations of interventions including use of digital technologies, and robust studies of accreditation and other broader PMR interventions.

Rapid response mechanism in conflict-affected settings of Cameroon: lessons learned from a multisector intervention for internally displaced persons

The Northwest and Southwest regions of Cameroon have experienced armed conflict over the last seven years, characterized by mass displacement and limited access to health care and social amenities. In response, an emergency intervention programme called “rapid response mechanism” (RRM) was initiated to provide lifesaving services to internally displaced persons. The intervention was multisectoral and included a health component, nutrition, water hygiene and sanitation, and child protection. RRM served communities of Ekondo Titi district, marked with high levels of insecurity, poor telecommunication networks and limited geographical access. Although the RRM was designed to provide rapid and lifesaving interventions to the affected populations; the RRM, in this case, was only initiated one year after the conflict escalated. Key benefits of the RRM included: (i) increased access to health care services through its integrated community case management approach, (ii) development of full displacement map within the health district, further strengthening the health system by establishing a community-based surveillance and response system through community health workers, and (iii) assisting the health district team in mass vaccination campaigns in seven of the nine health areas, which were otherwise completely inaccessible. The RRM model was largely primary health care focused compared to other RRMs in conflict-affected countries. It is important for RRM benefit packages to be harmonized to enable better preparedness and responses in conflicts. There is also a need for better coordination among sectoral partners to ensure improved response in crises.

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

BackgroundVillage 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.MethodsIn 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.ResultsSixty-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).ConclusionThe 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.

Improving outcomes for children with malaria, diarrhoea and pneumonia in Mozambique: A cluster randomised controlled trial of the inSCALE technology innovation.

The majority of post-neonatal deaths in children under 5 are due to malaria, diarrhoea and pneumonia (MDP). The WHO recommends integrated community case management (iCCM) of these conditions using community-based health workers (CHW). However iCCM programmes have suffered from poor implementation and mixed outcomes. We designed and evaluated a technology-based (mHealth) intervention package 'inSCALE' (Innovations At Scale For Community Access and Lasting Effects) to support iCCM programmes and increase appropriate treatment coverage for children with MDP. This superiority cluster randomised controlled trial allocated all 12 districts in Inhambane Province in Mozambique to receive iCCM only (control) or iCCM plus the inSCALE technology intervention. Population cross-sectional surveys were conducted at baseline and after 18 months of intervention implementation in approximately 500 eligible households in randomly selected communities in all districts including at least one child less than 60 months of age where the main caregiver was available to assess the impact of the intervention on the primary outcome, the coverage of appropriate treatment for malaria, diarrhoea and pneumonia in children 2-59months of age. Secondary outcomes included the proportion of sick children who were taken to the CHW for treatment, validated tool-based CHW motivation and performance scores, prevalence of cases of illness, and a range of secondary household and health worker level outcomes. All statistical models accounted for the clustered study design and variables used to constrain the randomisation. A meta-analysis of the estimated pooled impact of the technology intervention was conducted including results from a sister trial (inSCALE-Uganda). The study included 2740 eligible children in control arm districts and 2863 children in intervention districts. After 18 months of intervention implementation 68% (69/101) CHWs still had a working inSCALE smartphone and app and 45% (44/101) had uploaded at least one report to their supervising health facility in the last 4 weeks. Coverage of the appropriate treatment of cases of MDP increased by 26% in the intervention arm (adjusted RR 1.26 95% CI 1.12-1.42, p<0.001). The rate of care seeking to the iCCM-trained community health worker increased in the intervention arm (14.4% vs 15.9% in control and intervention arms respectively) but fell short of the significance threshold (adjusted RR 1.63, 95% CI 0.93-2.85, p = 0.085). The prevalence of cases of MDP was 53.5% (1467) and 43.7% (1251) in the control and intervention arms respectively (risk ratio 0.82, 95% CI 0.78-0.87, p<0.001). CHW motivation and knowledge scores did not differ between intervention arms. Across two country trials, the estimated pooled effect of the inSCALE intervention on coverage of appropriate treatment for MDP was RR 1.15 (95% CI 1.08-1.24, p <0.001). The inSCALE intervention led to an improvement in appropriate treatment of common childhood illnesses when delivered at scale in Mozambique. The programme will be rolled out by the ministry of health to the entire national CHW and primary care network in 2022-2023. This study highlights the potential value of a technology intervention aimed at strengthening iCCM systems to address the largest causes of childhood morbidity and mortality in sub-Saharan Africa.

Improving community health worker treatment for malaria, diarrhoea, and pneumonia in Uganda through inSCALE community and mHealth innovations: A cluster randomised controlled trial.

The inSCALE cluster randomised controlled trial in Uganda evaluated two interventions, mHealth and Village Health Clubs (VHCs) which aimed to improve Community Health Worker (CHW) treatment for malaria, diarrhoea, and pneumonia within the national Integrated Community Case Management (iCCM) programme. The interventions were compared with standard care in a control arm. In a cluster randomised trial, 39 sub-counties in Midwest Uganda, covering 3167 CHWs, were randomly allocated to mHealth; VHC or usual care (control) arms. Household surveys captured parent-reported child illness, care seeking and treatment practices. Intention-to-treat analysis estimated the proportion of appropriately treated children with malaria, diarrhoea, and pneumonia according to WHO informed national guidelines. The trial was registered at ClinicalTrials.gov (NCT01972321). Between April-June 2014, 7679 households were surveyed; 2806 children were found with malaria, diarrhoea, or pneumonia symptoms in the last one month. Appropriate treatment was 11% higher in the mHealth compared to the control arm (risk ratio [RR] 1.11, 95% CI 1.02, 1.21; p = 0.018). The largest effect was on appropriate treatment for diarrhoea (RR 1.39; 95% CI 0.90, 2.15; p = 0.134). The VHC intervention increased appropriate treatment by 9% (RR 1.09; 95% CI 1.01, 1.18; p = 0.059), again with largest effect on treatment of diarrhoea (RR 1.56, 95% CI 1.04, 2.34, p = 0.030). CHWs provided the highest levels of appropriate treatment compared to other providers. However, improvements in appropriate treatment were observed at health facilities and pharmacies, with CHW appropriate treatment the same across the arms. The rate of CHW attrition in both intervention arms was less than half that of the control arm; adjusted risk difference mHealth arm -4.42% (95% CI -8.54, -0.29, p = 0.037) and VHC arm -4.75% (95% CI -8.74, -0.76, p = 0.021). Appropriate treatment by CHWs was encouragingly high across arms. The inSCALE mHealth and VHC interventions have the potential to reduce CHW attrition and improve the care quality for sick children, but not through improved CHW management as we had hypothesised. Trial Registration:ClinicalTrials.gov (NCT01972321).

Integrated community case management of childhood illnesses; impact on training of community health workers in Vandeikya, North-East Zone of Benue State, Nigeria

Community health workers appropriately trained on Integrated Community Case Management (ICCM) of childhood illnesses can correctly treat children below 5 years who have pneumonia, diarrhoea and malaria. In Benue State, Nigeria, primary healthcare workers care for most children at community level, as such they need to be trained on ICCM. The objective of this study was to find out if training of primary healthcare workers in Vandeikya, North-East Zone of Benue State can improve their knowledge on ICCM. In Benue North-East, Vandeikya Local Government Area (LGA) was randomly selected out of seven LGAs. Health Officers’ in-charge of 30 Primary HealthCare Clinics were selected and trained based on our adapted ICCM training manual. The Pre- and Post-training assessment test for this study was designed based on the training manual. Paired sample t-test was conducted to find out if there was any significant difference in the knowledge of primary health care workers before and after receiving training. There was statistical difference in pre-training scores (X = 142.100, S1 = 25.925) and post-training scores (X =177.600, S2 =13.587) at (t=6.643, P=0.000). This result strongly indicated that the teaching intervention has improved the knowledge of the Primary Health Care workers on ICCM in Vandeikya LGA.

Quality of sick child management by health extension workers: role of a complex improvement intervention

BackgroundDespite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers.MethodsThe study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers’ consultations of sick 2–59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses.ResultsWe observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention.ConclusionThe intervention was not associated with improved quality of the health extension workers’ management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities.Trial registration numberISRCTN12040912, retrospectively registered on 19/12/ 2017.

Setting a research agenda to advance maternal, newborn, and child health in Ethiopia: An adapted CHNRI prioritization exercise.

Critical to the improvement of maternal, newborn, and child health (MNCH) in Ethiopia - where 14 000 mothers die from pregnancy-, childbirth-, or postpartum-related complications each year - is high-quality research and its effective translation into policy and practice. While Ethiopia has rapidly expanded the number of institutions that train and conduct MNCH research, the absence of a shared research agenda inhibits a coordinated approach to inform critical MNCH policy needs. The HaSET Maternal and Child Health Research Program (MCHRP) conducted a mixed methods formative assessment and prioritization exercise to guide investments in future MNCH research in Ethiopia. We adapted the Child Health and Nutrition Research Initiative (CHNRI) method, soliciting 56 priority research questions via key informant interviews. Through an online survey, experts scored these on their ability to generate new, actionable evidence that could inform more effective and equitable MNCH programs in Ethiopia. At a workshop in Addis Ababa, experts scored the questions by answerability and ethics, usefulness, disease burden reduction, and impact on equity. Research priority scores were calculated for both the online survey and workshop scoring and averaged to attain a ranked priority list. We validated and contextualized the results by conducting consensus-building discussions with MNCH experts and two community workshops. In total, approximately 100 participants were involved. Average research priority scores ranged from 58.4 to 83.7 out of 100.0. The top identified research priorities speak to critical needs in the Ethiopian context: to improve population coverage of proven interventions like integrated community case management (ICCM), family integrated newborn care, and kangaroo mother care (KMC); to better understand the determinants of outcomes like home deliveries, immunization drop-out, and antenatal and postpartum care-seeking; and to strengthen health system and workforce capabilities. This exercise expanded on the CHNRI methodology by comparing prioritization across different audiences, formats, and criteria. Agreement between both scoring rounds and consensus-building discussions was strong, demonstrating the reliability of the CHNRI method. By sharing this research priority list broadly among researchers, practitioners, and donors, we aim to improve coordinated MNCH evidence generation and translation into policy in Ethiopia.