Coaching Community Health Volunteers in Integrated Community Case Management Improves the Care of Sick Children Under-5: Experience from Bondo, Kenya

Factors influencing community-facility linkage for case management of possible serious bacterial infections among young infants in Kenya

Despite evidence showing the feasibility and acceptability of implementing the World Health Organization's guidelines on managing possible serious bacterial infection (PSBI) in Kenya, the initial implementation revealed sub-optimal community-facility referrals and follow-up of PSBI cases. This study explores facilitators and barriers of community-facility linkages in implementing PSBI guidelines in Busia and Migori counties, Kenya. We used an exploratory qualitative study design drawing on endline evaluation data from the 'COVID-19: Mitigating Neonatal Mortality' project collected between June and July 2022. Data include case narratives with caregivers of sick young infants (0-59 days old) (18), focus group discussions with community health volunteers (CHVs) (6), and in-depth interviews with facility-based providers (18). Data were analysed using an inductive thematic analysis framework. Between August 2021 and July 2022, CHVs assessed 10 187 newborns, with 1176 (12%) identified with PSBI danger signs and referred to the nearest facility, of which 820 (70%) accepted referral. Analysis revealed several factors facilitating community-facility linkage for PSBI treatment, including CHVs' relationship with community members and facilities, availability of a CHV desk and tools, use of mobile app, training and supportive supervision. However, challenges such as health system-related factors (inadequate providers, stockout of essential commodities and supplies, and lack of transport/ambulance) and individual-related factors (caregivers' refusal to take referrals) hindered community-facility linkage. Addressing common barriers and fostering positive relationships between community health workers and facilities can enhance acceptance and access to PSBI services at the community level. Combining community health workers' efforts with a mobile digital strategy can improve the efficiency of the identification, referral and tracking of PSBI cases in the community and facilitate linkage with primary healthcare facilities.

Effect of a Short Course on Improving the Cadres' Knowledge in the Context of Reducing Stunting through Home Visits in Yogyakarta, Indonesia

Background: Stunting is primarily a public health concern in Low- and Middle-Income Countries (LMIC). The involvement of Integrated Health Service Post (Indonesian: Posyandu) cadres is among the strategies to combat stunting in Indonesia. Objective: This study aimed to determine the effect of a short course on cadres' knowledge. Method: A single group pre-test post-test design was conducted in Yogyakarta, Indonesia, from March to May 2022. Thirty cadres were selected based on the following criteria: willingness to participate, the number of stunted children in their Posyandu, able to read and write, and full attendance at the short course. The knowledge scores were measured by a questionnaire using true and false answers after a short course (post-test 1) and 4 weeks later (post-test 2). We apply STATA 16 to calculate the Mean Difference (MD) using a t-test and a Generalized Estimated Equation (GEE). Furthermore, the adequacy of the short course was evaluated with in-depth interviews. Result: GEE analysis showed that after controlling for age, education, occupation, and years of experience, the short course improved cadres' knowledge significantly on post-tests 1 and 2, i.e., knowledge regarding Children Growth Monitoring (CGM) (Beta = 6.07, 95%CI: 5.10-7.03 and Beta = 8.57, 95%CI: 7.60-9.53, respectively), Children Development Monitoring (CDM) (Beta = 6.70, 95%CI: 5.75-7.65 and Beta = 9.27, 95%CI: 8.31-10.22, respectively), and Infant Young Children Feeding (IYCF) (Beta = 5.83, 95%CI: 4.44-7.23 and Beta = 11.7, 95%CI: 10.31-13.09, respectively). Furthermore, the short course increased their self-efficacy, confidence, and ability to assist stunted children through home visits. Conclusion: The short courses consistently and significantly boosted cadres' knowledge of CGM, CDM, and IYCF, and appropriately facilitated cadres in visits to the homes of stunted children's home.

Changing Perceptions of Rural Frontline Workers and Caregivers About Management of Childhood Diarrhea and Pneumonia Despite Several Inequities: The Nigraan Plus Trial in Pakistan

Purpose

Diarrhea and pneumonia greatly contribute to high childhood mortality in Pakistan. Frontline community health workers or the Lady Health Workers (LHWs) provide care at the doorstep of over 60% of Pakistan’s rural residents. Difficult terrain, lack of supplies, and inadequate supervision put these LHWs at an added disadvantage in the timely diagnosis and delivery of known treatment options to community caregivers (CCGs). This study aims to assess whether a supportive supervision intervention through Lady Health Supervisors (LHSs) using enhanced mentorship and written feedback cards have the potential to improve case management of childhood diarrhea and pneumonia.

Study Setting and Design

This perception-based qualitative inquiry nested within the Nigraan Plus trial included LHSs, LHWs, and CCGs as the participants. Twenty-two in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were conducted before a supportive supervision intervention in 2017, and 10 FGDs were conducted in 2019 once the intervention concluded. Data were analyzed using manual content analysis.

Results

The perceived ability of LHWs and LHSs to describe the danger signs of diarrhea and pneumonia, classify dehydration and relate respiratory rate to the severity of pneumonia improved over time. Appropriate prescription of zinc in diarrhea and antibiotics in pneumonia was noted. Furthermore, CCGs’ trust in LHWs increased following the intervention, and they reported a growing inclination to contact LHWs as their first point of care. LHWs in the intervention arm were more satisfied with their job due to frequent supervisory visits and continuous feedback by LHSs.

Conclusion

Despite geographic, social, and economic inequities, supportive supervision has the potential to improve knowledge, practice, and skills of frontline health workers related to CCM of childhood diarrhea and pneumonia in disadvantaged rural communities. Additionally, the trust of CCGs in the health workers’ ability to manage such cases is also enhanced.

Does supportive supervision intervention improve community health worker knowledge and practices for community management of childhood diarrhea and pneumonia? Lessons for scale-up from Nigraan and Nigraan Plus trials in Pakistan

BACKGROUND

Lack of programmatic support and supervision is one of the underlying reasons of the poor performance of Pakistan's Lady Health Worker Program (LHWP). This study describes the findings and potential for scale-up of a supportive supervision intervention in two districts of Pakistan for improving LHWs skills for integrated community case management (iCCM) of childhood diarrhea and pneumonia.

METHODS

The intervention comprised an enhanced supervision training to lady health supervisors (LHSs) and written feedback to LHWs by LHSs, implemented in Districts Badin and Mirpur Khas (MPK). Clinical skills of LHWs and LHSs and supervision skills of LHSs were assessed before, during, and after the intervention using structured tools.

RESULTS

LHSs' practice of providing written feedback improved between pre- and mid-intervention assessments in both trials (0% to 88% in Badin and 25% to 75% in MPK) in the study arm. Similarly, supervisory performance of study arm LHSs was better than that in the comparison arm in reviewing the treatment suggested by workers' (94% vs 13% in MPK and 94% vs 69% in Badin) during endline skills assessment in both trials. There were improvements in LHWs' skills for iCCM of childhood diarrhea and pneumonia in both districts. In intervention arm, LHWs' performance for correctly assessing for dehydration (28% to 92% in Badin and 74% to 96% in MPK), and measuring the respiratory rate correctly (12% to 44% in Badin and 46% to 79% in MPK) improved between baseline and endline assessments in both trials. Furthermore, study arm LHWs performed better than those in comparison arm in classifying diarrhea correctly during post-intervention skills assessment (68% vs 40% in Badin and 96% vs 83% in MPK).

CONCLUSION

Supportive supervision including written feedback and frequent supervisor contact could improve the performance of community-based workers in managing diarrhea and pneumonia among children. Positive lessons for provincial scale-up can be drawn. Trial registration Both trials are registered with the 'Australian New Zealand Clinical Trials Registry'. Registration numbers: Nigraan Trial: ACTRN1261300126170; Nigraan Plus: ACTRN12617000309381.

Quality of clinical assessment and management of sick children by Health Extension Workers in four regions of Ethiopia: A cross-sectional survey

BACKGROUND

Care-seeking for sick children at the Ethiopian primary health care level is low. This problem may partly be due to unfavorable community perceptions of the quality of care provided. There is, however, limited knowledge on the quality of the clinical assessment and management provided by the health extension workers at the health posts. This study aimed to examine the quality of clinical assessment, classification and management provided to sick under-five children by health extension workers in four regions of Ethiopia.

METHODS

Clinical observations of 620 consultations of sick children by health extension workers were conducted from December 2016 to February 2017. A clinical pathway analysis was performed to analyze whether sick children were appropriately assessed, classified and managed according to the integrated Community Case Management guidelines.

RESULTS

Most sick children presented with complaints of cough (58%), diarrhea (36%), and fever (26%).Three quarters of children with respiratory complaints had their respiratory rate counted (74%, 95% CI 69-78), while a third (33%, 95% CI 27-40) of children with diarrhea were assessed for dehydration. Half (53%, 95% CI 49-57) of the sick children were assessed for general danger signs, while a majority (89%, 95% CI 86-92) had their arm circumference measured for malnutrition. Half of the sick children received some treatment and less than one-fifth were referred according to the integrated Community Case management guidelines. Comprehensive counseling was provided to 38% (95% CI 35-42) of the caregivers.

CONCLUSION

The Ethiopian health extension workers' clinical assessment, classification and management of sick children did to a large extent not follow the clinical guidelines. This lack of adherence could lead to misdiagnoses and lack of potentially life-saving treatments.