Integrated community case management of malaria and pneumonia in eastern Uganda : care-seeking, adherence, and community health worker performance

Background: Despite being easily preventable and treatable, malaria and pneumonia are major killers of children aged less than five years. Integrated community based interventions through which lay persons called community health workers (CHWs) can manage malaria, pneumonia, diarrhea and neonatal conditions are recommended by WHO and UNICEF. However, there is limited information on care-seeking and performance of CHWs in the context of integrated illness management. Main aim: To assess care-seeking and quality of care in integrated community case management of malaria and pneumonia in children aged less than five years in Uganda so as to inform the implementation of integrated community case management of childhood illness strategy (ICCM). Methods: Four studies (I-IV) were nested in a cluster randomized trial in Iganga-Mayuge demographic surveillance site in eastern Uganda. In this trial CHWs treated malaria and pneumonia (intervention arm) or malaria alone (control arm) in children aged 4-59 months. Performance of CHWs (I) was assessed using: questionnaires (with knowledge tests, case scenarios) and record reviews for 125 CHWs; observations among 57 CHWs in the intervention arm; and four focus group discussions with CHWs. Adherence to treatment was assessed using pill counts and caregiver reports among 1256 children treated by CHWs (II). Receipt of prompt and appropriate antibiotics for pneumonia symptoms and treatment outcomes were assessed among 1276 children treated by CHWs (III). Care-seeking and management of malaria and pneumonia were assessed among 1095 children and from 13 key informant interviews (IV). Results: Care-seeking from CHWs was higher in the intervention than the control arm (31% vs 22%, p=0.01) (IV). CHWs’ performance on malaria symptoms was similar in the intervention and control arms on: overall knowledge, eliciting signs and symptoms, and prescribing (I). More children treated by CHWs received prompt and appropriate malaria treatment compared to other health providers (37% vs 9%, p<0.001) (IV). CHWs had high scores in prescribing for pneumonia but had lower: overall knowledge of pneumonia (40%), and scores on eliciting pneumonia signs and symptoms (25%). Only 35% of CHWs counted respiratory rates within two breaths of rates counted by the physician, and 12% of children without fast breathing received antibiotics while 82% with fast breathing received antibiotics (I). Children treated by CHWs in the intervention arm were more likely to receive prompt and appropriate antibiotics for pneumonia symptoms compared to the control arm (RR=3.51, 95% CI = 1.75-7.03) (III). There was also a higher reduction in the proportion of children with fast breathing from day one to day four in the intervention compared to the control arm (9.2% vs 4.2%, p=0.01); and a lower proportion of febrile children on day four (1% vs 4%; RR=0.29, 95% CI = 0.11-0.78) (III). Adherence to combined antimalarials and antibiotics was similar to adherence to antimalarials alone in the intervention arm (mean 99% both groups) (II). Conclusions: CHWs’ performance on malaria was not affected by additional roles of pneumonia management, but they had challenges in assessment of pneumonia symptoms. CHWs should be supported with continued training, adequate supervision and provision of drugs, diagnostics and other supplies

Appointment keeping for medical review among patients with selected chronic diseases in an urban area of Uganda

Introduction: proper management of chronic diseases is important for prevention of disease   complications and yet some patients miss appointments for medical review thereby missing the   opportunity for proper monitoring of their disease conditions. There is limited information on missed  appointments among chronic disease patients in resource limited settings. This study aimed to   determine the prevalence of missed appointments for medical review and associated factors among  chronic disease patients in an urban area of Uganda.Methods: patients or caregivers of children with chronic diseases were identified as they bought  medicines from a community pharmacy. They were visited at home to access their medical documents  and those whose chronic disease status was ascertained were enrolled. The data was collected using: questionnaires, review of medical documents, and in-depth interviews with chronic disease patients. Results: the prevalence of missed appointments was 42% (95%CI=35-49%). The factors associated with missed appointments were: monthly income ?30US Dollars (OR=2.56, CI=1.25–5.26), affording less than half of prescribed drugs (OR=3.92, CI=1.64–9.40), not experiencing adverse events (OR=2.66, CI=1.26–5.61), not sure if treatment helps (OR=2.84, CI=1.047.77), not having a medicines   administration schedule (OR=6.77, CI=2.11–21.68), and increasing number of drugs (OR=0.72,  CI=0.53–0.98).Conclusion: patients missed appointments mainly due to: financial and health system barriers,  conflicting commitments with appointments, and perceptions of the disease condition. Patients should be supported with accessible and affordable health servicesKey words: Chronic disease, medical review appointments, missed appointment

Appointment keeping for medical review among patients with selected chronic diseases in an urban area of Uganda

INTRODUCTION: Proper management of chronic diseases is important for prevention of disease complications and yet some patients miss appointments for medical review thereby missing the opportunity for proper monitoring of their disease conditions. There is limited information on missed appointments among chronic disease patients in resource limited settings. This study aimed to determine the prevalence of missed appointments for medical review and associated factors among chronic disease patients in an urban area of Uganda. METHODS: Patients or caregivers of children with chronic diseases were identified as they bought medicines from a community pharmacy. They were visited at home to access their medical documents and those whose chronic disease status was ascertained were enrolled. The data was collected using: questionnaires, review of medical documents, and in-depth interviews with chronic disease patients. RESULTS: The prevalence of missed appointments was 42% (95%CI = 35-49%). The factors associated with missed appointments were: monthly income ≤30US Dollars (OR = 2.56, CI = 1.25–5.26), affording less than half of prescribed drugs (OR = 3.92, CI = 1.64–9.40), not experiencing adverse events (OR = 2.66, CI = 1.26–5.61), not sure if treatment helps (OR = 2.84, CI = 1.047.77), not having a medicines administration schedule (OR = 6.77, CI = 2.11–21.68), and increasing number of drugs (OR = 0.72, CI = 0.53–0.98). CONCLUSION: Patients missed appointments mainly due to: financial and health system barriers, conflicting commitments with appointments, and perceptions of the disease condition. Patients should be supported with accessible and affordable health services

Integrated community case management by drug sellers influences appropriate treatment of paediatric febrile illness in South Western Uganda : a quasi-experimental study.

BACKGROUND: Fever case management is a major challenge for improved child health globally, despite existence of cheap and effective child survival health technologies. The integrated Community Case Management (iCCM) intervention of paediatric febrile illnesses though adopted by Uganda's Ministry of Health to be implemented by community health workers, has not addressed the inaccess to life-saving medicines and diagnostics. Therefore, the iCCM intervention was implemented in private drug shops and evaluated for its effect on appropriate treatment of paediatric fever in a low malaria transmission setting in South Western Uganda. METHODS: From June 2013 to September 2015, the effect of the iCCM intervention on drug seller paediatric fever management and adherence to iCCM guidelines was assessed in a quasi-experimental study in South Western Uganda. A total of 212 care-seeker exit interviews were done before and 285 after in the intervention arm as compared to 216 before and 268 care-seeker interviews at the end of the study period in the comparison arm. The intervention effect was assessed by difference-in-difference analysis of drug seller treatment practices against national treatment recommendations between the intervention and comparison arms. Observed proportions among care-seeker interviews were compared with corresponding proportions from 5795 child visits recorded in patient registries and 49 direct observations of drug seller-care-seeker encounters in intervention drug shops. RESULTS: The iCCM intervention increased the appropriate treatment of uncomplicated malaria, pneumonia symptoms and non-bloody diarrhoea by 80.2% (95% CI 53.2-107.2), 65.5% (95% CI 51.6-79.4) and 31.4% (95% CI 1.6-61.2), respectively. Within the intervention arm, drug seller scores on appropriate treatment for pneumonia symptoms and diagnostic test use were the same among care-seeker exit interviews and direct observation. A linear trend (negative slope, - 0.009 p value &lt; 0.001) was observed for proportions of child cases prescribed any antimicrobial medicine in the intervention arm drug shops. CONCLUSIONS: The iCCM intervention improved appropriate treatment for uncomplicated malaria, pneumonia symptoms and diarrhoea. Drug seller adherence to iCCM guidelines was high, without causing excessive prescription of antimicrobial medicines in this study. Further research should assess whether this effect is sustained over time and under routine supervision models

A Qualitative Exploration of the Referral Process of Children with Common Infections from Private Low-Level Health Facilities in Western Uganda

Over 50% of sick children are treated by private primary-level facilities, but data on patient referral processes from such facilities are limited. We explored the perspectives of healthcare providers and child caretakers on the referral process of children with common childhood infections from private low-level health facilities in Mbarara District. We carried out 43 in-depth interviews with health workers and caretakers of sick children, purposively selected from 30 facilities, until data saturation was achieved. The issues discussed included the process of referral, challenges in referral completion and ways to improve the process. We used thematic analysis, using a combined deductive/inductive approach. The reasons for where and how to refer were shaped by the patients’ clinical characteristics, the caretakers’ ability to pay and health workers’ perceptions. Caretaker non-adherence to referral and inadequate communication between health facilities were the major challenges to the referral process. Suggestions for improving referrals were hinged on procedures to promote caretaker adherence to referral, including reducing waiting time and minimising the expenses incurred by caretakers. We recommend that triage at referral facilities should be improved and that health workers in low-level private health facilities (LLPHFs) should routinely be included in the capacity-building trainings organised by the Ministry of Health (MoH) and in workshops to disseminate health policies and national healthcare guidelines. Further research should be done on the effect of improving communication between LLPHFs and referral health facilities by affordable means, such as telephone, and the impact of community initiatives, such as transport vouchers, on promoting adherence to referral for sick children

Capacity to provide care for common childhood infections at low-level private health facilities in Western, Uganda

BACKGROUND: Low-level private health facilities (LLPHFs) handle a considerable magnitude of sick children in low-resource countries. We assessed capacity of LLPHFs to manage malaria, pneumonia, diarrhea, and, possible severe bacterial infections (PSBIs) in under-five-year-olds. METHODS: We conducted a cross-sectional survey in 110 LLPHFs and 129 health workers in Mbarara District, Uganda between May and December 2019. Structured questionnaires and observation forms were used to collect data on availability of treatment guidelines, vital medicines, diagnostics, and equipment; health worker qualifications; and knowledge of management of common childhood infections. RESULTS: Amoxicillin was available in 97%, parental ampicillin and gentamicin in 77%, zinc tablets and oral rehydration salts in >90% while artemether-lumefantrine was available in 96% of LLPHF. About 66% of facilities stocked loperamide, a drug contraindicated in the management of diarrhoea in children. Malaria rapid diagnostic tests and microscopes were available in 86% of the facilities, timers/clocks in 57% but only 19% of the facilities had weighing scales and 6% stocked oxygen. Only 4% of the LLPHF had integrated management of childhood illness (IMCI) booklets and algorithm charts for management of common childhood illnesses. Of the 129 health workers, 52% were certificate nurses/midwives and (26% diploma nurses/clinical officers; 57% scored averagely for knowledge on management of common childhood illnesses. More than a quarter (38%) of nursing assistants had low knowledge scores. No notable significant differences existed between rural and urban LLPHFs in most parameters assessed. CONCLUSION: Vital first-line medicines for treatment of common childhood illnesses were available in most of the LLPHFs but majority lacked clinical guidelines and very few had oxygen. Majority of health workers had low to average knowledge on management of the common childhood illnesses. There is need for innovative knowledge raising interventions in LLPHFs including refresher trainings, peer support supervision and provision of job aides