Baseline malaria prevalence and care-seeking behaviours in rural Madagascar prior to a trial to expand malaria community case management to all ages

Background Integrated community case management of malaria, pneumonia, and diarrhoea can reduce mortality in children under five years (CU5) in resource-poor countries. There is growing interest in expanding malaria community case management (mCCM) to older individuals, but limited empirical evidence exists to guide this expansion. As part of a two-year cluster-randomized trial of mCCM expansion to all ages in southeastern Madagascar, a cross-sectional survey was conducted to assess baseline malaria prevalence and healthcare-seeking behaviours. Methods Two enumeration areas (EAs) were randomly chosen from each catchment area of the 30 health facilities (HFs) in Farafangana district designated for the mCCM age expansion trial; 28 households were randomly selected from each EA for the survey. All household members were asked about recent illness and care-seeking, and malaria prevalence was assessed by rapid diagnostic test (RDT) among children < 15 years of age. Weighted population estimates and Rao-Scott chi-squared tests were used to examine illness, care-seeking, malaria case management, and malaria prevalence patterns. Results Illness in the two weeks prior to the survey was reported by 459 (6.7%) of 8050 respondents in 334 of 1458 households surveyed. Most individuals noting illness (375/459; 82.3%) reported fever. Of those reporting fever, 28.7% (112/375) sought care; this did not vary by participant age (p = 0.66). Most participants seeking care for fever visited public HFs (48/112, 46.8%), or community healthcare volunteers (CHVs) (40/112, 31.0%). Of those presenting with fever at HFs or to CHVs, 87.0% and 71.0%, respectively, reported being tested for malaria. RDT positivity among 3,316 tested children < 15 years was 25.4% (CI: 21.5–29.4%) and increased with age: 16.9% in CU5 versus 31.8% in 5–14-year-olds (p < 0.0001). Among RDT-positive individuals, 28.4% of CU5 and 18.5% of 5–14-year-olds reported fever in the two weeks prior to survey (p = 0.044). Conclusions The higher prevalence of malaria among older individuals coupled with high rates of malaria testing for those who sought care at CHVs suggest that expanding mCCM to older individuals may substantially increase the number of infected individuals with improved access to care, which could have additional favorable effects on malaria transmission.

Cost-effectiveness analysis of integrated community case management delivery models utilizing drug sellers and community health workers for treatment of under-five febrile cases of malaria, pneumonia, diarrhoea in rural Uganda

Background Malaria, pneumonia and diarrhoea continue to be the leading causes of death in children under the age of five years (U5) in Uganda. To combat these febrile illnesses, integrated community case management (iCCM) delivery models utilizing community health workers (CHWs) or drug sellers have been implemented. The purpose of this study is to compare the cost-effectiveness of delivering iCCM interventions via drug sellers versus CHWs in rural Uganda. Methods This study was a cost-effectiveness analysis to compare the iCCM delivery model utilizing drug sellers against the model using CHWs. The effect measure was the number of appropriately treated U5 children, and data on effectiveness came from a quasi-experimental study in Southwestern Uganda and the inSCALE cross-sectional household survey in eight districts of mid-Western Uganda. The iCCM interventions were costed using the micro-costing (ingredients) approach, with costs expressed in US dollars. Cost and effect data were linked together using a decision tree model and analysed using the Amua modelling software. Results The costs per 100 treated U5 children were US$591.20 and US$298.42 for the iCCM trained-drug seller and iCCM trained-CHW models, respectively, with 30 and 21 appropriately treated children in the iCCM trained-drug seller and iCCM trained-CHW models. When the drug seller arm (intervention) was compared to the CHW arm (control), an incremental effect of 9 per 100 appropriately treated U5 children was observed, as well as an incremental cost of US$292.78 per 100 appropriately treated children, resulting in an incremental cost-effectiveness ratio (ICER) of US$33.86 per appropriately treated U5 patient. Conclusion Since both models were cost-effective compared to the do-nothing option, the iCCM trained-drug seller model could complement the iCCM trained-CHW intervention as a strategy to increase access to quality treatment.

A feasibility study to assess non-clinical community health workers’ capacity to use simplified protocols and tools to treat severe acute malnutrition in Niger state Nigeria

Background Severe acute malnutrition (SAM) is a major determinant of childhood mortality and morbidity. Although integrated community case management (iCCM) of childhood illnesses is a strategy for increasing access to life-saving treatment, malnutrition is not properly addressed in the guidelines. This study aimed to determine whether non-clinical Community Health Workers (called Community-Oriented Resource Persons, CORPs) implementing iCCM could use simplified tools to treat uncomplicated SAM. Methods The study used a sequential multi-method design and was conducted between July 2017 and May 2018. Sixty CORPs already providing iCCM services were trained and deployed in their communities with the target of enrolling 290 SAM cases. Competency of CORPs to treat and the treatment outcomes of enrolled children were documented. SAM cases with MUAC of 9 cm to < 11.5 cm without medical complications were treated for up to 12 weeks. Full recovery was at MUAC≥12.5 cm for two consecutive weeks. Supervision and quantitative data capturing were done weekly while qualitative data were collected after the intervention. Results CORPs scored 93.1% on first assessment and increment of 0.11 (95% CI, 0.05–0.18) points per additional supervision conducted. The cure rate from SAM to full recovery, excluding referrals from the denominator in line with the standard for reporting SAM recovery rates, was 73.5% and the median length of treatment was 7 weeks. SAM cases enrolled at 9 cm to < 10.25 cm MUAC had 31% less likelihood of recovery compared to those enrolled at 10.25 cm to < 11.5 cm. CORPs were not burdened by the integration of SAM into iCCM and felt motivated by children’s recovery. Operational challenges like bad terrains for supervision, supply chain management and referrals were reported by supervisors, while Government funding was identified as key for sustainability. Conclusion The study demonstrated that with training and supportive supervision, CORPs in Nigeria can treat SAM among under-fives, and refer complicated cases using simplified protocols as part of an iCCM programme. This approach seemed acceptable to all stakeholders, however, the effect of the extra workload of integrating SAM into iCCM on the quality of care provided by the CORPs should be assessed further.

Malaria Care-Seeking and Treatment Ideation among Gold Miners in Guyana

Background Although miners are a priority population in malaria elimination in Guyana, scant literature exists on the drivers of malaria-related behaviour. This study explores the relationship between gold miners’ malaria-related ideation and the adoption of malaria care-seeking and treatment behaviours including prompt care-seeking, malaria testing, and self-medication. Methods Data are from a cross-sectional quantitative survey of 1685 adult miners between the ages of 18–59 years who live in mining camps in Regions 1, 7, and 8. The analysis focused on miners who reported an episode of fever in the past year (n = 745). Malaria care-seeking and treatment ideation was defined as a composite additive score consisting of the following variables: general malaria knowledge, perceived severity, perceived susceptibility, beliefs, perceived self-efficacy, perceived norms, interpersonal communication, and perceived response efficacy. Multivariable logistic regressions explored the relationship between ideation on care-seeking/treatment behaviours, controlling for confounding variables. Results Most miners with a recent episode of fever had perceived risk (92%), self-efficacy (67%), susceptibility (53%) and high malaria knowledge (53%). Overall, miners' care-seeking/treatment ideation score ranged from 0 to 8 with a mean of 4.1. Ideation scores were associated with higher odds of care-seeking for fever (aOR:1.19; 95% CI: 1.04–1.36), getting tested for malaria (aOR: 1.22; 95% CI: 1.07–1.38) and lower odds of self-medication (aOR: 0.87; 95% CI: 0.77–0.99). Conclusions A national community case management initiative is using study findings as part of its scale-up, using volunteers to make testing and treatment services more accessible to miners. This is complemented by a multi-channel mass media campaign to improve miners’ ideation. Communication messages focus on increasing miners’ knowledge of malaria transmission and symptoms, encourage positive beliefs about malaria testing and volunteer testers, promote evidence about the effectiveness of testing, and reminders of how quick and easy it is to get a malaria test with the community case management initiative. Study findings also have implications for efforts to eliminate malaria across the Guiana Shield.

Facilitators and Barriers To The Integration of Integrated Community Case Management Into The Health System in Zambia: A Case Study of Kapiri Mposhi District

Background Zambia adopted the Integrated Community Case Management of childhood illness (ICCM) strategy in May 2010, targeting populations in rural communities and hard-to-reach areas. However, evidence suggests that ICCM integration into local health systems has been suboptimal, particularly at the district level. This study sought to explore factors that shape ICCM integration into the district health system in Kapiri Mposhi district, Zambia. Methods Data were gathered through 19 key informant interviews with district health managers, ICCM supervisors, health facility managers, and district health co-operating partners. The study was conducted in Kapiri Mposhi district, Zambia. Interviews were translated and transcribed verbatim. Data were were analyzed using thematic analysis in NVivo 11(QSR International). Results Facilitators to intergration of ICCM into the health system consisted of community involvement and support for the program, active community case detection and timeliness of health services, the program was not considered a significant shift from other community-based health interventions, district leadership and ownership of the program, availability of national and district-level policies supporting ICCM and engagement of international co-operating partners. Program incompatibility with some socio-cultural and religious cotexts, stock-out of prerequisite drugs and supplies, staff reshuffle and redeployment, inadequate supervision of health facilities, and nonpayment of community health worker incentives inhibited intergration of ICCM into the health system. Conclusion The study findings highlight key faciliators and barriers that should be considered by policy-makers, district health managers, ICCM supervisors, health facility managers, and co-operating partners, in designing context-specific implementation strategies, to ensure full integration of ICCM into the health system.

Implementation of community case management of malaria in malaria endemic counties of western Kenya: are community health volunteers up to the task in diagnosing malaria?

BackgroundCommunity case management of malaria (CCMm) is an equity-focused strategy that complements and extends the reach of health services by providing timely and effective management of malaria to populations with limited access to facility-based healthcare. In Kenya, CCMm involves the use of malaria rapid diagnostic tests (mRDT) and treatment of confirmed uncomplicated malaria cases with artemether lumefantrine (AL) by community health volunteers (CHVs). The test positivity rate (TPR) from CCMm reports collected by the Ministry of Health in 2018 was twofold compared to facility-based reports for the same period. This necessitated the need to evaluate the performance of CHVs in conducting malaria RDTs.MethodThe study was conducted in four counties within the malaria lake endemic zone in Kenya with a malaria prevalence in 2018 of 27%; the national prevalence of malaria was 8%. Multi-stage cluster sampling and random selection were used. Results from 200 malaria RDTs performed by CHVs were compared with test results obtained by experienced medical laboratory technicians (MLT) performing the same test under the same conditions. Blood slides prepared by the MLTs were examined microscopically later as a backup check of the results. A kappa score was calculated to assess level of agreement. Sensitivity, specificity, positive and negative predictive values were calculated to determine diagnostic accuracy.ResultsThe median age of CHVs was 46 (IQR: 38, 52) with a range [26, 73] years. Females were 72% of the CHVs. Test positivity rates for MLTs was 42% and for CHVs was 41%. The kappa score was 0.89 indicating an almost perfect agreement in mRDT results between CHVs and MLTs. The overall sensitivity and specificity between the CHVs and MLTs were 95.0% (95% CI: (87.7, 98.6) and 94.0% (95% CI; 88.0, 97.5) respectively.ConclusionEngaging CHVs to diagnose malaria cases under CCMm yielded results which compared well with results of qualified experienced laboratory personnel. CHVs can reliably continue to offer malaria diagnosis in the community setting.

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.

Community-based amoxicillin treatment for fast breathing pneumonia in young infants 7–59 days old: a cluster randomised trial in rural Bangladesh, Ethiopia, India and Malawi

IntroductionYoung infants 7–59 days old with fast breathing pneumonia presented to a primary level health facility receive a 7-day course of amoxicillin as per the WHO guideline. However, community-level health workers (CLHW) are not allowed to treat these infants. This trial evaluated the community level treatment of non-hypoxaemic young infants with fast breathing pneumonia by CLHWs.MethodsThis cluster-randomised, open-label, non-inferiority trial was conducted in rural areas of Bangladesh, Ethiopia, India and Malawi. We randomly allocated clusters (first-level health facility) 1:1, stratified by the population size, to an intervention group (enhanced community case management) or control group (standard community case management). Infants aged 7–59 days with a respiratory rate of ≥60 breaths/min and oxygen saturation (SpO2) ≥90% were enrolled. In the intervention clusters, these infants were treated with a 7-day course of oral amoxicillin (according to WHO weight bands) and were regularly followed up by CLHWs. In the control clusters, CLHWs continued the standard management (assess and refer after pre-referral antibiotic dose) and followed up according to the national programme guideline. The primary outcome of treatment failure was assessed in both groups by independent outcome assessors on days 6 and 14 after enrolment. Secondary outcomes (accuracy and impact of pulse oximetry) were also assessed.ResultsBetween September 2016 and December 2018, we enrolled 2334 infants (1168 in intervention and 1166 in control clusters) from 208 clusters (104 intervention and 104 control). Of 2334, 22 infants with fast breathing were excluded from analysis, leaving 2312 (1155 in intervention clusters and 1157 in control clusters) for intention-to-treat analysis. The proportion of treatment failure was 5.4% (63/1155) in intervention and 6.3% (73/1157) in the control clusters, including two deaths (0.2%) in each group. The adjusted risk difference for treatment failure between the two groups was −1.0% (95% CI −3.0% to 1.1%). The secondary outcome showed that CLHWs in the intervention clusters performed all recommended steps of pulse oximetry assessment in 94% (1050/1115) of enrolled patients.ConclusionsThe 7-day amoxicillin treatment for 7–59 days old non-hypoxaemic infants with fast breathing pneumonia by CLHWs was non-inferior to the currently recommended referral strategy.Trial registration numbersCTRI/2017/02/007761 and ACTRN12617000857303.

Determinants of quality in home-based management of malaria by community health volunteers in rural Kenya

Introduction: Kenya adopted the World Health Organization’s recommendation of community case management of malaria (CCMM) in 2012. Trained community health volunteers (CHVs) provide CCMM but information on quality of services is limited. This study aimed to establish determinants of quality of service of CCMM conducted by CHVs. Methodology: A cross-sectional survey was conducted in November 2016 in Bungoma County, Kenya. Data were collected through observing CHVs perform routine CCMM and through interviews of CHVs using structured questionnaires. A ≥ 75% score was considered as quality provision. Descriptive statistics were performed to describe basic characteristics of the study, followed by Chi-Square test and binary logistic regression to examine the differences and associations between the categorical variables. Results: A total of 147 CHVs participated; 62% of CHVs offered quality services. There was a direct association between quality of services and stock-outs of artemether-lumefantrine (AL), stock-outs of malaria rapid diagnostic tests (RDT) and support supervision. CHVs who were supervised during the year preceding the assessment were four times more likely to perform better than those not supervised (uOR 4.2, 95% CI: 1.38-12.85). CHVs with reliable supplies of AL and RDT kits performed three times better than those who experienced stock outs (uOR = 3.2, 95% CI: 1.03-10.03 and 3.3, 95% CI: 1.63-6.59 respectively). Biosafety and documentation were the most poorly performed. Conclusions: The majority of CHVs offered quality CCMM services despite safety gaps. Safety, continuous supplies of RDT, AL and supervision are essential for quality performance by CHV in delivering CCMM.