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Quality of sick child care delivered by Health Surveillance Assistants in Malawi.

Gilroy KE, Callaghan-Koru JA, Cardemil CV, Nsona H, Amouzou A, Mtimuni A, Daelmans B, Mgalula L, Bryce J, CCM-Malawi Quality of Care Working Gro - Health Policy Plan (2012)

Bottom Line: HSAs provided correct treatment with antimalarials to 79% of the 241 children presenting with uncomplicated fever, with oral rehydration salts to 69% of the 93 children presenting with uncomplicated diarrhoea and with antibiotics to 52% of 58 children presenting with suspected pneumonia (cough with fast breathing).About one in five children (18%) presented with danger signs.However, HSAs provided sick child care at levels of quality similar to those provided in first-level health facilities in Malawi, and quality should improve if the Ministry of Health and partners act on the results of this assessment.

View Article: PubMed Central - PubMed

Affiliation: Institute for International Programs, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore MD 21205-2103, USA. jbrycedanby@aol.com

ABSTRACT

Objective: To assess the quality of care provided by Health Surveillance Assistants (HSAs)-a cadre of community-based health workers-as part of a national scale-up of community case management of childhood illness (CCM) in Malawi.

Methods: Trained research teams visited a random sample of HSAs (n = 131) trained in CCM and provided with initial essential drug stocks in six districts, and observed the provision of sick child care. Trained clinicians conducted 'gold-standard' reassessments of the child. Members of the survey team also interviewed caregivers and HSAs and inspected drug stocks and patient registers.

Findings: HSAs provided correct treatment with antimalarials to 79% of the 241 children presenting with uncomplicated fever, with oral rehydration salts to 69% of the 93 children presenting with uncomplicated diarrhoea and with antibiotics to 52% of 58 children presenting with suspected pneumonia (cough with fast breathing). About one in five children (18%) presented with danger signs. HSAs correctly assessed 37% of children for four danger signs by conducting a physical exam, and correctly referred 55% of children with danger signs.

Conclusion: Malawi's CCM programme is a promising strategy for increasing coverage of sick child treatment, although there is much room for improvement, especially in the correct assessment and treatment of suspected pneumonia and the identification and referral of sick children with danger signs. However, HSAs provided sick child care at levels of quality similar to those provided in first-level health facilities in Malawi, and quality should improve if the Ministry of Health and partners act on the results of this assessment.

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Clinical pathways analysis Notes:aNumber of cases based on gold-standard clinician classification. bChild was correctly classified if the HSA classification matched the gold-standard clinician’s classification. cChild was treated correctly if he/she was given correct dose, frequency, and duration of first-line antimalarial (ACT) (184 cases; includes children that received one dose of antimalarial and were referred for a reason unrelated to fever (e.g. rash) (7 cases). dIncludes over- and under-dosing of antimalarial (6 cases) and antimalarial for child with fever under 5 months of age (2 cases). eNot treated includes: sick children with uncomplicated fever who did not receive any antimalarial; sick children with cough with fast breathing who did not receive Cotrimoxizole; sick children with diarrhoea who did not receive ORS. fStock-out of both formulations of antimalarial; of 28 fever cases correctly assessed and classified but not treated, 17/28 of HSAs had stock-outs of both antimalarial formulations. gChild was treated correctly if he/she was given correct dose, frequency and duration of Cotrimoxizole. hIncorrect treatment included under-dosing of appropriate medication (3 cases of under-dose for age; 1 case fewer days’ duration and 2 cases incomplete days mentioned). iChild was treated correctly if he/she was given ORS (regardless of amount); zinc was not generally available at the time of assessment and thus not included in correct diarrhoea treatment.
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czs095-F2: Clinical pathways analysis Notes:aNumber of cases based on gold-standard clinician classification. bChild was correctly classified if the HSA classification matched the gold-standard clinician’s classification. cChild was treated correctly if he/she was given correct dose, frequency, and duration of first-line antimalarial (ACT) (184 cases; includes children that received one dose of antimalarial and were referred for a reason unrelated to fever (e.g. rash) (7 cases). dIncludes over- and under-dosing of antimalarial (6 cases) and antimalarial for child with fever under 5 months of age (2 cases). eNot treated includes: sick children with uncomplicated fever who did not receive any antimalarial; sick children with cough with fast breathing who did not receive Cotrimoxizole; sick children with diarrhoea who did not receive ORS. fStock-out of both formulations of antimalarial; of 28 fever cases correctly assessed and classified but not treated, 17/28 of HSAs had stock-outs of both antimalarial formulations. gChild was treated correctly if he/she was given correct dose, frequency and duration of Cotrimoxizole. hIncorrect treatment included under-dosing of appropriate medication (3 cases of under-dose for age; 1 case fewer days’ duration and 2 cases incomplete days mentioned). iChild was treated correctly if he/she was given ORS (regardless of amount); zinc was not generally available at the time of assessment and thus not included in correct diarrhoea treatment.

Mentions: Figures 2a–c present an analysis of clinical steps for children presenting with uncomplicated fever, cough with fast breathing, and diarrhoea, as measured by the gold-standard clinician; these analyses indicate the common errors made by HSAs and the proportion of cases where the absence of essential drugs or a timing device may have influenced the quality of care. Overall, more than 90% of children with uncomplicated fever and diarrhoea were assessed and classified correctly; however, a smaller proportion of children received the appropriate treatment for fever (79%) or diarrhoea (69%) (antimalarials or ORS, respectively). Among children who did not receive treatment for fever, 52% were treated by an HSA who did not have antimalarials on the day of the assessment. Among children who were correctly assessed and classified with diarrhoea who were not treated with ORS, 72% were seen by an HSA who did not have ORS in stock on the day of the assessment. Among children with cough and fast breathing, 70% were correctly assessed; of the 43 children correctly assessed, 70% were correctly classified; only 52% overall were treated correctly with first-line antibiotics. Incorrect classification of cough and fast breathing was largely due to poor counting of respiratory rates by the HSA—only 30% of children with fast breathing had a respiratory rate that was measured within +/−2 breaths per minute of the measurement made by the gold-standard clinician. There were no stock-outs of cotrimoxazole on the day of the assessment where a child with suspected pneumonia was seen.Figure 2a–c


Quality of sick child care delivered by Health Surveillance Assistants in Malawi.

Gilroy KE, Callaghan-Koru JA, Cardemil CV, Nsona H, Amouzou A, Mtimuni A, Daelmans B, Mgalula L, Bryce J, CCM-Malawi Quality of Care Working Gro - Health Policy Plan (2012)

Clinical pathways analysis Notes:aNumber of cases based on gold-standard clinician classification. bChild was correctly classified if the HSA classification matched the gold-standard clinician’s classification. cChild was treated correctly if he/she was given correct dose, frequency, and duration of first-line antimalarial (ACT) (184 cases; includes children that received one dose of antimalarial and were referred for a reason unrelated to fever (e.g. rash) (7 cases). dIncludes over- and under-dosing of antimalarial (6 cases) and antimalarial for child with fever under 5 months of age (2 cases). eNot treated includes: sick children with uncomplicated fever who did not receive any antimalarial; sick children with cough with fast breathing who did not receive Cotrimoxizole; sick children with diarrhoea who did not receive ORS. fStock-out of both formulations of antimalarial; of 28 fever cases correctly assessed and classified but not treated, 17/28 of HSAs had stock-outs of both antimalarial formulations. gChild was treated correctly if he/she was given correct dose, frequency and duration of Cotrimoxizole. hIncorrect treatment included under-dosing of appropriate medication (3 cases of under-dose for age; 1 case fewer days’ duration and 2 cases incomplete days mentioned). iChild was treated correctly if he/she was given ORS (regardless of amount); zinc was not generally available at the time of assessment and thus not included in correct diarrhoea treatment.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC3753880&req=5

czs095-F2: Clinical pathways analysis Notes:aNumber of cases based on gold-standard clinician classification. bChild was correctly classified if the HSA classification matched the gold-standard clinician’s classification. cChild was treated correctly if he/she was given correct dose, frequency, and duration of first-line antimalarial (ACT) (184 cases; includes children that received one dose of antimalarial and were referred for a reason unrelated to fever (e.g. rash) (7 cases). dIncludes over- and under-dosing of antimalarial (6 cases) and antimalarial for child with fever under 5 months of age (2 cases). eNot treated includes: sick children with uncomplicated fever who did not receive any antimalarial; sick children with cough with fast breathing who did not receive Cotrimoxizole; sick children with diarrhoea who did not receive ORS. fStock-out of both formulations of antimalarial; of 28 fever cases correctly assessed and classified but not treated, 17/28 of HSAs had stock-outs of both antimalarial formulations. gChild was treated correctly if he/she was given correct dose, frequency and duration of Cotrimoxizole. hIncorrect treatment included under-dosing of appropriate medication (3 cases of under-dose for age; 1 case fewer days’ duration and 2 cases incomplete days mentioned). iChild was treated correctly if he/she was given ORS (regardless of amount); zinc was not generally available at the time of assessment and thus not included in correct diarrhoea treatment.
Mentions: Figures 2a–c present an analysis of clinical steps for children presenting with uncomplicated fever, cough with fast breathing, and diarrhoea, as measured by the gold-standard clinician; these analyses indicate the common errors made by HSAs and the proportion of cases where the absence of essential drugs or a timing device may have influenced the quality of care. Overall, more than 90% of children with uncomplicated fever and diarrhoea were assessed and classified correctly; however, a smaller proportion of children received the appropriate treatment for fever (79%) or diarrhoea (69%) (antimalarials or ORS, respectively). Among children who did not receive treatment for fever, 52% were treated by an HSA who did not have antimalarials on the day of the assessment. Among children who were correctly assessed and classified with diarrhoea who were not treated with ORS, 72% were seen by an HSA who did not have ORS in stock on the day of the assessment. Among children with cough and fast breathing, 70% were correctly assessed; of the 43 children correctly assessed, 70% were correctly classified; only 52% overall were treated correctly with first-line antibiotics. Incorrect classification of cough and fast breathing was largely due to poor counting of respiratory rates by the HSA—only 30% of children with fast breathing had a respiratory rate that was measured within +/−2 breaths per minute of the measurement made by the gold-standard clinician. There were no stock-outs of cotrimoxazole on the day of the assessment where a child with suspected pneumonia was seen.Figure 2a–c

Bottom Line: HSAs provided correct treatment with antimalarials to 79% of the 241 children presenting with uncomplicated fever, with oral rehydration salts to 69% of the 93 children presenting with uncomplicated diarrhoea and with antibiotics to 52% of 58 children presenting with suspected pneumonia (cough with fast breathing).About one in five children (18%) presented with danger signs.However, HSAs provided sick child care at levels of quality similar to those provided in first-level health facilities in Malawi, and quality should improve if the Ministry of Health and partners act on the results of this assessment.

View Article: PubMed Central - PubMed

Affiliation: Institute for International Programs, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore MD 21205-2103, USA. jbrycedanby@aol.com

ABSTRACT

Objective: To assess the quality of care provided by Health Surveillance Assistants (HSAs)-a cadre of community-based health workers-as part of a national scale-up of community case management of childhood illness (CCM) in Malawi.

Methods: Trained research teams visited a random sample of HSAs (n = 131) trained in CCM and provided with initial essential drug stocks in six districts, and observed the provision of sick child care. Trained clinicians conducted 'gold-standard' reassessments of the child. Members of the survey team also interviewed caregivers and HSAs and inspected drug stocks and patient registers.

Findings: HSAs provided correct treatment with antimalarials to 79% of the 241 children presenting with uncomplicated fever, with oral rehydration salts to 69% of the 93 children presenting with uncomplicated diarrhoea and with antibiotics to 52% of 58 children presenting with suspected pneumonia (cough with fast breathing). About one in five children (18%) presented with danger signs. HSAs correctly assessed 37% of children for four danger signs by conducting a physical exam, and correctly referred 55% of children with danger signs.

Conclusion: Malawi's CCM programme is a promising strategy for increasing coverage of sick child treatment, although there is much room for improvement, especially in the correct assessment and treatment of suspected pneumonia and the identification and referral of sick children with danger signs. However, HSAs provided sick child care at levels of quality similar to those provided in first-level health facilities in Malawi, and quality should improve if the Ministry of Health and partners act on the results of this assessment.

Show MeSH
Related in: MedlinePlus