Assessment of the impact of quality improvement interventions on the quality of sick child care provided by Health Extension Workers in Ethiopia.
Ontology highlight
ABSTRACT: Background
Ethiopia has scaled up integrated community case management of childhood illness (iCCM), including several interventions to improve the performance of Health Extension Workers (HEWs). We assessed associations between interventions to improve iCCM quality of care and the observed quality of care among HEWs.Methods
We assessed iCCM implementation strength and quality of care provided by HEWs in Ethiopia. Multivariate logistic regression analyses were performed to assess associations between interventions to improve iCCM quality of care and correct management of iCCM illnesses.Findings
Children who were managed by an HEW who had attended a performance review and clinical mentoring meeting (PRCMM) had 8.3 (95% confidence interval (CI) 2.34-29.51) times the odds of being correctly managed, compared to children managed by an HEW who did not attend a PRCMM. Management by an HEW who received follow-up training also significantly increased the odds of correct management (odds ratio (OR)?=?2.09, 95% CI 1.05-4.18). Supervision on iCCM (OR?=?0.63, 95% CI 0.23-1.72) did not significantly affect the odds of receiving correct care.Conclusions
These results suggest PRCMM and follow-up training were effective interventions, while implementation of supportive supervision needs to be reviewed to improve impact.
SUBMITTER: Miller NP
PROVIDER: S-EPMC5012232 | biostudies-literature | 2016 Dec
REPOSITORIES: biostudies-literature
Publications
Assessment of the impact of quality improvement interventions on the quality of sick child care provided by Health Extension Workers in Ethiopia.
Miller Nathan P NP Amouzou Agbessi A Hazel Elizabeth E Legesse Hailemariam H Degefie Tedbabe T Tafesse Mengistu M Black Robert E RE Bryce Jennifer J
Journal of global health 20161201 2
<h4>Background</h4>Ethiopia has scaled up integrated community case management of childhood illness (iCCM), including several interventions to improve the performance of Health Extension Workers (HEWs). We assessed associations between interventions to improve iCCM quality of care and the observed quality of care among HEWs.<h4>Methods</h4>We assessed iCCM implementation strength and quality of care provided by HEWs in Ethiopia. Multivariate logistic regression analyses were performed to assess ...[more]
Similar Datasets
Project description:BackgroundAs community case management of childhood illness expands in low-income countries, there is a need to assess the quality of care provided by community health workers. This study had the following objectives: 1) examine methods of recruitment of sick children for assessment of quality of care, 2) assess the validity of register review (RR) and direct observation only (DO) compared to direct observation with re-examination (DO+RE), and 3) assess the effect of observation on community health worker performance.MethodsWe conducted a survey to assess the quality of care provided by Ethiopian Health Extension Workers (HEWs). The sample of children was obtained through spontaneous consultation, HEW mobilization, or recruitment by the survey team. We assessed patient characteristics by recruitment method. Estimates of indicators of quality of care obtained using RR and DO were compared to gold standard estimates obtained through DO+RE. Sensitivity, specificity, and the area under receiver operator characteristic curve (AUC) were calculated to assess the validity of RR and DO. To assess the Hawthorne effect, we compared estimates from RR for children who were observed by the survey team to estimates from RR for children who were not observed by the survey team.ResultsParticipants included 137 HEWs and 257 sick children in 103 health posts, plus 544 children from patient registers. Children mobilized by HEWs had the highest proportion of severe illness (27%). Indicators of quality of care from RR and DO had high sensitivity for most indicators, but specificity was low. The AUC for different indicators from RR ranged from 0.47 to 0.76, with only one indicator above 0.75. The AUC of indicators from DO ranged from 0.54 to 1.0, with three indicators above 0.75. The differences between estimates of correct care for observed versus not observed children were small.ConclusionsMobilization by HEWs and recruitment by the survey teams were feasible, but potentially biased, methods of obtaining sick children. Register review and DO underestimated performance errors. Our data suggest that being observed had only a small positive effect on the performance of HEWs.
| S-EPMC4638333 | biostudies-literature
Project description:BackgroundCare-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.MethodsClinical 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.ResultsMost 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.ConclusionThe 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.
| S-EPMC7518593 | biostudies-literature
Project description:BACKGROUND:Community health worker (CHW) interventions to manage childhood illness is a strategy promoted by the global health community which involves training and supporting CHW to assess, classify and treat sick children at home, using an algorithm adapted from the Integrated Management of Childhood Illness (IMCI). To inform CHW policy, the Government of Tanzania launched a program in 2011 to determine if community case management (CCM) of malaria, pneumonia and diarrhea could be implemented by CHW in that country. METHODS:This paper reports the results of an observational study on the CCM service delivery quality of a trial cohort of CHW in Tanzania, called WAJA. In 2014, teams of data collectors, employees of the Ministry of Health and Social Welfare trained in IMCI, assessed the IMCI skills rendered by a sample of WAJA on sick children who presented to WAJA with illness signs and symptoms in their communities. The assessment included direct observations of WAJA IMCI episodes and expert re-assessment of the same children seen by WAJA to assess the congruence between the assessment, classification and treatment outcomes of WAJA cases and those from cases conducted by expert re-assessors. RESULTS:In the majority of cases, WAJA correctly assess sick children for CCM-treatable illnesses (malaria, pneumonia, and diarrhea) and general danger signs (90% and 89%, respectively), but too few correctly assess for physical danger signs (39%); on classification in the majority of cases (73%) WAJA correctly classified illness, though more for CCM-treatable illnesses (83%). In majority of cases (78%) WAJA treated children correctly (84% of malaria, 74% pneumonia, and 71% diarrhea cases). Errors were often associated with lapses in health systems support, mainly supervision and logistics. CONCLUSION:CCM is a feasible strategy for CHW in Tanzania, who, in the majority of cases, implemented the approach as well as IMCI expert re-assessors. Nevertheless, for CCM to be effective, in Tanzania, a strategy to implement it must be coordinated with efforts to strengthen local health systems.
| S-EPMC6358652 | biostudies-literature
Project description:ObjectiveThough efforts were made to expand community-based sick child healthcare in Ethiopia, the quality of care provided remained low. Improving quality of care requires understanding providers' knowledge of appropriate care and their actual execution of tasks. This study examined gap between what health extension workers (HEWs) knew and did during the management of sick children in Ethiopia.DesignFacility-based cross-sectional study was conducted.SettingThe study was carried out in 52 districts across 4 regions in Ethiopia.ParticipantsWe interviewed 274 HEWs and performed observations of consultations done by 150 HEWs supplemented with facility assessment from December 2018 to February 2019.OutcomeWe compared providers' knowledge and performance in the management of childhood pneumonia and diarrhoea. Know-do gap implies the difference in proportion between knowledge and actual practice of HEWs. Logistic regression was used to identify predictors of knowledge and actual practice.ResultsProviders' correct knowledge ranged from 27.8% to 76.0% for signs and symptoms of pneumonia, and 32.0% to 84% for dehydration signs. Their actual practices ranged from 15.1% to 47.3% for pneumonia and 27.0% to 42.6% for dehydration. The correct knowledge and actual practices for pneumonia and dehydration management were 88.3% vs 15.6% and 93.9% vs 51.3%, respectively. There was significant know-do gap in assessments (16.7%, p=0.002) and management of childhood conditions (68.5%, p<0.0001). Mentorships were associated with providers' knowledge of clinical management, while medicines availability was associated with their actual management practice.ConclusionsWhile knowledge and actual practice for assessment and management of pneumonia and dehydration ranged from very low to high, what is more concerning is the huge know-do gap among HEWs. Our findings suggest that knowledge-based training is necessary but not sufficient for ensuring correct assessment and management of sick children by HEWs. Continuous support through mentorships and the supply of commodities are critically needed.
| S-EPMC10450039 | biostudies-literature
Project description:BackgroundWhile health care provider knowledge is a commonly used measure for process quality of care, evidence demonstrates that providers don't always perform as much as they know. We describe this know-do gap for malaria care for sick children among providers in Ethiopia and examine what may predict this gap.MethodsWe use a 2014 nationally-representative survey of Ethiopian providers that includes clinical knowledge vignettes of malaria care and observations of care provided to children in facilities. We compare knowledge and performance of assessment, treatment and counseling items and overall. We subtract performance scores from knowledge and use regression analysis to examine what facility and provider characteristics predict the gap. 512 providers that completed the malaria vignette and were observed providing care to sick children were included in the analysis.ResultsVignette and observed performance were both low, with providers on average scoring 39% and 34% respectively. The know-do gap for assessment was only 1%, while the gap for treatment and counseling items was 39%. Doctors had the largest gap between knowledge and performance. Only provider type and availability of key equipment significantly predicted the know-do gap.ConclusionsWhile both provider knowledge and performance in sick child care are poor, there is a gap between knowledge and performance particularly with regard to treatment and counseling. Interventions to improve quality of care must address not only deficiencies in provider knowledge, but also the gap between knowledge and action.
| S-EPMC6291134 | biostudies-literature
Project description:BACKGROUND:Strong scientific evidence is needed to support low-income countries in building effective and sustainable immunization programs and proactively engaging in global vaccine development and implementation initiatives. This study aimed to implement and evaluate the effectiveness of system-wide continuous quality improvement (CQI) interventions to improve national immunization programme performance in Ethiopia. METHODS:The study used a prospective, quasi-experimental design with an interrupted time-series analysis to collect data from 781 government health sectors (556 healthcare facilities, 196 district health offices, and 29 zonal health departments) selected from developing and emerging regions in Ethiopia. Procedures included baseline quality assessment of immunization programme and services using structured checklists; immunization systems strengthening using onsite technical support, training, and supportive supervision interventions in a Plan-Do-Check-Act cycle over 12?months; and collection and analysis of data at baseline and at the 6th and 12th month of interventions using statistical process control and the t-test. Outcome measures were the coverage of the vaccines pentavalent 3, measles, Bacillus Calmette-Guérin vaccine (BCG), Pneumococcal Conjugate Vaccine (PCV), as well as full vaccination status; while process measures were changes in human resources, planning, service delivery, logistics and supply, documentation, coordination and collaboration, and monitoring and evaluation. Analysis and interpretation of data adhered to SQUIRE 2.0 guidelines. RESULTS:Prior to the interventions, vaccination coverage was low and all seven process indicators had an aggregate score of below 50%, with significant differences in performance at healthcare facility level between developing and emerging regions (P =?0.0001). Following the interventions, vaccination coverage improved significantly from 63.6% at baseline to 79.3% for pentavalent (P =?0.0001), 62.5 to 72.8% for measles (P =?0.009), 62.4 to 73.5% for BCG (P =?0.0001), 65.3 to 81.0% for PCV (P =?0.02), and insignificantly from 56.2 to 74.2% for full vaccination. All seven process indicators scored above 75% in all regions, with no significant differences found in performance between developing and emerging regions. CONCLUSIONS:The CQI interventions improved immunization capacity and vaccination coverage in Ethiopia, where the unstable transmission patterns and intensity of infectious diseases necessitate for a state of readiness of the health system at all times. The approach was found to empower zone, district, and facility-level health sectors to exercise accountability and share ownership of immunization outcomes. While universal approaches can improve routine immunization, local innovative interventions that target local problems and dynamics are also necessary to achieve optimal coverage.
| S-EPMC6267782 | biostudies-other
Project description:Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrition workers through electronic worklists, performance dashboards, and one-on-one feedback sessions. We visualized performance indicators and child nutrition outcomes during the improvement intervention using run charts and control charts. In this small community-based sample (125 households at program initiation), over the two-year improvement period, there were marked improvements in the delivery of program components, such as growth monitoring services and micronutrient supplements. The prevalence of child stunting fell from 42.4 to 30.6%, meeting criteria for special cause variation. The mean length/height-for-age Z-score rose from -1.77 to -1.47, also meeting criteria for special cause variation. In conclusion, the addition of structured performance visualization and audit and feedback components to an existing community-based nutrition program improved child health indicators significantly through improving the fidelity of an existing evidence-based nutrition package.
| S-EPMC7831302 | biostudies-literature
Project description:BackgroundEthiopia has scaled up its community-based programs over the past decade by training and deploying health extension workers (HEWs) in rural communities throughout the country. Consequently, child mortality has declined substantially, placing Ethiopia among the few countries that have achieved the United Nations' fourth Millennium Development Goal. As Ethiopia continues its efforts, results must be assessed regularly to provide timely feedback for improvement and to generate further support for programs. More specifically the expansion of HEWs at the community level provides a unique opportunity to build a system for real-time monitoring of births and deaths, linked to a civil registration and vital statistics system that Ethiopia is also developing. We tested the accuracy and completeness of births and deaths reported by trained HEWs for monitoring child mortality over 15 -month periods.Methods and findingsHEWs were trained in 93 randomly selected rural kebeles in Jimma and West Hararghe zones of the Oromia region to report births and deaths over a 15-month period from January, 2012 to March, 2013. Completeness of number of births and deaths, age distribution of deaths, and accuracy of resulting under-five, infant, and neonatal mortality rates were assessed against data from a large household survey with full birth history from women aged 15-49. Although, in general HEWs, were able to accurately report events that they identified, the completeness of number of births and deaths reported over twelve-month periods was very low and variable across the two zones. Compared to household survey estimates, HEWs reported only about 30% of births and 21% of under-five deaths occurring in their communities over a twelve-month period. The under-five mortality rate was under-estimated by around 30%, infant mortality rate by 23% and neonatal mortality by 17%. HEWs reported disproportionately higher number of deaths among the very young infants than among the older children.ConclusionBirth and death data reported by HEWs are not complete enough to support the monitoring of changes in childhood mortality. HEWs can significantly contribute to the success of a CRVS in Ethiopia, but cannot be relied upon as the sole source for identification of vital events. Further studies are needed to understand how to increase the level of completeness.
| S-EPMC4659609 | biostudies-literature
Project description:IntroductionAssessment of pregnant mothers for nutritional status is a neglected intervention. In Kaabong Hospital, nutritional status of pregnant mothers was not assessed during antenatal care (ANC) visits. A quality improvement (QI) project was initiated to increase nutritional assessment using midupper arm circumference (MUAC) among pregnant mothers during ANC visits from 0 to 90% between April and September 2015.MethodBaylor-Uganda formed ANC Work Improvement Team (WIT) that reviewed ANC register, identified gaps in quality of care, analyzed root causes using cause-effect diagram, developed solutions, and tested and implemented the solution using Plan-Do-Study-Act cycles. Planned and tested changes included the provision of anthropometric tools, integrated ANC register, and data use.ResultIn April 2015 (baseline), none (0/235) of the pregnant women were assessed for nutritional status using MUAC. Following QI interventions, nutritional assessment improved to 79% (200/252) in May 2015 and to 100% (241/241) in June 2015. The 100% performance was sustained until August 2016. Overall, 39 cases of malnutrition-1 (2.6%) severe (MUAC < 19.0 cm) and 38 (97.4%) moderate acute malnutrition (MUAC 19-22.0 cm)-were identified and linked to nutritional rehabilitation program.ConclusionQI interventions are critical in achieving high rates of nutritional status assessment and identifying malnourished pregnant women during ANC visits.
| S-EPMC5468564 | biostudies-literature
Project description:BACKGROUND: Governments are increasingly reliant on community health workers to undertake health promotion and provide essential curative care. In 2003, the Government of Ethiopia launched the Health Extension Programme and introduced a new cadre, health extension workers (HEWs), to improve access to care in rural communities. In 2013, to inform the government's plans for HEWs to take on an enhanced role in community-based newborn care, a time and motion study was conducted to understand the range of HEW responsibilities and how they allocate their time across health and non-health activities. METHODS: The study was administered in 69 rural kebeles in the Southern Nations Nationalities and People's Region and Oromia Region that were intervention areas of a trial to evaluate a package of community-based interventions for newborns. Over 4 consecutive weeks, HEWs completed a diary and recorded all activities undertaken during each working day. HEWs were also surveyed to collect data on seasonal activities and details of the health post and kebele in which they work. The average proportion of productive time (excluding breaks) that HEWs spent on an activity, at a location, or with a recipient each week, was calculated. RESULTS: The self-reported diary was completed by 131 HEWs. Over the course of a week, HEWs divided their time between the health post (51%) and the community (37%), with the remaining 11% of their time spent elsewhere. Curative health activities represented 16% of HEWs' time each week and 43% of their time was spent on health promotion and prevention. The remaining time included travel, training and supervision, administration, and community meetings. HEWs spent the majority (70%) of their time with individuals, families, and community members. CONCLUSIONS: HEWs have wide-ranging responsibilities for community-based health promotion and curative care. Their workload is diverse and they spend time on activities relating to family health, disease prevention and control, hygiene and sanitation, as well as other community-based activities. Reproductive, maternal, newborn, and child health activities represent a major component of the HEW's work and, as such, they can have a critically important role in improving the health outcomes of mothers and children in Ethiopia.
| S-EPMC4209031 | biostudies-literature