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Using Data to Improve Programs: Assessment of a Data Quality and Use Intervention Package for Integrated Community Case Management in Malawi.

ABSTRACT: Health Surveillance Assistants (HSAs) have been providing integrated community case management (iCCM) for sick children in Malawi since 2008. HSAs report monthly iCCM program data but, at the time of this study, little of it was being used for service improvement. Additionally, HSAs and facility health workers did not have the tools to compile and visualize the data they collected to make evidence-based program decisions. From 2012 to 2013, we worked with Ministry of Health staff and partners to develop and pilot a program in Dowa and Kasungu districts to improve data quality and use at the health worker level. We developed and distributed wall chart templates to display and visualize data, provided training to 426 HSAs and supervisors on data analysis using the templates, and engaged health workers in program improvement plans as part of a data quality and use (DQU) package. We assessed the package through baseline and endline surveys of the HSAs and facility and district staff in the study areas, focusing specifically on availability of reporting forms, completeness of the forms, and consistency of the data between different levels of the health system as measured through results verification ratio (RVR). We found evidence of significant improvements in reporting consistency for suspected pneumonia illness (from overreporting cases at baseline [RVR=0.82] to no reporting inconsistency at endline [RVR=1.0]; P=.02). Other non-significant improvements were measured for fever illness and gender of the patient. Use of the data-display wall charts was high; almost all HSAs and three-fourths of the health facilities had completed all months since January 2013. Some participants reported the wall charts helped them use data for program improvement, such as to inform community health education activities and to better track stock-outs. Since this study, the DQU package has been scaled up in Malawi and expanded to 2 other countries. Unfortunately, without the sustained support and supervision provided in this project, use of the tools in the Malawi scale-up is lower than during the pilot period. Nevertheless, this pilot project shows community and facility health workers can use data to improve programs at the local level given the opportunity to access and visualize the data along with supervision support.

SUBMITTER: Hazel E

PROVIDER: S-EPMC5620334 | biostudies-literature | 2017 Sep

REPOSITORIES: biostudies-literature

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Using Data to Improve Programs: Assessment of a Data Quality and Use Intervention Package for Integrated Community Case Management in Malawi.

Hazel Elizabeth E Chimbalanga Emmanuel E Chimuna Tiyese T Nsona Humphreys H Mtimuni Angella A Kaludzu Ernest E Gilroy Kate K Guenther Tanya T

Global health, science and practice 20170928 3

Health Surveillance Assistants (HSAs) have been providing integrated community case management (iCCM) for sick children in Malawi since 2008. HSAs report monthly iCCM program data but, at the time of this study, little of it was being used for service improvement. Additionally, HSAs and facility health workers did not have the tools to compile and visualize the data they collected to make evidence-based program decisions. From 2012 to 2013, we worked with Ministry of Health staff and partners to ...[more]

PMID: 28963172

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Project description:AimTo identify better performing iCCM programs in sub-Saharan Africa (SSA) and identify factors associated with better performance using routine data.MethodsWe examined 15 evaluations or studies of integrated community case management (iCCM) programs in SSA conducted between 2008 and 2013 and with information about the program; routine data on treatments, supervision, and stockouts; and, where available, data from community health worker (CHW) surveys on supervision and stockouts. Analyses included descriptive statistics, Fisher exact test for differences in median treatment rates, the Kruskal-Wallis test for differences in the distribution of treatment rates, and Spearman's correlation by program factors.ResultsThe median percent of annual expected cases treated was 27% (1-74%) for total iCCM, 37% (1-80%) for malaria, 155% (7-552%) for pneumonia, and 27% (1-74%) for diarrhoea. Seven programs had above median total iCCM treatments rates. Four programs had above median treatment rates, above median treatments per active CHW per month, and above median percent of expected cases treated. Larger populations under-five targeted were negatively associated with treatment rates for fever, malaria, diarrhea, and total iCCM. The ratio of CHWs per population was positively associated with diarrhoea treatment rates. Use of rapid diagnostic tests (RDTs) was negatively associated with treatment rates for pneumonia. Treatment rates and percent of annual expected cases treated were equivalent between programs with volunteer CHWs and programs with salaried CHWs.ConclusionsThere is large variation in iCCM program performance in SSA. Four programs appear to be higher performing in terms of treatment rates, treatments per CHW per month, and percent of expected cases treated. Treatment rates for diarrhoea are lower than expected across most programmes. CHWs in many programmes are overtreating pneumonia. Programs targeting larger populations under-five tend to have lower treatment rates. The reasons for lower pneumonia treatment rates where CHWs use RDTs need to be explored. Programs with volunteer CHWs and those with salaried CHWs can achieve similar treatment rates and percent of annual expected cases treated but to do so volunteer programs must manage more CHWs per population and salaried CHWs must provide more treatments per CHW per month.

Project description:BackgroundWhile community health workers are being recognized as an integral work force with growing responsibilities, increased demands can potentially affect motivation and performance. The ubiquity of mobile phones, even in hard-to-reach communities, has facilitated the pursuit of novel approaches to support community health workers beyond traditional modes of supervision, job aids, in-service training, and material compensation. We tested whether supportive short message services (SMS) could improve reporting of pregnancies and pregnancy outcomes among community health workers (Health Surveillance Assistants, or HSAs) in Malawi.Methods and findingsWe designed a set of one-way SMS that were sent to HSAs on a regular basis during a 12-month period. We tested the effectiveness of the cluster-randomized intervention in improving the complete documentation of a pregnancy. We defined complete documentation as a pregnancy for which a specific outcome was recorded. HSAs in the treatment group received motivational and data quality SMS. HSAs in the control group received only motivational SMS. During baseline and intervention periods, we matched reported pregnancies to reported outcomes to determine if reporting of matched pregnancies differed between groups and by period. The trial is registered as ISCTRN24785657.ConclusionsStudy results show that the mHealth intervention improved the documentation of matched pregnancies in both the treatment (OR 1.31, 95% CI: 1.10-1.55, p<0.01) and control (OR 1.46, 95% CI: 1.11-1.91, p = 0.01) groups relative to the baseline period, despite differences in SMS content between groups. The results should be interpreted with caution given that the study was underpowered. We did not find a statistically significant difference in matched pregnancy documentation between groups during the intervention period (OR 0.94, 95% CI: 0.63-1.38, p = 0.74). mHealth applications have the potential to improve the tracking and data quality of pregnancies and pregnancy outcomes, particularly in low-resource settings.

Project description:BackgroundThe use of mobile health (mHealth) technology to improve quality of care (QoC) has increased over the last decade; limited evidence exists to espouse mHealth as a decision support tool, especially at the community level. This study presents evaluation findings of using a mobile application for integrated community case management (iCCM) by Malawi's health surveillance assistants (HSAs) in four pilot districts to deliver lifesaving services for children.MethodsA quasi-experimental study design compared adherence to iCCM guidelines between HSAs using mobile application (n = 137) and paper-based tools (n = 113), supplemented with 47 key informant interviews on perceptions about QoC and sustainability of iCCM mobile application. The first four sick children presenting to each HSA for an initial consultation of an illness episode were observed by a Ministry of Health iCCM trainer for assessment, classification, and treatment. Results were compared using logistic regression, controlling for child-, HSA-, and district-level characteristics, with Holm-Bonferroni-adjusted significance levels for multiple comparison.ResultsHSAs using the application tended to assess sick children according to iCCM guidelines more often than HSAs using paper-based tools for cough (adjusted proportion, 98% vs 91%; P < 0.01) and five physical danger signs - chest in-drawing; alertness; palmar pallor; malnourishment; oedema (80% vs 62%; P < 0.01), but not for fever (97% vs 93%; P = 0.06), diarrhoea (94% vs 87%; P = 0.03), and three danger signs - not able to eat or drink; vomits everything; has convulsions (88% vs 79%; P = 0.01). Across illnesses and danger signs, 81% of HSAs using the application correctly classified sick children, compared to 58% of HSAs using paper-based tools (P < 0.01). No differences existed for their treatment (P = 0.27). Interview respondents corroborated these findings that using iCCM mobile application ensures protocol adherence. Respondents noted barriers to its consistent and wide use including hardware problems and limited resources.ConclusionGenerally, the mobile application is a promising tool for improving adherence to the iCCM protocol for assessing sick children and classifying illness by HSAs. Limited effects on treatments and inconsistent use suggest the need for more studies on mHealth to improve QoC at community level.

Project description:IntroductionGuidelines recommend that patients with acute venous thromboembolism (VTE) represented by low-risk deep vein thrombosis (DVT) and pulmonary embolism (PE) receive initial treatment at home versus at the hospital, but a large percentage of these patients are not managed at home. This study assessed the effectiveness of a quality intervention on provider knowledge and confidence in evaluating outpatient treatment for patients with VTE in the emergency department (ED).MethodsA pilot program to overcome obstacles to outpatient VTE treatment in appropriate patients was initiated at Baylor Scott & White Health Temple ED. Subsequently, a formalized quality intervention with a targeted educational program was developed and delivered to ED providers. Provider surveys were administered pre- and post-quality intervention in order to assess clinical knowledge, confidence levels, and perceived barriers. Patient discharge information was extracted from electronic health records.ResultsTwenty-five ED providers completed the pre- and post-surveys; 690 and 356 patients with VTE were included in the pre- and post-pilot and pre- and post-quality intervention periods, respectively. Many ED providers reported that a major barrier to discharging patients to outpatient care was the lack of available and adequate patient follow-up appointments. Notably, after the quality intervention, an increase in provider clinical knowledge and confidence scores was observed. Discharge rates for patients with VTE increased from 25.6% to 27.5% after the pilot intervention and increased from 28.5% to 29.9% after the quality intervention, but these differences were not statistically significant. Despite instantaneous uptick in discharge rates after the interventions, there was not a long-lasting effect.ConclusionAlthough the quality intervention led to improvements in provider clinical knowledge and confidence and identified barriers to discharging patients with VTE, discharge rates remained stable, underscoring the need for additional endeavors.

Project description:BackgroundIntegrated community case management (iCCM) involves delivery of simple medicines to children with pneumonia, diarrhea and/or malaria by community health workers (CHWs). Between 2010 and 2012, an iCCM intervention trial was implemented by Healthy Child Uganda. This study used qualitative tools to assess whether project stakeholders perceived that iCCM improved access to care for children under five years of age.MethodsThe intervention involved training and equipping 196 CHWs in 98 study villages in one sub-county in Uganda in iCCM. During the eight-month intervention, CHWs assessed sick children, provided antimalarials (coartem) for fever, antibiotics (amoxicillin) for cough and fast breathing, oral rehydration salts/zinc for diarrhea, and referred very sick children to health facilities. In order to examine community perceptions and acceptability of iCCM, post-intervention focus groups and key respondent interviews involving caregivers, health workers, CHWs and local leaders were carried out by experienced facilitators using semi-structured interview guides. Data were analyzed using thematic analysis techniques.ResultsRespondents reported increased access to health care for children as a result of iCCM. Access was reportedly closer to home, available more hours in a day, and the availability of CHWs was perceived as more reliable. CHW care was reported to be trustworthy and caring. Families reported saving money especially due to reduced transportation costs, and less time away from home. Respondents also perceived better health outcomes. Linkages between health facilities and communities were reportedly improved by the iCCM intervention due to the presence of trained CHWs in the community.ConclusionsiCCM delivered by CHWs may improve access to health care and is acceptable to families. Policymakers should continue to seek opportunities to implement and support iCCM, particularly in remote communities where there are health worker shortages.

Project description:BackgroundHIV-positive mothers who face the dual burden of HIV-positive status and motherhood, may benefit from holistic services that include early childhood development (ECD). We evaluated the acceptability and impact of integrated ECD-PMTCT interventions for mothers and their children.MethodsWe implemented an integrated ECD-PMTCT intervention in 4 health facilities in Malawi for HIV-positive mothers and their infants. WHO/UNICEF Care for Child Development (CCD) education and counseling sessions were offered during routine PMTCT visits between infant age 1.5-24 months. From June-July 2019, we conducted in-depth interviews with 29 mothers enrolled in the intervention for ≥6 months across 4 health facilities. The interview guide focused on perceived impact of the intervention on mothers' ECD and PMTCT practices, including barriers and facilitators, and unmet needs related to the program. Data were coded and analyzed using constant comparison methods in Atlas ti.8.ResultsThe vast majority of mothers believed the ECD-PMTCT intervention improved their overall experience with the PMTCT services, strengthened their relationship with providers, and excited and motivated them to attend PMTCT services during the postpartum period. Unlike prior experience, mothers felt more welcome at the health facility, and looked forward to the next visit in order to interact with other mothers and learn new ECD skills. Mothers formed new social support networks with other mothers engaged in ECD sessions, and they provided emotional and financial support to one another, including encouragement regarding ART adherence. Mothers believed their infants reached developmental milestones faster compared to non-intervention children they observed at the same age, and they experienced improved engagement in caregiving activities among male caregivers. Nearly half of women requested additional support with depression or anxiety, coping mechanisms to deal with the stresses of life, or support in building positive dynamics with their male partner.ConclusionThe integrated ECD-PMTCT intervention improved mother's experiences with PMTCT programs and health care providers, increased ECD practices such as responsive and stimulating parenting, and created social support networks for women with other PMTCT clients.

Dataset Information

Using Data to Improve Programs: Assessment of a Data Quality and Use Intervention Package for Integrated Community Case Management in Malawi.

Publications

Using Data to Improve Programs: Assessment of a Data Quality and Use Intervention Package for Integrated Community Case Management in Malawi.

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