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Impact of Different Levels of Supervision on the Recovery of Severely Malnourished Children Treated by Community Health Workers in Mali.

ABSTRACT: (1) Background: The Ministry of Health in Mali included the treatment of severe acute malnutrition (SAM) into the package of activities of the integrated community case management (iCCM). This paper evaluates the most effective model of supervision for treating SAM using community health workers (CHWs). Methods (2): This study was a prospective non-randomized community intervention trial with two intervention groups and one control group with different levels of supervision. It was conducted in three districts in rural areas of the Kayes Region. In the high supervision group, CHWs received supportive supervision for the iCCM package and nutrition-specific supervision. In the light supervision group, CHWs received supportive supervision based on the iCCM package. The control group had no specific supervision. (3) Results: A total of 6112 children aged 6-59 months with SAM without medical complications were included in the study. The proportion of cured children was 81.4% in those treated by CHWs in the high supervision group, 86.2% in the light supervision group, and 66.9% in the control group. Children treated by the CHWs who received some supervision had better outcomes than those treated by unsupervised CHWs (p < 0.001). There was no difference between areas with light and high supervision, although those with high supervision performed better in most of the tasks analyzed. (4) Conclusions: Public policies in low-income countries should be adapted, and their model of supervision of CHWs for SAM treatment in the community should be evaluated.

SUBMITTER: Charle-Cuellar P

PROVIDER: S-EPMC7911749 | biostudies-literature | 2021 Jan

REPOSITORIES: biostudies-literature

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Impact of Different Levels of Supervision on the Recovery of Severely Malnourished Children Treated by Community Health Workers in Mali.

Charle-Cuéllar Pilar P López-Ejeda Noemí N Traore Mamadou M Coulibaly Adama Balla AB Landouré Aly A Diawara Fatou F Bunkembo Magloire M Vargas Antonio A Gil Ruth R Briend André A

Nutrients 20210126 2

(1) Background: The Ministry of Health in Mali included the treatment of severe acute malnutrition (SAM) into the package of activities of the integrated community case management (iCCM). This paper evaluates the most effective model of supervision for treating SAM using community health workers (CHWs). Methods (2): This study was a prospective non-randomized community intervention trial with two intervention groups and one control group with different levels of supervision. It was conducted in ...[more]

PMID: 33530333

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Project description:Community health workers (CHWs) in Mozambique (known as Agentes Polivalentes Elementares (APEs)) are key actors in providing health services in rural communities. Supervision of CHWs has been shown to improve their work, although details of how it is implemented are scarce. In Mozambique, APE supervision structures and scope of work are clearly outlined in policy and rely on supervisors at the health facility of reference. The aim of this study was to understand how and which aspects of supervision impact on APE motivation and programme implementation.Qualitative research methodologies were used. Twenty-nine in-depth interviews were conducted to capture experiences and perceptions of purposefully selected participants. These included APEs, health facility supervisors, district APE supervisors and community leaders. Interviews were recorded, translated and transcribed, prior to the development of a thematic framework.Supervision was structured as dictated by policy but in practice was irregular and infrequent, which participants identified as affecting APE's motivation. When it did occur, supervision was felt to focus more on fault-finding than being supportive in nature and did not address all areas of APE's work - factors that APEs identified as demotivating. Supervisors, in turn, felt unsupported and felt this negatively impacted performance. They had a high workload in health facilities, where they had multiple roles, including provision of health services, taking care of administrative issues and supervising APEs in communities. A lack of resources for supervision activities was identified, and supervisors felt caught up in administrative issues around APE allowances that they were unable to solve. Many supervisors were not trained in providing supportive supervision. Community governance and accountability mechanisms were only partially able to fill the gaps left by the supervision provided by the health system.The findings indicate the need for an improved supervision system to enhance support and motivation and ultimately performance of APEs. Our study found disconnections between the APE programme policy and its implementation, with gaps in skills, training and support of supervisors leading to sub-optimal supervision. Improved methods of supervision could be implemented including those that maximize the opportunities during face-to-face meetings and through community-monitoring mechanisms.

Project description:BackgroundMany countries have adopted integrated community case management (iCCM) to reduce mortality among children under five years from common childhood illnesses. The 2016-2020 Malian Red Cross iCCM program trained 441 Community Health Workers (CHWs) to treat malaria, pneumonia, diarrhea, and malnutrition for children under five years of age in six districts. Implementation strength and quality of care (QoC) were assessed through the program's supervision function, using the Malian Ministry of Health's system.ObjectiveThis paper compares methods and results of program supervision data and an independent evaluation to assess the effectiveness of program implementation and supervision and inform program improvement. It also presents the benefits and limitations of each method.MethodAn independent QoC evaluation was conducted using tools developed by the Real Accountability: Data Analysis for Results (RADAR) project, hereafter referred to as the RADAR evaluation. RADAR evaluation data collected in July and August 2018 were compared with program supervision data collected mostly between May and December 2018.ResultsThe RADAR evaluation provided detailed findings on correct assessment, classification, and treatment per illness, medication type, and dosage. Program supervision combined the findings for all illnesses, medication type, and dosage due to limitations in the data collection process. Six indicators were comparable between both methods. Findings were similar for temperature and mid-upper arm circumference measurements but diverged between program supervision and the RADAR evaluation, respectively, on correct classification for all illnesses (87.1% vs. 65.3%), correct treatment for all illnesses (69.5% vs. 39.8%), correct respiratory rate counting (88.5% vs. 54.7%), and administering the first dose by CHW (75.4% vs. 65.0%). Findings from the RADAR evaluation guided improvements in program supervision.ConclusionsA robust program supervision system can serve as a credible method to assess QoC. However, a rigorous independent QoC evaluation provides a valuable benchmark to gauge the effectiveness of the supervisory process.

Project description:IntroductionCommunity health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services.ObjectivesWe examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge.MethodsWe used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong.ResultsAmong 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge.ConclusionHigher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes.Trial registrationTrial registration number: https://doi.org/10.1186/ISRCTN83902145.

Project description:BackgroundSupportive supervision is considered critical to community health worker programme performance, but there is relatively little understanding of how it can be sustainably done at scale. Supportive supervision is a holistic concept that encompasses three key functions: management (ensuring performance), education (promoting development) and support (responding to needs and problems). Drawing on the experiences of the ward-based outreach team (WBOT) strategy, South Africa's national community health worker (CHW) programme, this paper explores and describes approaches to supportive supervision in policy and programme guidelines and how these are implemented in supervision practices in the North West Province, an early adopter of the WBOT strategy. Outreach teams typically consist of six CHWs plus a nurse outreach team leader (OTL).MethodsA qualitative, descriptive study that combined a document review of national policy and guidelines with key informant interviews in two districts of the North West Province was conducted. An overall WBOT policy statement and four guidelines on aspects of the strategy, spanning the period 2011-2017, were reviewed for statements on the three core facets of supervision outlined above. Eight focus group discussions, involving facility managers, team leaders and community health workers (total 40 respondents), purposively selected from four sub-districts in two districts, assessed local-level supervision practices. Alignment across policy and guidance documents and between policy/guidance and practice was examined.FindingsWhile all the official policy documents and guidelines reviewed acknowledged the need for supervision and support, these elements were inadequately developed and poorly aligned, both in terms of scope and in providing firm guidance on the supervision of WBOTs. The practices of supervision entailed a variety of reporting lines, while development and support processes were informal and often lacking, and teams poorly resourced. There was internal cohesion and support within teams amongst CHWs and between CHWs and OTLs. However, primary health care clinic managers, who were supposed to supervise the WBOTs, struggled to fulfil this role amidst the high workloads in facilities, and relationships between WBOTs and facility staff often remained strained.ConclusionThis study identified weaknesses in both the design and implementation of the supervision system of WBOTs. The lack of explicit, coherent and holistic guidance in policy and the failure to address constraints to supervision at local level undermine the performance and sustainability of the WBOT strategy in South Africa.

Project description:BACKGROUND:In Bangladesh, pneumonia has a higher mortality among malnourished children aged <5 years. Evaluating pneumonia etiology among malnourished children may help improve empiric treatment guidelines. METHODS:During April 2015-December 2017, we conducted a case-control study among severe acute malnourished (SAM) children aged <5 years admitted to the Dhaka hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). We enrolled hospital admitted SAM children with clinical or radiological pneumonia as cases (during April 2015 to March 2017) and hospital admitted SAM children without any respiratory symptom in the past 10 days before admission as controls (during February 2016 to December 2017). We tested nasopharyngeal wash from both case and control for respiratory syncytial virus (RSV), human metapneumovirus (HMPV), influenza viruses, human parainfluenza viruses (HPIV), rhinovirus and adenovirus by singleplex real-time reverse transcriptase polymerase chain reaction. To identify the independent association of pneumonia with viral pathogens during February 2016 to March 2017, we used multivariable logistic regression for calculating adjusted odds ratios. RESULTS:We enrolled 360 cases and 334 controls. For case and control the median age was 8 months (IQR: 5-13) and 11 months (IQR: 6-18) (p = 0.001) respectively. Weight/age Z-score was -4.3 (SD ±0.7) for cases and -4.1 (SD ±1.1) for controls (p = 0.01). Among cases 68% had both clinical and radiological pneumonia, 1% had clinical pneumonia and 31% had only radiological pneumonia. Respiratory virus detection was high in cases compared to controls [69.9% (251) vs. 44.8% (148), p = 0.0001]. The most frequently detected viruses among cases were rhinoviruses (79, 22.0%) followed by RSV (32, 8.9%), adenovirus (23, 6.4%), HPIV (22, 6.1%), influenza virus (16, 4.5%), and HMPV (16, 4.5%). Among the controls, rhinoviruses (82, 24.8%) were most commonly detected one followed by adenovirus (26,7.9%), HMPV (5, 1.5%), HPIV (4, 1.2%), RSV (3, 0.9%), and influenza virus (2, 0.6%). RSV (OR 13.1; 95% CI: 1.6, 106.1), influenza virus (OR 8.7; 95% CI: 1.0, 78.9), HPIV (3.8; 95% CI: 1.0, 14.8), and HMPV (2.7; 95% CI: 1.3, 5.5) were independently associated with pneumonia while compared between 178 cases and 174 controls. CONCLUSION:Viral etiology of pneumonia in SAM children were mainly attributable to RSV, influenza, HPIV and HMPV. Our study findings may help in planning further studies targeting vaccines or drugs against common respiratory viruses responsible for pneumonia among SAM children.

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Impact of Different Levels of Supervision on the Recovery of Severely Malnourished Children Treated by Community Health Workers in Mali.

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Impact of Different Levels of Supervision on the Recovery of Severely Malnourished Children Treated by Community Health Workers in Mali.

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