Impact of Integration of Severe Acute Malnutrition Treatment in Primary Health Care Provided by Community Health Workers in Rural Niger.
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SUBMITTER: Ogobara Dougnon A
PROVIDER: S-EPMC8625976 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:The Malian Nutrition Division of the Ministry of Health and Action Against Hunger tested the feasibility of integrating treatment of severe acute malnutrition (SAM) into the existing Integrated Community Case Management package delivered by community health workers (CHWs). This study assessed costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care. METHODS:Activity-based costing methods were used, and a societal perspective employed to include all relevant costs incurred by institutions, beneficiaries and communities. The intervention and control arm enrolled different numbers of children so a modelled scenario sensitivity analysis was conducted to assess the cost-effectiveness of the two arms, assuming equal numbers of children enrolled. RESULTS:In the base case, with unequal numbers of children in each arm, for CHW-delivered care, the cost per child treated was 244 USD and cost per child recovered was 259 USD. Outpatient facility-based care was less cost-effective at 442 USD per child and 501 USD per child recovered. The conclusions of the analysis changed in the modelled scenario sensitivity analysis, with outpatient facility-based care being marginally more cost-effective (cost per child treated is 188 USD, cost per child recovered is 214 USD), compared to CHW-delivered care. This suggests that achieving good coverage is a key factor influencing cost-effectiveness of CHWs delivering treatment for SAM in this setting. Per week of treatment, households receiving CHW-delivered care spent half of the time receiving treatment and three times less money compared with those receiving treatment from the outpatient facility. CONCLUSIONS:This study supports existing evidence that the delivery of treatment by CHWs is a cost-effective intervention, provided that good coverage is achieved. A major benefit of this strategy was the lower cost incurred by the beneficiary household when treatment is available in the community. Further research is needed on the implementation costs that would be incurred by the government to increase the operability of these results.
| S-EPMC5819265 | biostudies-literature
Project description:An alternative Community-based Management of Acute Malnutrition model with community health workers (CHWs) delivering treatment for uncomplicated severe acute malnutrition (SAM) was piloted in Mali. The capacity of the CHWs to evaluate, classify, and treat cases of uncomplicated SAM, to provide nutritional counselling to caretakers of children receiving treatment for SAM, malaria, pneumonia or diarrhoea and to correctly refer cases of complicated SAM, was assessed. This was done using direct observation by trained enumerators of the management of SAM cases using checklists, re-diagnosing the cases admitted for treatment and reviewing admissions cards and registers. One hundred twenty-five cases, assessed and treated by the CHWs, were observed. The majority of children were correctly assessed for the presence of major clinical signs (cough, diarrhoea, fever, and vomiting; 97.6%), and similarly most children were checked for the presence of danger signs (95.2%). Mid-upper arm circumference was correctly assessed in 96.8% of children and oedema was correctly assessed in 78.4% (The composite indicator, which includes all essential tasks to provide high-quality treatment, was achieved in 79.5% of cases. This paper concludes that well-trained and supervised CHWs are capable of managing cases of uncomplicated SAM. This suggests that such a strategy is an opportunity to increase access to quality treatment in Mali for SAM cases. However, further evidence is required to ensure that this level of care can be achieved at scale.
| S-EPMC6866144 | biostudies-literature
Project description:Previous studies have described barriers to access of childhood severe acute malnutrition (SAM) treatment, including long travel distances and high opportunity costs. To increase access in remote communities, the International Rescue Committee developed a simplified SAM treatment protocol and low-literacy-adapted tools for community-based distributors (CBD, the community health worker cadre in South Sudan) to deliver treatment in the community. A mixed-methods pilot study was conducted to assess whether low-literate CBDs can adhere to a simplified SAM treatment protocol and to examine the community acceptability of CBDs providing treatment. Fifty-seven CBDs were randomly selected to receive training. CBD performance was assessed immediately after training, and 44 CBDs whose performance score met a predetermined standard were deployed to test the delivery of SAM treatment in their communities. CBDs were observed and scored on their performance on a biweekly basis through the study. Immediately after training, 91% of the CBDs passed the predetermined 80% performance score cut-off, and 49% of the CBDs had perfect scores. During the study, 141 case management observations by supervisory staff were conducted, resulting in a mean score of 89.9% (95% CI: 86.4%-96.0%). For each performance supervision completed, the final performance score of the CBD rose by 2.0% (95% CI: 0.3%-3.7%), but no other CBD characteristic was associated with the final performance score. This study shows that low-literate CBDs in South Sudan were able to follow a simplified treatment protocol for uncomplicated SAM with high accuracy using low-literacy-adapted tools, showing promise for increasing access to acute malnutrition treatment in remote communities.
| S-EPMC7199048 | biostudies-literature
Project description:BackgroundCommunity health workers (CHWs) are recommended to screen for acute malnutrition in the community by assessing mid-upper arm circumference (MUAC) on children between 6 and 59 months of age. MUAC is a simple screening tool that has been shown to be a better predictor of mortality in acutely malnourished children than other practicable anthropometric indicators. This study compared, under program conditions, mothers and CHWs in screening for severe acute malnutrition (SAM) by color-banded MUAC tapes.MethodsThis pragmatic interventional, non-randomized efficacy study took place in two health zones of Niger's Mirriah District from May 2013 to April 2014. Mothers in Dogo (Mothers Zone) and CHWs in Takieta (CHWs Zone) were trained to screen for malnutrition by MUAC color-coded class and check for edema. Exhaustive coverage surveys were conducted quarterly, and relevant data collected routinely in the health and nutrition program. An efficacy and cost analysis of each screening strategy was performed.ResultsA total of 12,893 mothers and caretakers were trained in the Mothers Zone and 36 CHWs in the CHWs Zone, and point coverage was similar in both zones at the end of the study (35.14 % Mothers Zone vs 32.35 % CHWs Zone, p = 0.9484). In the Mothers Zone, there was a higher rate of MUAC agreement (75.4 % vs 40.1 %, p <0.0001) and earlier detection of cases, with median MUAC at admission for those enrolled by MUAC <115 mm estimated to be 1.6 mm higher using a smoothed bootstrap procedure. Children in the Mothers Zone were much less likely to require inpatient care, both at admission and during treatment, with the most pronounced difference at admission for those enrolled by MUAC < 115 mm (risk ratio = 0.09 [95 % CI 0.03; 0.25], p < 0.0001). Training mothers required higher up-front costs, but overall costs for the year were much lower ($8,600 USD vs $21,980 USD.).ConclusionsMothers were not inferior to CHWs in screening for malnutrition at a substantially lower cost. Children in the Mothers Zone were admitted at an earlier stage of SAM and required fewer hospitalizations. Making mothers the focal point of screening strategies should be included in malnutrition treatment programs.Trial registrationThe trial is registered with clinicaltrials.gov (Trial number NCT01863394).
| S-EPMC5011948 | biostudies-literature
Project description:BackgroundLittle is known about the contribution of community health posts and community health workers (CHWs) to geographical accessibility of primary healthcare (PHC) services at community level and strategies for optimising geographical accessibility to these services.MethodsUsing a complete georeferenced census of community health posts and CHWs in Niger and other high-resolution spatial datasets, we modelled travel times to community health posts and CHWs between 2000 and 2013, accounting for training, commodities and maximum population capacity. We estimated additional CHWs needed to optimise geographical accessibility of the population beyond the reach of the existing community health post network. We assessed the efficiency of geographical targeting of the existing community health post network compared with networks designed to optimise geographical targeting of the estimated population, under-5 deaths and Plasmodium falciparum malaria cases.ResultsThe per cent of the population within 60-minute walking to the nearest community health post with a CHW increased from 0.0% to 17.5% between 2000 and 2013. An estimated 10.4 million people (58.5%) remained beyond a 60-minute catchment of community health posts. Optimal deployment of 7741 additional CHWs could increase geographical coverage from 41.5% to 82.9%. Geographical targeting of the existing community health post network was inefficient but optimised networks could improve efficiency by 32.3%-47.1%, depending on targeting metric.InterpretationsWe provide the first estimates of geographical accessibility to community health posts and CHWs at national scale in Niger, highlighting improvements between 2000 and 2013, geographies where gaps remained and approaches for optimising geographical accessibility to PHC services at community level.
| S-EPMC8186743 | biostudies-literature
Project description:BackgroundSevere 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.MethodsThe 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.ResultsCORPs 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.ConclusionThe 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.
| S-EPMC8520247 | biostudies-literature
Project description:BackgroundCommunity Health Workers (CHWs) have a positive impact on the provision of community-based primary health care through screening, treatment, referral, psychosocial support, and accompaniment. With a broad scope of work, CHW programs must balance the breadth and depth of tasks to maintain CHW motivation for high-quality care delivery. Few studies have described the CHW perspective on intrinsic and extrinsic motivation to enhance their programmatic activities.MethodsWe utilized an exploratory qualitative study design with CHWs employed in the household model in Neno District, Malawi, to explore their perspectives on intrinsic and extrinsic motivators and dissatisfiers in their work. Data was collected in 8 focus group discussions with 90 CHWs in October 2018 and March-April 2019 in seven purposively selected catchment areas. All interviews were audiotaped, transcribed verbatim, coded, and analyzed using Dedoose.ResultsThemes of complex intrinsic and extrinsic factors were generated from the perspectives of the CHWs in the focus group discussions. Study results indicate that enabling factors are primarily intrinsic factors such as positive patient outcomes, community respect, and recognition by the formal health care system but can lead to the challenge of increased scope and workload. Extrinsic factors can provide challenges, including an increased scope and workload from original expectations, lack of resources to utilize in their work, and rugged geography. However, a positive work environment through supportive relationships between CHWs and supervisors enables the CHWs.ConclusionThis study demonstrated enabling factors and challenges for CHW performance from their perspective within the dual-factor theory. We can mitigate challenges through focused efforts to limit geographical distance, manage workload, and strengthen CHW support to reinforce their recognition and trust. Such programmatic emphasis can focus on enhancing motivational factors found in this study to improve the CHWs' experience in their role. The engagement of CHWs, the communities, and the formal health care system is critical to improving the care provided to the patients and communities, along with building supportive systems to recognize the work done by CHWs for the primary health care systems.
| S-EPMC8840069 | biostudies-literature
Project description:BackgroundCommunity health worker (CHW)-delivered acute malnutrition treatment programs have been tested previously, but not with low-literate/-numerate cadres who operate in areas with the highest malnutrition burden and under-five mortality rates. The International Rescue Committee developed low-literacy-adapted tools and treatment protocol to enable low-literate/-numerate community-based distributors (CBD, the CHW cadre in South Sudan) to treat children for severe acute malnutrition (SAM) in their communities.MethodsWe conducted a prospective cohort study in March-September 2017, with 44 CBDs enrolling a total of 308 SAM children into treatment in their communities. Child treatment outcomes and length of treatment were documented. Uncomplicated SAM cases, defined for our study as children with mid-upper arm circumference (MUAC) of 90 to <115 mm or bilateral pitting oedema, without any medical complications, were treated for up to 16 weeks, and were considered fully recovered when they reached MUAC≥125 mm for two consecutive weeks.ResultsThe recovery rate from the severe to the moderate acute malnutrition (MAM) cut-off of MUAC 115 mm was 91% (95% confidence interval (CI) = 88%-95%). The median length of treatment was five weeks. The recovery rate of children from SAM to full recovery was 75% (95% CI = 69%-81%). The median time to full recovery was eight weeks. The recovery rates reported here exclude children referred for care from the denominator, per standard reporting of acute malnutrition treatment recovery rates. When the data were compared against routine monitoring and evaluation data from nearby static clinics, children treated by CBDs appeared to have improved continuity of care and shorter time to recovery.ConclusionsThe recovery rate for SAM children enrolled in acute malnutrition treatment by low-literate CBDs shows promise that deploying CHWs to treat SAM in areas with high prevalence and low treatment access may lead to higher recovery, better continuity of care in the transition between SAM and MAM, and shorter treatment time. Proper adaptations of tools and protocols can empower CHW cadres with low literacy and numeracy to successfully complete treatment steps. Key questions of scalability and cost-effectiveness remain.
| S-EPMC7295452 | biostudies-literature
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:Geographical and economic access barriers to health facilities (HF) have been identified as some of the most important causes of the low coverage of severe acute malnutrition (SAM) treatment. The objective of this study is to assess the effectiveness and coverage of SAM treatment delivered by community health workers (CHWs) in the Guidimakha region in Mauritania, compared to the HF based approach. This study was a nonrandomized controlled trial, including two rural areas. The control group received outpatient treatment for uncomplicated SAM from HF, whilst the intervention group received outpatient treatment for uncomplicated SAM from HF or CHWs. A total of 869 children aged 6-59 months with SAM without medical complications were included in the study. The proportion of cured children was 82.3% in the control group, and 76.4% in the intervention group, we found no significant difference between the groups. Coverage in the intervention zone increased from 53.6% to 71.7%. In contrast, coverage remained at approximately 44% in the control zone from baseline to end-line. This study is the first to demonstrate in Mauritania that the decentralization model of CHWs treating SAM improves acute malnutrition treatment coverage and complies with the international quality standards for community treatment of acute malnutrition. The non-randomized study design may limit the quality of the evidence, but these results could be used by political decision-makers as a first step in revising the protocol for acute malnutrition management.
| S-EPMC8700149 | biostudies-literature