Quality of care in integrated community case management services in Bugoye, Uganda:a retrospective observational study
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Date
2018Author
Miller, James S.
English, Lacey
Matte, Michael
Mbusa, Rapheal
Ntaro, Moses
Bwambale, Shem
Kenney, Jessica
Siedner, Mark J.
Reyes, Raquel
Lee, Patrick T.
Mulogo, Edgar Mugema
Stone, Geren S.
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Background: Village health workers (VHWs) in fve villages in Bugoye subcounty (Kasese District, Uganda) provide
integrated community case management (iCCM) services, in which VHWs evaluate and treat malaria, pneumonia, and
diarrhoea in children under 5 years of age. VHWs use a “Sick Child Job Aid” that guides them through the evaluation
and treatment of these illnesses. A retrospective observational study was conducted to measure the quality of iCCM
care provided by 23 VHWs in 5 villages in Bugoye subcounty over a 2-year period.
Methods: Patient characteristics and clinical services were summarized using existing aggregate programme data.
Lot quality assurance sampling of individual patient records was used to estimate adherence to the iCCM algorithm,
VHW-level quality (based on adherence to the iCCM protocol), and change over time in quality of care (using generalized estimating equations regression modelling).
Results: For each of 23 VHWs, 25 patient visits were randomly selected from a 2-year period after iCCM care initiation.
In these visits, 97% (150) of patients with diarrhoea were treated with oral rehydration and zinc, 95% (216) of patients
with pneumonia were treated with amoxicillin, and 94% (240) of patients with malaria were treated with artemisininbased combination therapy or rectal artesunate. However, only 44% (44) of patients with a negative rapid test for
malaria were appropriately referred to a health facility. Overall, 75% (434) of patients received all the correct evaluation
and management steps. Only 9 (39%) of the 23 VHWs met the pre-determined LQAS threshold for high-quality care
over the 2-year observation period. Quality of care increased signifcantly in the frst 6 months after initiation of iCCM
services (p = 0.003), and then plateaued during months 7–24.
Conclusions: Quality of care was high for uncomplicated malaria, pneumonia and diarrhoea. Overall quality of care
was lower, in part because VHWs often did not follow the guidelines to refer patients with fever who tested negative
for malaria. Quality of care appears to improve in the initial months after iCCM implementation, as VHWs gain initial
experience in iCCM care
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