Measuring Knowledge of Community Health Workers at the Last Mile in Liberia: Feasibility and Results of Clinical Vignette Assessments

Downey, Jordan; McKenna, Anne H; Mendin, Savior; Waters, Adele; Dunbar, Nelson; Tehmeh, Lekilay; Siedner, Mark J.; Panjabi, Raj; Kraemer, John; Kenny, Avi; Ly, E John; Bass, Jennifer; Huang, Kuang-Ning; Khan, Mirbaz; Uchtmann, Nathan; Agarwal, Anup; Hirschhorn, Lisa R.

doi:10.9745/ghsp-d-20-00380

Cited by 8 publications

(6 citation statements)

References 17 publications

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“…The trend was the same for the two additional DRC-specific signs triggering RAS use, although the association was not significant in children suffering from “weakness or asthenia”. Findings from Liberia have shown that the proportions of correct diagnosis and treatment by community-based healthcare providers varied substantially for uncomplicated disease, but consistency was better for more severe cases, even though the accurate recognition of danger signs was sub-optimal [ 38 ]. Findings from this study suggest that danger signs increase substantially the probability of receiving RAS, but not subsequent referral and treatment at a RHF.…”

Section: Discussionmentioning

confidence: 99%

Key factors predicting suspected severe malaria case management and health outcomes: an operational study in the Democratic Republic of the Congo

Okitawutshu

Signorell

Kalenga

et al. 2022

Malar J

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Background Evidence suggests that pre-referral Rectal Artesunate (RAS) can be a life-saving intervention for severe malaria in remote settings in Africa. Recognition of danger signs indicative of severe malaria is critical for prompt and appropriate case management. Methods This was an observational study conducted in three Health Zones of the Democratic Republic of the Congo to determine the distribution of dangers signs for severe malaria and assess their impact on RAS use, referral completion, injectable treatment and ACT provision, and health outcomes including death. An individual-level analysis was carried out, using multilevel-mixed effects logistic regression models. Severely ill febrile children < 5 years seeking care from community-based healthcare providers were recruited into a patient surveillance system based on the presence of key danger signs. Clinical and case management data were collected comprehensively over a 28 days period. Treatment seeking was elicited and health outcomes assessed during 28 days home visits. Results Overall, 66.4% of patients had iCCM general danger signs. Age of 2–5 years and iCCM general danger signs predicted RAS use (aOR = 2.77, 95% CI 2.04–3.77). RAS administration positively affected referral completion (aOR = 0.63, 95% CI 0.44–0.92). After RAS rollout, 161 children died (case fatality ratio: 7.1%, 95% CI 6.1–8.2). RAS improved the health status of the children on Day 28 (aOR = 0.64, 95% CI 0.45–0.92) and there was a non-significant trend that mortality was higher in children not receiving RAS (aOR = 1.50, 95% CI 0.86–2.60). Full severe malaria treatment at the RHF including injectable anti-malarial and a course of ACT was highly protective against death (aOR = 0.26, 95% CI 0.09–0.79). Conclusions The main findings point towards the fact that danger signs are reasonably well recognized by health provider at the primary care level, and that RAS could influence positively health outcomes of such severe disease episodes and death. Its effectiveness is hampered by the insufficient quality of care at RHF, especially the provision of a full course of ACT following parenteral treatment. These are simple but important findings that requires urgent action by the health system planners and implementers.

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Section: Discussionmentioning

confidence: 99%

Key factors predicting suspected severe malaria case management and health outcomes: an operational study in the Democratic Republic of the Congo

Okitawutshu

Signorell

Kalenga

et al. 2022

Malar J

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“…Evaluation of precursor programs to Liberia's National CHA Program found substantial improvements in childhood illness care seeking from a qualified provider, including consistent improvements in care for childhood fever, diarrhea, and acute respiratory illness by qualified providers [11,12]. Further, Liberian community health assistants have been found to have acceptable levels of knowledge about childhood disease treatment [25]. Finally, a recent analysis of Liberian District Health Information System data found that, in areas served by community health assistants after the launch of the NCHAP program, a little over half of malaria diagnoses had shifted from facilities to community health assistants, 95% of diagnoses were confirmed with RDT or microscopy, and diagnosis appeared to be sustained during the first nine months of the covid-19 pandemic [26].…”

Section: Discussionmentioning

confidence: 99%

Impact of the Liberian National Community Health Assistant Program on childhood illness care in Grand Bassa County, Liberia

Mendin¹,

Kolubah²,

Karlay³

et al. 2022

PLOS Glob Public Health

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Liberia launched its National Community Health Assistant Program in 2016, which seeks to ensure that all people living 5 kilometers or farther from a health facility have access to trained, supplied, supervised, and paid community health workers (CHWs). This study aims to evaluate the impact of the national program following implementation in Grand Bassa County in 2018 using data from population-based surveys that included information on 1291 illness episodes. We measured before-to-after changes in care for childhood illness by qualified providers in a portion of the county that implemented in a first phase compared to those which had not yet implemented. We also assessed changes in whether children received oral rehydration therapy for diarrhea and malaria rapid diagnostic tests if they had a fever by a qualified provider (facility based or CHW). For these analyses, we used a difference-in-differences approach and adjusted for potential confounding using inverse probability of treatment weighting. We also assessed changes in the source from which care was received and examined changes by key dimensions of equity (distance from health facilities, maternal education, and household wealth). We found that care of childhood illness by a qualified provider increased by 60.3 percentage points (95%CI 44.7–76.0) more in intervention than comparison areas. Difference-in-differences for oral rehydration therapy and malaria rapid diagnostic tests were 37.6 (95%CI 19.5–55.8) and 38.5 (95%CI 19.9–57.0) percentage points, respectively. In intervention areas, care by a CHW increased from 0 to 81.6% and care from unqualified providers dropped. Increases in care by a qualified provider did not vary significantly by household wealth, remoteness, or maternal education. This evaluation found evidence that the Liberian National Community Health Assistant Program has increased access to effective care in rural Grand Bassa County. Improvements were approximately equal across three measured dimensions of marginalization.

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“…Likewise, the trend was the same for the two additional signs triggering RAS use in DRC, although the association was not significant in children suffering from asthenia (weakness). Findings from Liberia have shown that the proportions of correct diagnosis and lifesaving treatment varied, especially for uncomplicated disease, but that the variability was lower for more severe cases, even though the accurate recognition of danger signs was sub-optimal (34).…”

Section: Discussionmentioning

confidence: 99%

Danger signs and management of suspected severe malaria cases at community level and in referral health facilities: an operational study in the Democratic Republic of the Congo

Okitawutshu

Signorell

Kalenga

et al. 2021

Preprint

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BackgroundEvidence from one trial in Africa suggests that pre-referral Rectal Artesunate (RAS) can be a life-saving intervention for severe malaria in remote settings, where parenteral treatment is not available. Recognition of danger signs indicative of severe malaria is critical for prompt and appropriate case management.MethodsAn observational study was conducted in the Democratic Republic of the Congo (DRC) in the frame of the multi-country CARAMAL project, to assess the effectiveness of RAS under real-world conditions. Severely ill feverish children <5 years seeking care from a community-based healthcare provider were recruited in three rural health zones into a patient surveillance system. They were subsequently followed within the healthcare system and at home after 28 days to determine care seeking, antimalarial treatment provision and health outcomes.ResultsOverall, 66.4% of patients had iCCM general danger signs, as well as more specific danger signs. Children aged 2-5 years (aOR=1.58, 95% CI 1.20–2.08) and those presenting iCCM general danger signs were more likely to receive RAS (aOR = 2.77, 95% CI 2.04–3.77). Injectable treatment was less likely with RAS pre-referral treatment (aOR=0.21, 95% 0.13– 0.33). In the post-RAS phase, the case fatality ratio was 7.1%. Children not receiving RAS had a higher risk of dying, but this was not statistically significant (aOR = 1.50, 95% CI 0.86– 2.60). The odds of dying were reduced in patients without iCCM general danger signs, but just not statistically so (aOR = 0.64, 95% CI 0.38–1.06). Full oral therapy at a RHF was highly protective (aOR = 0.13, 95% CI 0.07-0.26), while a full treatment of severe malaria (injectable + oral) was shown to also decrease massively the odds of dying (aOR = 0.26, 95% CI 0.09– 0.79) compared to injectable treatment alone.ConclusionsBetter understanding the determinants of successful case management, and targeted improvements of the health system (especially the provision of a full course of an oral antimalarial) are crucial for improving health oucomes of children with suspected severe malaria.

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Measuring Knowledge of Community Health Workers at the Last Mile in Liberia: Feasibility and Results of Clinical Vignette Assessments

Cited by 8 publications

References 17 publications

Key factors predicting suspected severe malaria case management and health outcomes: an operational study in the Democratic Republic of the Congo

Key factors predicting suspected severe malaria case management and health outcomes: an operational study in the Democratic Republic of the Congo

Impact of the Liberian National Community Health Assistant Program on childhood illness care in Grand Bassa County, Liberia

Danger signs and management of suspected severe malaria cases at community level and in referral health facilities: an operational study in the Democratic Republic of the Congo

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