The performance of community health workers in the management of multiple childhood infectious diseases in Lira, northern Uganda – a mixed methods cross-sectional study

Abstract

BackgroundCommunity health workers (CHWs) have the potential to reduce child mortality by improving access to care, especially in remote areas. Uganda has one of the highest child mortality rates globally. Moreover, rural areas bear the highest proportion of this burden. The optimal performance of CHWs is critical. In this study, we assess the performance of CHWs in managing malaria, pneumonia, and diarrhea in the rural district of Lira, in northern Uganda.DesignsA cross-sectional mixed methods study was undertaken to investigate the performance of 393 eligible CHWs in the Lira district of Uganda. Case scenarios were conducted with a medical officer observing CHWs in their management of children suspected of having malaria, pneumonia, or diarrhea. Performance data were collected using a pretested questionnaire with a checklist used by the medical officer to score the CHWs. The primary outcome, CHW performance, is defined as the ability to diagnose and treat malaria, diarrhea, and pneumonia appropriately. Participants were described using a three group performance score (good vs. moderate vs. poor). A binary measure of performance (good vs. poor) was used in multivariable logistic regression to show an association between good performance and a range of independent variables. The qualitative component comprised seven key informant interviews with experts who had informed knowledge with regard to the functionality of CHWs in Lira district.ResultsOverall, 347 CHWs (88.3%) had poor scores in managing malaria, diarrhea, and pneumonia, 26 (6.6%) had moderate scores, and 20 (5.1%) had good scores. The factors that were positively associated with performance were secondary-level education (adjusted odds ratio [AOR] 2.72; 95% confidence interval [CI] 1.50–4.92) and meeting with supervisors in the previous month (AOR 2.52; 95% CI 1.12–5.70). Those factors negatively associated with CHW performance included: serving 100–200 households (AOR 0.24; 95% CI 0.12–0.50), serving more than 200 households (AOR 0.22; 95% CI 0.10–0.48), and an initial training duration lasting 2–3 days (AOR 0.13; 95% CI 0.04–0.41). The qualitative findings reinforced the quantitative results by indicating that refresher training, workload, and in-kind incentives were important determinants of performance.ConclusionsThe performance of CHWs in Lira was inadequate. There is a need to consider pre-qualification testing before CHWs are appointed. Providing ongoing support and supervision, and ensuring that CHWs have at least secondary education can be helpful in improving their performance. Health system managers also need to ensure that the CHWs’ workload is moderated as work overload will reduce performance. Finally, although short training programs are beneficial to some degree, they are not sufficient and should be followed up with regular refresher training.

Ongoing training of community health workers in low-income and middle-income countries: a systematic scoping review of the literature

“…Guidelines produced by the The United States Agency for International Development (USAID) Health Care Improvement Project recommend that refresher training should be provided at least every 6 months to update CHWs on new skills, reinforce initial training and ensure they are practising skills learnt, 16 yet some CHWs have not had refresher training for over 5 years. 17 This finding of a poor provision of ongoing training is commonplace and mentioned in several other studies, across multiple geographic contexts. 18–21 A multinational analysis from several countries in sub-Saharan Africa concluded that the current provision of refresher training courses was ‘not sufficient to meaningfully improve the quality of care in these countries’, raising into question the need to assess the effectiveness of training programmes, both from the perspective of the individual CHW and the health system in which they operate.…”

Towards a framework for analyzing determinants of performance of community health workers in malaria prevention and control: a systematic review

“…A total of 16 studies are included in this review, 5 of which were from East Africa, 4 from Central Africa, 3 from West Africa, and 4 from Southern Africa. Countries represented were Uganda with four studies [ 11 – 14 ], Kenya with three [ 15 – 17 ], one from Rwanda [ 18 ], one from Tanzania [ 19 ], one from Burkina Faso [ 20 ], one from Ghana [ 21 ], one from Mali [ 22 ], one from Malawi [ 23 ], and three from Zambia [ 24 – 27 ]. Twelve of the studies had a cross-sectional design [ 11 – 18 , 20 , 22 , 23 , 25 ], one was a mixed methods prospective study [ 24 ], one was a cluster randomized control trial [ 26 ], one was a randomized crossover trial [ 22 ], and one randomized control stepped wedge trial [ 21 ] (Table 1 ).…”

Longitudinal analysis of the capacities of community health workers mobilized for seasonal malaria chemoprevention in Burkina Faso

“…The progress is significant even though the baselines are already quite high and margins for progress are naturally limited. Research suggests that the capacities of community health workers tend to wane rather quickly [11,23,24] and that refresher training effectively enhances their performance [12,25,26]. The CBDs of the 2017 and 2018 campaigns thus seemed to have benefited from the cumulative contribution of each initial campaign training session, the supervision provided by the health teams during each round, and the regular refresher training preceding each round.…”