Treatment of Sick Children Seeking Care in the Private Health Sector in Uganda: A Cluster Randomized Trial

Abstract

The main objective of this study was to assess whether training of private health providers and community sensitization on the importance of effective prompt care seeking and the need for referral could improve treatment of sick children in the private health sector in Uganda. Private providers were trained to diagnose and treat sick children according to the integrated community case management (iCCM) guidelines. In the control arm, routine services were offered. The outcomes were seeking care within 24 hours of onset of symptoms and appropriate case management for malaria, pneumonia, and diarrhea among children aged < 5 years. A total of 10,809 sick children (5,955 in the intervention arm and 4,854 in the control arm) presented for diagnosis and treatment. The percentage seeking care within 24 hours of onset of symptoms was 45.4% (95% CI 36.0-48.8) in the intervention arm versus 43.9% (95% CI 38.1-49.8) in the control arm (P = 0.04). Adherence to malaria rapid diagnostic test (mRDT) results was high, with 1,459 (94.3%) in the intervention arm versus 1,402 (83.0%) in the control arm (P = 0.04). Appropriate treatment of mRDT-positive children with artemisininbased combination therapy was seen in 93.1% (95% CI 88.5-97.7) in the intervention arm versus 85.1% (95% CI 78.6-91.7) in the control arm (P = 0.03). Adherence to iCCM guidelines was very high: 89.1% of children with diarrhea in the intervention arm and 80.4% in the control arm were given oral rehydration salts and zinc (P = 0.01). Of the children with a respiratory rate > 40 breaths/minute, 1,596 (85.1%) in the intervention arm versus 104 (54.5%) in the control arm were given amoxicillin (P = 0.01). In conclusion, the intervention improved treatment of malaria, pneumonia, and diarrhea because of provider adherence to treatment guidelines. The policy implications of these findings are to initiate a dialogue at district and national levels on how to scale up the intervention in the private sector. NCT02450630 registered with ClinicalTrials.gov: May 9, 2015.

“Testing for malaria does not cure any pain” A qualitative study exploring low use of malaria rapid diagnostic tests at drug shops in rural Uganda

“…Drug shop vendors expressed a desire to receive training to improve the health services they provide for the community, and trainings were an acceptable option to health officials and VHTs. While previous interventions in Uganda trained drug shop vendors on how to use and interpret RDTs [21][22][23][24][25], vendors in our study reported high levels of comfort using RDTs. Therefore, we recommend trainings focus on more nuanced aspects of RDT use, such as counseling.…”

“…Several programs in Uganda have increased the use of RDTs at drug shops, and improved the quality of malaria case management more generally, through vendor trainings, community-level demand generation activities, provision of free or subsidized RDTs, and peer supervision [21][22][23][24][25][26]. While most studies were pilot interventions focused on RDT introduction [21][22][23][24], these diagnostic tests are now commonly stocked at drug shops [27].…”

Appropriateness of Care for Common Childhood Infections at Low-Level Private Health Facilities in a Rural District in Western Uganda

“…Inappropriate care for these common childhood infections has been described by other researchers in Uganda and other LMICs. Mbonye et al in their research among private clinics and drug shops found that children with normal respiratory rates received unnecessary antibiotics for pneumonia [44], while Kjaergaad et al found inappropriate prescription rate of antibiotics for viral upper respiratory tract infections of 23-68% in Uganda and other countries across the globe [45]. Other studies carried out in private and public health facilities in Uganda and other African countries found that 7-24% children testing positive for malaria never received the correct malaria medicine [46,47].…”

Management of Childhood Infections in Poorly Planned Urban Settlements in Kampala and Wakiso Districts of Uganda

“…The intervention improved prompt care seeking within 24 hours of onset of symptoms, included a high adherence to mRDT results, and appropriate treatment of mRDT-positive children with ACTs was high, as well as diagnosis and treatment of diarrhea and pneumonia. 11 This provides further justification to scale up iCCM in poorly planned settlements in Uganda.…”

“…Even in planned urban settlements with a well-established formal and informal private sectors, it has been shown that treatments received in these areas are often inadequate or inappropriate. 3 – 11 Training of accredited private sector providers to deliver iCCM remains an alternative approach that has yet to be tested—but has so far been identified as a priority for research. 2 – 4 …”