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Integrated community case management by drug sellers influences appropriate treatment of paediatric febrile illness in South Western Uganda: a quasi-experimental study.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.ORCID iD: 0000-0001-8036-168x
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2017 (English)In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 16, no 1, article id 425Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Fever case management is a major challenge for improved child health globally, despite existence of cheap and effective child survival health technologies. The integrated Community Case Management (iCCM) intervention of paediatric febrile illnesses though adopted by Uganda's Ministry of Health to be implemented by community health workers, has not addressed the inaccess to life-saving medicines and diagnostics. Therefore, the iCCM intervention was implemented in private drug shops and evaluated for its effect on appropriate treatment of paediatric fever in a low malaria transmission setting in South Western Uganda.

METHODS: From June 2013 to September 2015, the effect of the iCCM intervention on drug seller paediatric fever management and adherence to iCCM guidelines was assessed in a quasi-experimental study in South Western Uganda. A total of 212 care-seeker exit interviews were done before and 285 after in the intervention arm as compared to 216 before and 268 care-seeker interviews at the end of the study period in the comparison arm. The intervention effect was assessed by difference-in-difference analysis of drug seller treatment practices against national treatment recommendations between the intervention and comparison arms. Observed proportions among care-seeker interviews were compared with corresponding proportions from 5795 child visits recorded in patient registries and 49 direct observations of drug seller-care-seeker encounters in intervention drug shops.

RESULTS: The iCCM intervention increased the appropriate treatment of uncomplicated malaria, pneumonia symptoms and non-bloody diarrhoea by 80.2% (95% CI 53.2-107.2), 65.5% (95% CI 51.6-79.4) and 31.4% (95% CI 1.6-61.2), respectively. Within the intervention arm, drug seller scores on appropriate treatment for pneumonia symptoms and diagnostic test use were the same among care-seeker exit interviews and direct observation. A linear trend (negative slope, - 0.009 p value < 0.001) was observed for proportions of child cases prescribed any antimicrobial medicine in the intervention arm drug shops.

CONCLUSIONS: The iCCM intervention improved appropriate treatment for uncomplicated malaria, pneumonia symptoms and diarrhoea. Drug seller adherence to iCCM guidelines was high, without causing excessive prescription of antimicrobial medicines in this study. Further research should assess whether this effect is sustained over time and under routine supervision models.

Place, publisher, year, edition, pages
2017. Vol. 16, no 1, article id 425
Keywords [en]
Appropriate treatment, Diagnostics, Drug sellers, Febrile illness, Integrated case management, Malaria, Pneumonia, Private sector, Uganda
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:uu:diva-332597DOI: 10.1186/s12936-017-2072-9ISI: 000413685400004PubMedID: 29061148OAI: oai:DiVA.org:uu-332597DiVA, id: diva2:1153533
Available from: 2017-10-30 Created: 2017-10-30 Last updated: 2018-09-07Bibliographically approved
In thesis
1. Towards a functioning retail health market: Evaluating the integrated Community Case Management Intervention for Pediatric Febrile Illness in Drug Shops in Rural South Western Uganda
Open this publication in new window or tab >>Towards a functioning retail health market: Evaluating the integrated Community Case Management Intervention for Pediatric Febrile Illness in Drug Shops in Rural South Western Uganda
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objectives: This thesis examined the health systems effects of implementing the integrated Community Case Management (iCCM) intervention for paediatric febrile illnesses in a retail health market in South Western Uganda. More specifically, it evaluated drug seller interpretation of malaria Rapid Diagnostics Test (RDT) results (study I), adherence to iCCM guidelines (study II) and the intervention effect on households’ perceived quality of drug seller fever care and care-seeking choice. Study IV qualitatively analysed the iCCM intervention implementation and causal mechanisms for observed effects. Improved understanding of such retail health markets will inform policy decisions and interventions for Universal Health Coverage.

Methods: The study used mixed-methods design with an intervention and comparison arm, and pre-test assessment in both study arms. Data collection methods included care-seeker drug shop exit interviews and household surveys using structured questionnaires, focus group discussions, in-depth interviews, review of secondary data and a laboratory analysis of finger-prick capillary blood samples.

Results: Among those tested for malaria parasites, there was 93% (95% CI 88.3, 96.2) agreement between drug sellers and laboratory scientist re-reading and with a kappa value of 0.84 (95% CI 0.75, 0.92) (Study I). The drug seller compliance with the reported malaria RDT results was 92.5% (95% CI 87.9, 95.7) (Study I). The iCCM intervention improved appropriate treatment for uncomplicated malaria by 34.5% (95% CI 8.6, 60.4), for pneumonia symptoms by 54.7% (95% CI 28.4, 81.0) and reduced appropriate treatment for non-bloody diarrhoea -11.2% (95% CI -65.5, 43.1), after adjusting for extraneous variables (Study II). Implementing the iCCM intervention in drug shops decreased the odds of households perceiving drug seller fever care as good but increased the household odds of choosing to seek care from private health facilities versus within the community (Study III). Drug sellers operated in a retail market system influenced by knowledge and actions of care-seekers, CHWs, government health workers and regulators, and also how formal and informal rules and norms were applied (Study IV). Implementation of the iCCM intervention at drug shops was modified and shaped by the emerging actor perceptions and behaviours (Study IV).

Conclusions: This thesis demonstrates the implementation, causal mechanisms and contextual factors of the iCCM intervention in a rural retail health market. Fidelity and quality of iCCM intervention by drug sellers was acceptably high, probably as a result of co-interventions. Interventions in retail health markets should comprise of components that target the multiple actors or influences that shape that market. Multi-component health system interventions are complex to implement and also create complexity in their evaluation. When technologies are involved, their analysis should go beyond their substance as products and view them as items that encapsulate interests of different actors, some of which maybe converging with or competing against societal goals.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 102
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1494
Keywords
Integrated community case management; Malaria, Pneumonia symptoms, Drug shops, Retail health markets, Uganda, Under-five, Evaluation, Mixed-methods, Febrile illness, Universal Health Coverage
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-359992 (URN)978-91-513-0439-7 (ISBN)
Public defence
2018-10-23, Gunnesalen, Akademiska sjukhuset - Entrance 10, Uppsala, 09:00 (English)
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Available from: 2018-10-01 Created: 2018-09-07 Last updated: 2018-10-16

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Kitutu, Freddy EricEkholm Selling, KatarinaPeterson, Stefan

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