title: Community case management of malaria: exploring support, capacity and motivation of community medicine distributors in Uganda.
abstract: BACKGROUND
  In Uganda, community services for febrile children are expanding from presumptive treatment of fever with anti-malarials through the home-based management of fever (HBMF) programme, to include treatment for malaria, diarrhoea and pneumonia through Integrated Community Case Management (ICCM). To understand the level of support available, and the capacity and motivation of community health workers to deliver these expanded services, we interviewed community medicine distributors (CMDs), who had been involved in the HBMF programme in Tororo district, shortly before ICCM was adopted.
  
  
  METHODS
  Between October 2009 and April 2010, 100 CMDs were recruited to participate by convenience sampling. The survey included questionnaires to gather information about the CMDs' work experience and to assess knowledge of fever case management, and in-depth interviews to discuss experiences as CMDs including motivation, supervision and relationships with the community. All questionnaires and knowledge assessments were analysed. Summary contact sheets were made for each of the 100 interviews and 35 were chosen for full transcription and analysis.
  
  
  RESULTS
  CMDs faced multiple challenges including high patient load, limited knowledge and supervision, lack of compensation, limited drugs and supplies, and unrealistic expectations of community members. CMDs described being motivated to volunteer for altruistic reasons; however, the main benefits of their work appeared related to 'becoming someone important', with the potential for social mobility for self and family, including building relationships with health workers. At the time of the survey, over half of CMDs felt demotivated due to limited support from communities and the health system.
  
  
  CONCLUSIONS
  Community health worker programmes rely on the support of communities and health systems to operate sustainably. When this support falls short, motivation of volunteers can wane. If community interventions, in increasingly complex forms, are to become the solution to improving access to primary health care, greater attention to what motivates individuals, and ways to strengthen health system support are required.
authors.affiliation: Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda kristin.banek@lshtm.ac.uk.
authors.forename: Kristin
authors.initials: K
authors.lastname: Banek
authors.affiliation: Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
authors.forename: Joaniter
authors.initials: J
authors.lastname: Nankabirwa
authors.affiliation: Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
authors.forename: Catherine
authors.initials: C
authors.lastname: Maiteki-Sebuguzi
authors.affiliation: Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
authors.forename: Deborah
authors.initials: D
authors.lastname: DiLiberto
authors.affiliation: Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
authors.forename: Lilian
authors.initials: L
authors.lastname: Taaka
authors.affiliation: Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
authors.forename: Clare I R
authors.initials: CI
authors.lastname: Chandler
authors.affiliation: Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
authors.forename: Sarah G
authors.initials: SG
authors.lastname: Staedke
mesh_terms: D000328:Adult; D000962:Antimalarials / Q000627:therapeutic use*; D019090:Case Management; D003153:Community Health Services; D003150:Community Health Workers / Q000523:psychology*; D005260:Female; D006801:Humans; D008288:Malaria / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D009042:Motivation; D012424:Rural Population; D011795:Surveys and Questionnaires; D014454:Uganda; D014838:Volunteers
chemical_list: D000962:Antimalarials
keywords: Malaria; Uganda; case management; community health; community health volunteers; community health workers; community medicine distributors; health workers; motivation