title: Evaluating the effect of innovative motivation and supervision approaches on community health worker performance and retention in Uganda and Mozambique: study protocol for a randomised controlled trial.
abstract: BACKGROUND
  If trained, equipped and utilised, community health workers (CHWs) delivering integrated community case management for sick children can potentially reduce child deaths by 60%. However, it is essential to maintain CHW motivation and performance. The inSCALE project aims to evaluate, using a cluster randomised controlled trial, the effect of interventions to increase CHW supervision and performance on the coverage of appropriate treatment for children with diarrhoea, pneumonia and malaria.
  
  
  METHODS
  Participatory methods were used to identify best practices and innovative solutions. Quantitative community based baseline surveys were conducted to allow restricted randomisation of clusters into intervention and control arms. Individual informed consent was obtained from all respondents. Following formative research and stakeholder consultations, two intervention packages were developed in Uganda and one in Mozambique. In Uganda, approximately 3,500 CHWs in 39 clusters were randomised into a mobile health (mHealth) arm, a participatory community engagement arm and a control arm. In Mozambique, 275 CHWs in 12 clusters were randomised into a mHealth arm and a control arm. The mHealth interventions encompass three components: 1) free phone communication between users; 2) data submission using phones with automated feedback, messages to supervisors for targeted supervision, and online data access for district statisticians; and 3) motivational messages. The community engagement arm in Uganda established village health clubs seeking to 1) improve the status and standing of CHWs, 2) increase demand for health services and 3) communicate that CHWs' work is important. Process evaluation was conducted after 10 months and end-line surveys will establish impact after 12 months in Uganda and 18 months in Mozambique. Main outcomes include proportion of sick children appropriately treated, CHW performance and motivation, and cost effectiveness of interventions.
  
  
  CONCLUSIONS
  Study strengths include a user-centred design to the innovations, while weaknesses include the lack of a robust measurement of coverage of appropriate treatment. Evidence of cost-effective innovations that increase motivation and performance of CHWs can potentially increase sustainable coverage of iCCM at scale.
  
  
  BACKGROUND
  (identifier NCT01972321 ) on 22 April 22 2013.
authors: Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2A 4LT, UK. k.kallander@malariaconsortium.org.|Department of Public Health Sciences, Tomtebodavägen 18A, Karolinska Institutet, 17177, Stockholm, Sweden. k.kallander@malariaconsortium.org.|Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Science, PO box 8045, Kampala, Uganda. k.kallander@malariaconsortium.org.
authors: Karin
authors: K
authors: Källander
authors: Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK. d.strachan@ucl.ac.uk.
authors: Daniel
authors: D
authors: Strachan
authors: Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK. Seyi.Soremekun@lshtm.ac.uk.
authors: Seyi
authors: S
authors: Soremekun
authors: Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK. zhill.ich@gmail.com.
authors: Zelee
authors: Z
authors: Hill
authors: Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK. raghu.lingam@newcastle.ac.uk.
authors: Raghu
authors: R
authors: Lingam
authors: Malaria Consortium Africa, Plot 25 Upper Naguru East Road, Kampala, Uganda. j.tibenderana@malariaconsortium.org.
authors: James
authors: J
authors: Tibenderana
authors: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. Frida.Kasteng@lshtm.ac.uk.
authors: Frida
authors: F
authors: Kasteng
authors: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. Anna.Vassal@lshtm.ac.uk.
authors: Anna
authors: A
authors: Vassall
authors: Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2A 4LT, UK. s.meek@malariaconsortium.org.
authors: Sylvia
authors: S
authors: Meek
authors: Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK. Betty.Kirkwood@lshtm.ac.uk.
authors: Betty
authors: B
authors: Kirkwood
mesh_terms: D001291:Attitude of Health Personnel; D019985:Benchmarking; D019090:Case Management; D002648:Child; D002662:Child Health Services / Q000191:economics; D002983:Clinical Competence / Q000191:economics; D003150:Community Health Workers / Q000191:economics / Q000523:psychology*; D003299:Cooperative Behavior; D003362:Cost-Benefit Analysis; D019033:Delivery of Health Care, Integrated / Q000191:economics; D003967:Diarrhea / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D004059:Diffusion of Innovation; D017048:Health Care Costs; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008288:Malaria / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D009042:Motivation; D009073:Mozambique / Q000453:epidemiology; D010348:Patient Care Team / Q000191:economics; D010563:Personnel Turnover / Q000191:economics; D011014:Pneumonia / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D017216:Telemedicine; D014454:Uganda / Q000453:epidemiology; D000078329:Workforce