Impact of an integrated community case management programme on uptake of appropriate diarrhoea and pneumonia treatments in Uganda: A propensity score matching and equity analysis study.
BACKGROUND
Pneumonia and diarrhoea disproportionately affect children in resource-poor settings. Integrated community case management (iCCM) involves community health workers treating diarrhoea, pneumonia and malaria. Studies on impact of iCCM on appropriate treatment and its effects on equity in access to the same are limited. The objective of this study was to measure the impact of integrated community case management (iCCM) as the first point of care on uptake of appropriate treatment for children with a classification of pneumonia (cough and fast breathing) and/or diarrhoea and to measure the magnitude and distribution of socioeconomic status related inequality in use of iCCM.


METHODS
Following introduction of iCCM, data from cross-sectional household surveys were examined for socioeconomic inequalities in uptake of treatment and use of iCCM among children with a classification of pneumonia or diarrhoea using the Erreygers' corrected concentration index (CCI). Propensity score matching methods were used to estimate the average treatment effects on the treated (ATT) for children treated under the iCCM programme with recommended antibiotics for pneumonia, and ORS plus or minus zinc for diarrhoea.


RESULTS
Overall, more children treated under iCCM received appropriate antibiotics for pneumonia (ATT = 34.7%, p < 0.001) and ORS for diarrhoea (ATT = 41.2%, p < 0.001) compared to children not attending iCCM. No such increase was observed for children receiving ORS-zinc combination (ATT = -0.145, p < 0.05). There were no obvious inequalities in the uptake of appropriate treatment for pneumonia among the poorest and least poor (CCI = -0.070; SE = 0.083). Receiving ORS for diarrhoea was more prevalent among the least poor groups (CCI = 0.199; SE = 0.118). The use of iCCM for pneumonia was more prevalent among the poorest groups (CCI = -0.099; SE = 0.073). The use of iCCM for diarrhoea was not significantly different among the poorest and least poor (CCI = -0.073; SE = 0.085).


CONCLUSIONS
iCCM is a potentially equitable strategy that significantly increased the uptake of appropriate antibiotic treatment for pneumonia and ORS for diarrhoea, but not the uptake of zinc for diarrhoea. For maximum impact, interventions increasing zinc uptake should be considered when scaling up iCCM programmes.
Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18 A, Floor 4, Stockholm, SE-171 77, Sweden. nyonjoagie@gmail.com.|Malaria Consortium Uganda Office, Plot 25, Upper East Naguru, P.O. Box 8045, Kampala, Uganda. nyonjoagie@gmail.com.
Agnes
A
Nanyonjo
Malaria Consortium Uganda Office, Plot 25, Upper East Naguru, P.O. Box 8045, Kampala, Uganda. J.Ssekitoleeko@malariaconsortium.org.
James
J
Ssekitooleko
Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2A 4LT, UK. h.counihan@malariaconsortium.org.
Helen
H
Counihan
Department of Epidemiology and Biostatistics, Makerere School of Public Health, Makerere University, New Mulago Hospital Complex, P.O. Box 7062, Kampala, Uganda. fmakumbi@musph.ac.ug.
Frederick
F
Makumbi
Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18 A, Floor 4, Stockholm, SE-171 77, Sweden. Goran.tomson@ki.se.|Medical Management Centre (MMC), Karolinska Institutet, Stockholm, Sweden. Goran.tomson@ki.se.
Göran
G
Tomson
Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18 A, Floor 4, Stockholm, SE-171 77, Sweden. Karin.kallander@ki.se.|Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2A 4LT, UK. Karin.kallander@ki.se.|Department of Epidemiology and Biostatistics, Makerere School of Public Health, Makerere University, New Mulago Hospital Complex, P.O. Box 7062, Kampala, Uganda. Karin.kallander@ki.se.
Karin
K
Källander
D019090:Case Management / Q000458:organization & administration*; D003150:Community Health Workers; D003430:Cross-Sectional Studies; D003967:Diarrhea / Q000188:drug therapy*; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D011014:Pneumonia / Q000188:drug therapy*; D057216:Propensity Score; D012923:Social Class; D014454:Uganda