title: Health Facility Utilisation Changes during the Introduction of Community Case Management of Malaria in South Western Uganda: An Interrupted Time Series Approach.
abstract: BACKGROUND
  Malaria endemic countries have scaled-up community health worker (CHW) interventions, to diagnose and treat malaria in communities with limited access to public health systems. The evaluations of these programmes have centred on CHW's compliance to guidelines, but the broader changes at public health centres including utilisation and diagnoses made, has received limited attention.
  
  
  METHODS
  This analysis was conducted during a CHW-intervention for malaria in Rukungiri District, Western Uganda. Outpatient department (OPD) visit data were collected for children under-5 attending three health centres one year before the CHW-intervention started (pre-intervention period) and for 20 months during the intervention (intervention-period). An interrupted time series analysis with segmented regression models was used to compare the trends in malaria, non-malaria and overall OPD visits during the pre-intervention and intervention-period.
  
  
  RESULTS
  The introduction of a CHW-intervention suggested the frequency of diagnoses of diarrhoeal diseases, pneumonia and helminths increased, whilst the frequency of malaria diagnoses declined at health centres. In May 2010 when the intervention began, overall health centre utilisation decreased by 63% compared to the pre-intervention period and the health centres saw 32 fewer overall visits per month compared to the pre-intervention period (p<0.001). Malaria visits also declined shortly after the intervention began and there were 27 fewer visits per month during the intervention-period compared with the pre-intervention period (p<0.05). The declines in overall and malaria visits were sustained for the entire intervention-period. In contrast, there were no observable changes in trends of non-malarial visits between the pre-intervention and intervention-period.
  
  
  CONCLUSIONS
  This analysis suggests introducing a CHW-intervention can reduce the number of child malaria visits and change the profile of cases presenting at health centres. The reduction in workload of health workers may allow them to spend more time with patients or undertake additional curative or preventative roles.
authors.affiliation: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Sham
authors.initials: S
authors.lastname: Lal
authors.affiliation: C/O Vector Control Division, Ministry of Health, Kampala, Uganda.
authors.forename: Richard
authors.initials: R
authors.lastname: Ndyomugenyi
authors.affiliation: MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Neal D
authors.initials: ND
authors.lastname: Alexander
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Mylene
authors.initials: M
authors.lastname: Lagarde
authors.affiliation: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Lucy
authors.initials: L
authors.lastname: Paintain
authors.affiliation: Institute of International Health, Immunology and Microbiology & Institute of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
authors.forename: Pascal
authors.initials: P
authors.lastname: Magnussen
authors.affiliation: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Daniel
authors.initials: D
authors.lastname: Chandramohan
authors.affiliation: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Siân E
authors.initials: SE
authors.lastname: Clarke
mesh_terms: D019090:Case Management / Q000706:statistics & numerical data*; D002648:Child; D002675:Child, Preschool; D003150:Community Health Workers; D005843:Geography; D006268:Health Facilities / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D065186:Interrupted Time Series Analysis; D008288:Malaria / Q000453:epidemiology*; D010045:Outpatients / Q000706:statistics & numerical data; D012044:Regression Analysis; D012111:Residence Characteristics; D014454:Uganda / Q000453:epidemiology