title: Improving the quality of paediatric malaria diagnosis and treatment by rural providers in Myanmar: an evaluation of a training and support intervention.
abstract: BACKGROUND
  This study evaluates the effectiveness of a training programme for improving the diagnostic and treatment quality of the most complex service offered by Sun Primary Health (SPH) providers, paediatric malaria. The study further assesses whether any quality improvements were sustained over the following 12 months.
  
  
  METHODS
  The study took place in 13 townships in central Myanmar between January 2011 and October 2012. A total of 251 community health workers were recruited and trained in the provision of paediatric and adult malaria diagnosis and treatment; 197 were surveyed in all three rounds: baseline, 6 and 12 months. Townships were selected based on a lack of alterative sources of medical care, averaging 20 km from government or private professional health care treatment facilities. Seventy percent of recruits were assistant nurse midwives or had other basic health training; the rest had no health training experience. Recruits were evaluated on their ability to properly diagnosis and treat a simulated 5-year-old patient using a previously validated method known as Observed Simulated Patient. A trained observer scored SPH providers on a scale of 1-100, based on WHO and Myanmar MOH established best practices. During a pilot test, 20 established private physicians operating in malaria-endemic areas of Myanmar scored an average of 70/100.
  
  
  RESULTS
  Average quality scores of newly recruited SPH providers prior to training (baseline) were 12/100. Six months after training, average quality scores were 48/100. This increase was statistically significant (p < 0.001). At 12 months after training, providers were retested and average quality scores were 45/100 (R3-R1, p < 0.001).
  
  
  CONCLUSIONS
  The SPH training programme was able to improve the quality of paediatric malaria care significantly, and to maintain that improvement over time. Quality of care remains lower than that of trained physicians; however, SPH providers operate in rural areas where no trained physicians operate. More research is needed to establish acceptable and achievable levels of quality for community health workers in rural communities, especially when there are no other care options.
authors.affiliation: Research Department, Population Services International-Myanmar, Yangon, Myanmar. taung@psimyanmar.org.
authors.forename: Tin
authors.initials: T
authors.lastname: Aung
authors.affiliation: Strategic Research and Evaluation, Population Services International, Washington, DC, USA. klongfield@psi.org.
authors.forename: Kim
authors.initials: K
authors.lastname: Longfield
authors.affiliation: Research Department, Population Services International-Myanmar, Yangon, Myanmar. nyomea@gmail.com.
authors.forename: Nyo Me
authors.initials: NM
authors.lastname: Aye
authors.affiliation: Research Department, Population Services International-Myanmar, Yangon, Myanmar. aksan@psimyanmar.org.
authors.forename: Aung Kyaw
authors.initials: AK
authors.lastname: San
authors.affiliation: UCSF Global Health Sciences, San Francisco, CA, USA. thea.s.sutton@gmail.com.
authors.forename: Thea S
authors.initials: TS
authors.lastname: Sutton
authors.affiliation: Private Health Sector Initiative (PSHi), UCSF Global Health Group, 550 16th Street, 3rd Floor, Box 1224, San Francisco, CA, 94158, USA. dominic.montagu@ucsf.edu.
authors.forename: Dominic
authors.initials: D
authors.lastname: Montagu
mesh_terms: D000328:Adult; D003150:Community Health Workers; D004501:Education, Medical; D005260:Female; D006302:Health Services Research; D006801:Humans; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D008297:Male; D002052:Myanmar; D011361:Professional Competence; D012424:Rural Population; D055815:Young Adult