title: Contribution of community health workers to improving access to timely and appropriate case management of childhood fever in Mozambique.
abstract: BACKGROUND
  Large scale evaluations in several settings have demonstrated that lay community health workers can be trained to provide quality case management of childhood illnesses. In 2010, Mozambique introduced the integrated community case management (iCCM) strategy to reach children in remote areas with care provided throughAgentes Polivalentes Elementares(APEs). We assessed the contribution of the program to improved care-seeking and appropriate treatment of childhood febrile illness in Nampula Province.
  
  
  METHODS
  We used a post-test quasi-experimental design with three intervention and one comparison districts to compare access and appropriateness of care for sick children in Nampula province. We carried out a household survey in the study districts to measure levels of care-seeking and treatment of childhood fever after approximately two years of full implementation of the iCCM program in the intervention districts. We also assessed consistency of care with standard case management protocols comparing children receiving care from (APEs) to those receiving care from first-level health facilities.
  
  
  RESULTS
  A total of 773 children 6-59 months with fever in the last two weeks were included in the study. In iCCM served areas, APEs were the predominant source of care and treatment; 87.1% (95% confidence interval CI 80.8-93.4) of children 6-59 months with fever who sought care were taken first to an APE and APEs accounted for 86.2% (95% CI 79.7-92.7) of all first-line antimalarial treatments. Public health facilities were the leading source of care in comparison areas, providing care to 86.1% (95% CI 79.0-93.3) of children with fever taken for care outside the home. Timeliness of treatment was significantly better in intervention areas, where 63.9% (95% CI 54.4-73.3) of children received treatment within 24 hours of symptom onset compared to 37.5% (95% CI 31.1-43.9) in comparison areas. Children taken first to an APE were more likely to receive a rapid diagnostic test (RDT) (68.1%; 95% CI 57.2-79.0) and to have their respiratory rate assessed (60.0%; 95% CI 45.4-74.6) compared to children taken to health facilities (41.4%; 95% CI33.7-49.2 and 19.4%; 95% CI 8.4-30.5, respectively). Overall, 61.3% (95% CI 51.5-71.0) of children with fever receiving care from APEs received the correct drug within 24 hours and for the correct duration compared to 26.0% (95% CI 18.2-33.9) of those receiving care from health facilities.
  
  
  CONCLUSIONS
  iCCM contributed to improved timely and appropriate treatment for fever for children living far from facilities. Trained, supplied and supervised APEs provided care consistent with iCCM protocols and performed significantly better than first level facilities on most measures of adherence to case management protocols. These findings reinforce the need for comprehensive efforts to strengthen the health system in Mozambique to enable reliable support for quality of case management of childhood illness at both health facility and community levels.
authors.affiliation: Save the Children US, Washington, DC, USA.
authors.forename: Tanya
authors.initials: T
authors.lastname: Guenther
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Salim
authors.initials: S
authors.lastname: Sadruddin
authors.affiliation: Johns Hopkins University, Institute of International Programs, Baltimore, Maryland, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Finnegan
authors.affiliation: Save the Children International, Maputo, Mozambique.
authors.forename: Erica
authors.initials: E
authors.lastname: Wetzler
authors.affiliation: Save the Children International, Maputo, Mozambique.
authors.forename: Fatima
authors.initials: F
authors.lastname: Ibo
authors.affiliation: Save the Children International, Maputo, Mozambique.
authors.forename: Paulo
authors.initials: P
authors.lastname: Rapaz
authors.affiliation: Save the Children US, Washington, DC, USA.
authors.forename: Jeanne
authors.initials: J
authors.lastname: Koepsell
authors.affiliation: Save the Children International, Islamabad, Pakistan.
authors.forename: Ibad Ul Haque
authors.initials: IU
authors.lastname: Khan
authors.affiliation: Johns Hopkins University, Institute of International Programs, Baltimore, Maryland, USA.
authors.forename: Agbessi
authors.initials: A
authors.lastname: Amouzou
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use; D019090:Case Management / Q000706:statistics & numerical data*; D002675:Child, Preschool; D003153:Community Health Services / Q000592:standards* / Q000706:statistics & numerical data; D003150:Community Health Workers / Q000193:education*; D005260:Female; D005334:Fever; D019983:Guideline Adherence; D006801:Humans; D007223:Infant; D008297:Male; D009073:Mozambique; D065228:Non-Randomized Controlled Trials as Topic / Q000379:methods; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D056152:Respiratory Rate / Q000502:physiology*
chemical_list: D000962:Antimalarials