Assessing the Quality of Sick Child Care Provided by Community Health Workers

Background As community case management of childhood illness expands in low-income countries, there is a need to assess the quality of care provided by community health workers. This study had the following objectives: 1) examine methods of recruitment of sick children for assessment of quality of care, 2) assess the validity of register review (RR) and direct observation only (DO) compared to direct observation with re-examination (DO+RE), and 3) assess the effect of observation on community health worker performance. Methods We conducted a survey to assess the quality of care provided by Ethiopian Health Extension Workers (HEWs). The sample of children was obtained through spontaneous consultation, HEW mobilization, or recruitment by the survey team. We assessed patient characteristics by recruitment method. Estimates of indicators of quality of care obtained using RR and DO were compared to gold standard estimates obtained through DO+RE. Sensitivity, specificity, and the area under receiver operator characteristic curve (AUC) were calculated to assess the validity of RR and DO. To assess the Hawthorne effect, we compared estimates from RR for children who were observed by the survey team to estimates from RR for children who were not observed by the survey team. Results Participants included 137 HEWs and 257 sick children in 103 health posts, plus 544 children from patient registers. Children mobilized by HEWs had the highest proportion of severe illness (27%). Indicators of quality of care from RR and DO had high sensitivity for most indicators, but specificity was low. The AUC for different indicators from RR ranged from 0.47 to 0.76, with only one indicator above 0.75. The AUC of indicators from DO ranged from 0.54 to 1.0, with three indicators above 0.75. The differences between estimates of correct care for observed versus not observed children were small. Conclusions Mobilization by HEWs and recruitment by the survey teams were feasible, but potentially biased, methods of obtaining sick children. Register review and DO underestimated performance errors. Our data suggest that being observed had only a small positive effect on the performance of HEWs.


Weight
A2A. Does the HEW weigh the child?

Danger Signs
A3A. Does the HEW ask if the child is NOT able to drink or breastfeed ANYTHING?
A3B. Does the HEW check if the child is able to drink or breastfeed (by offering water or breastmilk)?
A6. Does the HEW check for lethargy or unconsciousness (try to wake up the child)?

Cough/Difficult Breathing
A7A. Does the HEW ask if the child has cough or difficult breathing? (1) Yes (2) No  Skip to A8A (3) Avail.
A7B. Does the child have cough or difficult breathing? (1) Yes (2) No  Skip to A8A A7C. Does the HEW ask how long the child has had cough or difficult breathing?

Diarrhoea
A8A. Does the HEW ask if the child has diarrhoea (loose stools)?

A8F.
Does the HEW offer the child fluid?
A8G. Does the HEW pinch the skin of the abdomen? (1) Yes (2) No Fever A9A. Does the HEW ask or feel for fever (reported or now) or take the child's temperature?
A9B. Does the HEW take the child's temperature?

A9F.
Does the HEW ask if the fever has been present every day? (1) Yes (2) No (3) Avail.
A9G. Does the HEW check if the child has a stiff neck? (1) Yes (2) No A9H. Does the HEW check if the child has bulged fontanel? (1) Yes (2) No A9I. Does the HEW ask if the child has had measles in the last 3 months or check for signs of measles? Note: Signs of measles defined as generalized rash and one of these: cough, runny nose, red eyes. Observe the child for runny nose and red eyes.
A9K. Does the child have history of measles in the last 3 months or signs of measles?

5"
A9L. Does the HEW check if the child has mouth ulcers? (1) Yes (2) No A9M. Does the HEW look at the child's eyes for pus or clouding of the cornea? (1) Yes (2) No (3) Avail.

Ear Problem
A10A. Does the HEW ask if the child has an ear problem? (1) Yes (2) No  Skip to A11A (3) Avail.
A10B. Does the child have an ear problem? (1) Yes (2) No  Skip to A11A A10C. Does the HEW ask how long the child has had an ear problem?

11"
T6G. Does the HEW give or ask the caretaker to give the first dose of Coartem before leaving the health post?

15"
T17G. Does the HEW advise on when to return for followup?

Job Aids
T18A. Does the HEW use the iCCM chart booklet at any time during the encounter with the child?
(1) Yes (2) No T18B. Does the HEW use the iCCM registration book at any time during the encounter with the child?

21"
EX6A. Was a FIFTH medicine prescribed or given?

22"
EX6F. How many days will you give the medicine to <CHILD>?
(1) Yes (2) No RE6D. Was an RDT performed for the child by the HEW? (1) Yes Skip to RE6F (2) No (3) Yes, but incorrectly RE6E. Was an RDT performed for the child by the reexaminer? Note: RDT should be performed in low or high malaria area or if child has traveled to a malarious area in the 2 weeks before the illness began.

RE7A.
Has the child had measles in the last 3 months or does the child have signs of measles (generalized rash and one of these: cough, runny nose, red eyes)? Baatii sadan darban keessatti daa'imni gifirri/shiftoon ykn mallattoon gifiraa irratti mul'ateeraa?

Check immunization status
Review the child's immunization card. If the card is not available, probe the caretaker using the immunization questions provided to obtain as much information as possible regarding the child's vaccines.

RE11C. Immunization classification:
(1) Vaccination status up-to-date (2) Vaccination status not up-to-date (3) Completed (4) Not started RE11A. If the child is under 24 months, has the child received all appropriate vaccines?

R1. Is there an iCCM registration book available in the health post?
(1) Yes (2) No  Skip to R11 R2. What is the number of initial consultations for children 0 -59 months recorded in the register for the previous month by sex?
R3. How many of these initial consultations were for children between the ages of 0 days -2 months in the previous month?
Initial consultations for children 0 days -2 months: ………… R4. How many sick children (0 -59 months) were referred in the previous month? (1) Yes (2) No  Skip to R9 R8. Record the following information for the past 10 cases of sick children with iCCM illness 0 days -2 months with an iCCM illness.
Include patients receiving initial consultation and having at least one iCCM-related symptom. (1) Yes (2) No  Skip to R11 R10. Record the following information for the past 10 cases of sick children 2 -59 months with an iCCM illness.
Include patients receiving initial consultation and having at least one iCCM-related symptom.