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Contribution of community health workers to the treatment of common illnesses among under 5-year-olds in rural Uganda

Abstract

Background

The control of malaria, pneumonia, and diarrhoea is important for the reduction in morbidity and mortality among children under 5 years. Uganda has adopted the Integrated Community Case Management strategy using Community Health Workers (CHWs) to address this challenge. The extent and trend of these three conditions managed by the CHWs are not well documented. This study was done to describe the epidemiology and trends of the three common illnesses treated by the CHWs in Bugoye Sub-County in rural Uganda.

Methods

A retrospective review of monthly morbidity data for children less than 5 years of age for the period April 2014–December 2018 for CHWs in rural Bugoye Sub-County in Kasese district, Uganda was done. The total number reviewed was 18,430 records. The data were analysed using STATA version 14.

Results

In total male were 50.2% of the sample, pneumonia was the highest cause of illness among the infants (< 1 year), while malaria was the highest among the children 1 year–59 months. Infection with a single illness was the commonest recorded cause of presentation but there were some children recorded with multiple illnesses. All the CHWs were managing the three common illnesses among children under 5 years. The trend of the three common illnesses was changing from malaria to pneumonia being the commonest. Children aged 12–24 months and 25–59 months were at 2.1 times (95% CI 1.7–2.4) and 5.2 times (95% CI 4.6–5.9), respectively, more likely to get malaria but less likely to get pneumonia and diarrhoea.

Conclusion

Community Health Workers in rural Uganda are contributing significantly to the management of all the three commonest illnesses among under-5 years-old children. The trend of the commonest illness is changing from malaria to pneumonia. Children under 1 year are at a higher risk of getting pneumonia and diarrhoea and at a lower risk of getting malaria.

Background

Malaria, pneumonia, and diarrhoea are still among the commonest causes of childhood morbidity and mortality globally in, sub-Saharan Africa and in Uganda [1, 2]. Volunteer Community Health Workers (CHWs) are community members who are not paid and are selected by fellow community members to provide accurate health information, counsel, mobilize communities and provide linkage for curative, prevention, health promotion, and care services. The World Health Organization (WHO) estimates that 57 countries in Asia and Africa including Uganda are using the Integrated Community Case Management (ICCM) strategy for the management of childhood illnesses in the community [2,3,4,5,6,7].

The Ministry of Health (MoH) in Uganda established Community Health Workers in 2001 and the integrated Community Case Management guidelines in 2010 to improve access to Universal Primary Health Care. Their role and contribution to the community management of the three commonest childhood illnesses have been proven to be quite crucial and successful especially in the rural areas that have limited access to health care [2, 7,8,9,10,11,12]. The WHO and UNICEF in 2006 developed a manual on the management of the sick child by CHWs with various case studies and models including the Homapak® (malaria treatment) strategy in Uganda and these were demonstrated to have positive outcomes for the specific illnesses [7, 13, 14].

Using the Uganda MoH training guidelines, Community Health Workers (CHW/VHTs) are trained for 5 days during the initial training and later trained for additional 5 days on the Integrated Community Case Management (ICCM) full package by the Uganda Ministry of Health National Training Staff. Community Health Workers in Uganda under the Integrated Community Case Management (ICCM) strategy are involved in testing for malaria using Rapid Diagnostic Test (RDT) kits, assessing and treating of pneumonia and diarrhoea, and other prevention and health promotion activities in the community under the supervision of trained health workers at the health facility in the catchment area [3, 7, 15,16,17,18,19].

Community Health Workers report quarterly on all these indicators to the National District Health Information Software 2 (DHIS2). There has been limited data for long-term trends of these major cases seen by the CHWs over years in Uganda. It is important to know this because it helps the health providers to prioritize service delivery based on information. There is limited documentation of the trends of the common illnesses managed by Community Health Workers in the typical rural community within Bugoye Sub-County. This study focused on documenting the above gaps in Kasese district, Southwestern Uganda.

Methods

The aim was to determine the epidemiology and a trend of the three most common illnesses among children less than 5 years of age for the period April 2014–December 2018 in rural Bugoye Sub-County in Kasese district, Uganda. A retrospective review of monthly morbidity reporting data of the CHWs for children less than 5 years of age was done. The data contained information on age, sex, diagnosis (malaria, pneumonia, and diarrhoea), and their respective treatment. Cleaning, validating, and analysis of this Integrated Community Case Management data was done for the period April 2014–December 2018. This is data collected every month at Bugoye Health Centre III by the CHWs in the catchment area supervised by the health facility.

Study setting

Bugoye Health Centre III is situated in Bugoye Sub-County, which is located in Kasese district in southwestern Uganda. The population served by the Health Centre is approximately 46,124 of which 9225 are children under 5 years of age, it has 7650 households in 35 villages. This data included five villages in 2014 and 2015, eight villages in 2016, 2017, and 2018 when the ICCM programme was gradually being rolled out.

Data collection

Data from the monthly Integrated Community Case Management reporting forms were aggregated and entered into a database in Epi-Data software from April 2014–December 2018. The data were then cleaned with comparison to paper records in case of a mismatch between reporting month and visit date or potential inaccuracy. This data set is available for any required review.

Data analysis

The data set was exported to STATA 14 and analyses were done for the demographic characteristics, epidemiology, and trends of the cases that are seen and managed by the CHWs and the proportions of the prevalence of the three most common illnesses among the under-5 years-olds. Bivariate logistic regression for odds of the association was also done with the demographic characteristics (sex and age categories) and the common illnesses for an association between the demographic characteristics and the common illnesses. The independent variables included age category and sex, and the outcome was malaria cases, pneumonia cases, and diarrhoea cases.

Ethical issues

This study was approved by the Research Ethics Committee of Mbarara University of Science and Technology and permission was got from the Kasese District administration to analyze and use the facility data. The analysis of the data was anonymous so consent for the individual cases was not done as they had identification numbers that were randomly allocated and kept anonymous. (Study number: 06/03–17).

Results

Demographic characteristics of children managed by the Community Health Workers

The total number of child encounters of the CHWs reviewed was 18,430 and males were 50.2% (9192) females were 49.8% (9105). These children were from eight villages and four parishes from Bugoye Sub-County in the Kasese district, details in Table 1.

Table 1 Sex distribution for the three illness treated by CHWs

Amongst the three diagnosed illnesses managed by the CHWs, pneumonia was the highest cause of illness among the infants (< 1 year) while malaria was the highest cause of illness among the children 1 year to 59 months, details in Table 2.

Table 2 Illness episodes among the different age categories

The three common illnesses of malaria, pneumonia, and diarrhoea were prevalent every month and throughout the years from 2014 to 2018. Single infection with one of the three illnesses was a common occurrence and malaria was the commonest illness while diarrhea was the least common throughout the review, details in Fig. 1.

Fig. 1
figure 1

Five-year trend of the three common illnesses managed by CHWs

Multiple illnesses were prevalent every month of the year and over the whole study period. Combined illness with malaria and pneumonia was the commonest while the combination of malaria, pneumonia, and diarrhoea was the least common. Figure 2 shows the trends of multiple illnesses.

Fig. 2
figure 2

Multiple illness trends of the three conditions managed by CHWs

Being less than 1 year of age was associated with a higher risk of getting diarrhoea OR 0.8 CI 0.72–0.85 compared to “12–24” months of age and also higher risk of pneumonia OR 0.7 CI 0.60–0.71 compared to “12–24” months of age but lower risk of getting malaria, see Table 3.

Table 3 Associations of being under 1 year of age and having diarrhoea, pneumonia, or malaria

Discussion

Malaria, pneumonia, and diarrhoea remain the three commonest causes of illness in Bugoye Sub-County for the period of 2014 to 2018 just like the other parts of Africa and Uganda which had similar documentation [1, 17, 20]. This current study showed that although most children had single infections, twenty-five percent had 2 or all 3 illnesses for the three commonest illnesses of malaria pneumonia, and diarrhoea. The findings are similar to six other sub-Saharan countries in Africa including Uganda [20, 21].

The treatment of children under 5 years of age for malaria, pneumonia, and diarrhoea are performed by each of the active and trained CHWs in each of the eight villages in Bugoye Sub-County for the ones that seek for treatment from them. This finding is similar to other countries, including Uganda, that adopted the Integrated Community Case Management (ICCM) in Africa and some regions in Southeast Asia [3,4,5, 8, 9, 16, 17, 19, 22, 29]. Community Health Workers are an important resource in the management of these illnesses [28].

For the period of the study that is April 2014–December 2018, out of the 24,000 and more children assessed and treated there was no reported death. These potentially good outcomes reflect similar findings of other studies of CHWS treatment for these three common illnesses [2, 4, 12, 14, 23,24,25]. This could also mean that the CHWs can identify very sick children with danger signs and refer them promptly.

The 5-year trend for the three commonest illnesses among children under 5 years of age in this study had malaria highest followed by pneumonia then diarrhoea during the first 4 years. This changed with illness due to malaria dropping drastically to about the same level as diarrhoea. This may be attributed to the malaria control interventions that have been strengthened over the last 10 years in Uganda and this has been evidenced by the gradual reduction in malaria test positivity and a drop in all-cause under-five malaria mortality (137–64/1000) over the last 10 years in Uganda in the 2018 WHO World Malaria Report and fact sheet of USAID [26, 27]. The 5-years trend of the multiple infections has malaria and pneumonia as the highest followed by malaria and diarrhoea, then diarrhoea and pneumonia and then the triple infection least this is consistent with a study in a Nigerian hospital in 2018 [12].

Limitations

Because of the limited capacity of the CHWs on the understanding of the importance of reporting the data was not complete but this was addressed by cross-checking with the health facility data during the process of cleaning and validating the data. The data at the health facility is a combination of the data from the CHWs and that of the patients seen at the facility only data of the CHWs was analysed for this study.

Conclusion

Community Health Workers are involved in the management of all the three commonest illnesses in Bugoye Sub-County, which are malaria, pneumonia, and diarrhoea. These illnesses sometimes present as multiple infections with various combinations of pneumonia, malaria, and diarrhoea. The trends of the three commonest illnesses among children under 5 years of age are changing with pneumonia now becoming the commonest cause of illness since 2017.

Children less than 1 year of age were associated with a lower risk of having malaria but a higher risk of having pneumonia or diarrhoea compared to children 1–5 years of age. Given the changing disease profile especially in children under 1 year, the focus of health interventions should put more pronounced emphasis on addressing the prevention and control of pneumonia among these vulnerable age groups of under 1-year-old. There needs to be monitoring of trends over time to ensure the Community Health Worker programme remains current with prevailing health conditions, and there is also importance of continuous monitoring and evaluation as part of the programme.

Availability of data and materials

All data supporting the study findings are contained in the paper. There are no restrictions to the data sources, however full details to the data may be accessed on reasonable request from the corresponding author.

Abbreviations

CHW:

Community Health Worker

VHT:

Village Health Team)

CI:

Confidence interval

DHIS:

District Health Information System

ICCM:

Integrated Community Case Management

OR:

Odds Ratio

P-value:

Probability

RDT:

Rapid Diagnostic Test

UNICEF:

United Nations Children’s Fund

USAID:

United States Agency for International Development

WHO:

World Health Organization

References

  1. Habimana A, Harerimana A, Asingizwe D, Nyandwi T, Kato JN. Community Health Workers’ knowledge, attitudes and practices about malaria prevention in Gicumbi district, Rwanda. Rwanda J. 2016;3:27.

    Article  Google Scholar 

  2. Hategeka C, Tuyisenge G, Bayingana C, Tuyisenge L. Effects of scaling up various community-level interventions on child mortality in Burundi, Kenya, Rwanda, Uganda, and Tanzania: a modeling study. Glob Health Res Policy. 2019;4:1.

    Article  Google Scholar 

  3. Miller JS, English L, Matte M, Mbusa R, Ntaro M, Bwambale S, et al. Quality of care in integrated community case management services in Bugoye, Uganda: a retrospective observational study. Malar J. 2018;17:99.

    Article  Google Scholar 

  4. Brenner JL, Barigye C, Maling S, Kabakyenga J, Nettel-Aguirre A, Buchner D, et al. Where there is no doctor: can volunteer Community Health Workers in rural Uganda provide integrated community case management? Afr Health Sci. 2017;17:237–46.

    Article  Google Scholar 

  5. Altaras R, Montague M, Graham K, Strachan CE, Senyonjo L, King RL, et al. Integrated community case management in a peri-urban setting: a qualitative evaluation in Wakiso district, Uganda. BMC Health Serv Res. 2017;17:785.

    Article  Google Scholar 

  6. Babughirana G, Tusaasire J, Musasizi B, Lule M, Muhuma MC, Twinomujuni E. Utilization of the Community Health Worker assessment and improvement matrix to strengthen village health team systems in Uganda: a case for Kitgum District. Sci J Public Health. 2017;5:275–87.

    Article  Google Scholar 

  7. Ministry of Health Uganda. Village health team: a handbook to improve health in communities. 2009. https://www.k4health.org/sites/default/files/VHT%20BOOK.pdf.

  8. Mazzi M, Bajunirwe F, Aheebwe E, Nuwamanya S, Bagenda FN. Proximity to a community health worker is associated with utilization of malaria treatment services in the community among under-five children: a cross-sectional study in rural Uganda. Int Health. 2019;11:143–9.

    Article  Google Scholar 

  9. Ratnayake R, Ratto J, Hardy C, Blanton C, Miller L, Choi M, et al. The effects of an integrated community case management strategy on the appropriate treatment of children and child mortality in Kono District, Sierra Leone. a program evaluation. Am J Trop Med Hyg. 2017;97:964–73.

    Article  Google Scholar 

  10. Shaw B, Amouzou A, Miller NP, Tsui AO, Bryce J, Tafesse M, et al. Determinants of utilization of health extension workers in the context of scale-up of integrated community case management of childhood illnesses in Ethiopia. Am J Trop Med Hyg. 2015;93:636–64.

    Article  Google Scholar 

  11. Brenner JL, Kabakyenga J, Kyomuhangi T, Wotton KA, Pim C, Ntaro M, et al. Can volunteer Community Health Workers decrease child morbidity and mortality in southwestern Uganda? An impact evaluation. PLoS ONE. 2011;6: e27997.

    Article  CAS  Google Scholar 

  12. Chinawa Josephat M, Aniwada EC, Ugwunna NC, Eze JN, Ndu Ikenna K, Obidike EO. Pattern and prevalence of common pediatric illnesses presenting in a private hospital in Onitsha, southeast Nigeria: a comparative analysis. Curr Ped Res. 2018;22:88–94.

    Google Scholar 

  13. Langston A, Wittcoff A, Ngoy P, O’Keefe J, Kozuki N, Taylor H, et al. Testing a simplified tool and training package to improve integrated Community Case Management in Tanganyika Province, Democratic Republic of Congo: a quasi-experimental study. J Glob Health. 2019;9: 010810.

    Article  Google Scholar 

  14. Buchner DL, Brenner JL, Kabakyenga J, Kyomuhangi T, Maling S, Barigye C, et al. Stakeholders’ perceptions of integrated community case management by Community Health Workers: a post-intervention qualitative study. PLoS ONE. 2014;9: e98610.

    Article  Google Scholar 

  15. Davlantes E, Salomao C, Wate F, Sarmento D, Rodrigues H, Halsey ES, et al. Malaria case management commodity supply and use by Community Health Workers in Mozambique, 2017. Malar J. 2019;18:47.

    Article  Google Scholar 

  16. Tefera F, Barnabee G, Sharma A, Feleke B, Atnafu D, Haymanot N, et al. Evaluation of facility and community-based active household tuberculosis contact investigation in Ethiopia: a cross-sectional study. BMC Health Serv Res. 2019;22(19):234.

    Article  Google Scholar 

  17. Baynes C, Mboya D, Likasi S, Maganga D, Pemba S, Baraka J, et al. Quality of sick child-care delivered by community health workers in Tanzania. Int J Health Policy Manag. 2018;7:1097–109.

    Article  Google Scholar 

  18. Nsibande D, Loveday M, Daniels K, Sanders D, Doherty T, Zembe W. Approaches and strategies used in the training and supervision of Health Extension Workers (HEWs) delivering integrated community case management (iCCM) of childhood illness in Ethiopia: a qualitative rapid appraisal. Afr Health Sci. 2018;18:188–97.

    Article  Google Scholar 

  19. Sunguya BF, Mlunde LB, Ayer R, Jimba M. Towards eliminating malaria in high endemic countries: the roles of Community Health Workers and related cadres and their challenges in integrated community case management for malaria: a systematic review. Malar J. 2017;16:10.

    Article  Google Scholar 

  20. Lainez YB, Wittcoff A, Mohamud AI, Amendola P, Perry HB, D’Harcourt E. Insights from Community case management data in six sub-Saharan African countries. Am J Trop Med Hyg. 2012;87(Suppl 5):144–50.

    Article  Google Scholar 

  21. WHO/UNICEF. Management of sick children by community health workers, intervention models, and program examples. 2006.

  22. Bagonza J, Kibira SP, Rutebemberwa E. Performance of Community Health Workers managing malaria, pneumonia, and diarrhea under the community case management program in central Uganda: a cross-sectional study. Malar J. 2014;13:367.

    Article  Google Scholar 

  23. Goudet S, Jayaraman A, Chanani S, Osrin D, Devleesschauser B, Bogin B, et al. Cost-effectiveness of community-based prevention and treatment of acute malnutrition program in Mumbai slums, India. PLoS One. 2018;13: e0205688.

    Article  CAS  Google Scholar 

  24. Kitutu FE, Mayora C, Johansson EW, Peterson S, Wamani H, Bigdeli M, et al. Health system effects of implementing integrated community case management(iCCM) intervention in private retail drug shops in South Western Uganda: a qualitative, study. BMJ Glob Health. 2017;2: e000334.

    Article  Google Scholar 

  25. Perry H, Morrow M, Davis T, Borger S, Weiss J, DeCoster M, et al. Care Groups II: a summary of the child survival outcomes achieved using volunteer community health workers in resource-constrained settings. Glob Health Sci Pract. 2015;3:370–81.

    Article  Google Scholar 

  26. WHO. World Malaria Report 2018. Geneva: World Health Organization; 2018.

    Google Scholar 

  27. USAID Presidential Malaria Initiative. Uganda Country Profile (2018) www.pmi.gov/docs/default-source/default-document-library/country-profiles/uganda_profile.pdf?sfvrsn=26. Accessed 25 Jul 2019

  28. Kelly JM, Osamba B, Garg RM, Hamel MJ, Lewis JJ, Rowe SY, et al. Community health worker performance in the management of multiple childhood illnesses: Siaya District, Kenya, 1997–2001. Am J Public Health. 2001;10:1617–24.

    Article  Google Scholar 

  29. Ministry of Health Uganda. Integrated Community Case Management of malaria, pneumonia, and diarrhea: implementation guidelines. Kampala, 2010.

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Acknowledgements

The study team acknowledge; David Bangsberg, Anna Louise Baylor, Libby Cunningham, Raquel Reyes, Pat Lee, Sara Mian-McCarthy, Moses Wetyanga, Sarah Masika, Raphael Mbusa, Nobert Mumbere the Community Health Workers for assessing, treating, and reporting cases, the health workers who compiled the data, the community for utilizing the services and the people who cleaned and validated the data.

Funding

The research was financially supported by the partners, Center for Global Health Massachusetts General Hospital (US).

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Authors and Affiliations

Authors

Contributions

FB was involved in the design, implementation, data analysis, interpretation of findings, and write-up of the paper. EMM, MN, BB were involved in the conception of the idea, design, implementation, interpretation of findings, and review of the paper. ACW, RN, RM, and SB were involved in the design, implementation, analysis, and write-up of the paper. GS, PP, RR, and DG were involved in the conception of the idea, design, and review, and write-up of the paper. DSA was involved in the interpretation of findings and write-up of the manuscript. All the authors have read and approved this manuscript.

Corresponding author

Correspondence to Fred Bagenda.

Ethics declarations

Ethical approval and consent of participants

Ethical approval for this study was sought and obtained from the Research Ethics Committee at Mbarara University of Science and Technology. Permission to use and analyze the data was obtained from the Kasese local district authorities.

Consent for publication

Not applicable as no personal information is provided.

Competing interests

The authors declare that there are no competing interests.

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Bagenda, F., Wesuta, A.C., Stone, G. et al. Contribution of community health workers to the treatment of common illnesses among under 5-year-olds in rural Uganda. Malar J 21, 296 (2022). https://doi.org/10.1186/s12936-022-04316-1

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Keywords

  • Common illnesses
  • Community Health Worker
  • Uganda
  • Under-five children