Integrated community case management (iCCM) of childhood infection saves lives in hard-to-reach communities in Nicaragua

Abstract

Objective. To describe Nicaragua’s integrated community case management (iCCM) program for hard-to-reach, rural communities and to evaluate its impact using monitoring data, including annual, census-based infant mortality data. Method. This observational study measured the strength of iCCM implementation and estimated trends in infant mortality during 2007–2013 in 120 remote Nicaraguan communities where brigadistas (“health brigadiers”) offered iCCM services to children 2–59 months old. The study used program monitoring data from brigadistas’ registers and supervision checklists, and derived mortality data from annual censuses conducted by the Ministry of Health. The mortality ratio (infant deaths over number of children alive in the under-1-year age group) was calculated and point estimates and exact binomial confidence intervals (CIs) were reported. Results. Monitoring data revealed strong implementation of iCCM over the study period, with medicine availability, completeness of recording, and correct classification always exceeding 80%. Treatments provided by brigadistas for pneumonia and diarrhea closely tracked expected cases and caregivers consistently sought treatment more frequently from brigadistas than from health facilities. The infant mortality ratio decreased more in iCCM areas compared to the non-iCCM areas. Statistically significant reduction ranged from 52% in 2010 (mortality rate ratio 0.48; 95% CI: 0.25–0.92) to 59% in 2013 (mortality rate ratio 0.41; 95% CI: 0.21–0.81). Conclusions. The iCCM has been found to be an effective and feasible strategy to save infant lives in hard-to-reach communities in Nicaragua. The impact was likely mediated by increased use of curative interventions, made accessible and available at the community level, and delivered through high-quality services, by brigadistas.

Enabling Community Health Worker Recognition and Referral of Surgical Diseases: Pilot Study Results of a Pictorial Guide

“…The baseline assessment revealed low knowledge of identifying and referring surgical conditions among community members and informal CHWs, regardless of education level. Limited knowledge of surgical conditions contrasts with ample baseline CHW, and increasingly societal, knowledge among issues such as sanitation, immunization, maternal health, and breastfeeding observed in these and other areas [14]. There is a paucity of evidence documenting knowledge, attitudes, and behaviors pertaining to surgical conditions in the pre‐hospital setting; these data may corroborate perceptions that most surgical conditions are more “complex” and beyond the scope of public health initiatives and basic training of CHWs in LMIC.…”

“…CHWs are uniquely positioned to provide culturally appropriate care, and the role of the CHWs can be played by individuals from diverse backgrounds, from volunteer lay health workers with no medical training and limited education (lay health workers), to paraprofessionals with informal training (level 1), and paraprofessionals with formal training who have a formal role and are typically compensated (level 2) [11]. Within Latin America, CHWs have reduced the infant mortality rate, and fulfilled roles of case managers for diarrhea as well as acute respiratory infection [14][15][16]. Targeted public health campaigns have also been shown to increase community and CHW awareness of conditions, such as retinoblastoma, that require timely hospital care [17].…”