The influence of observation and setting on community health workers’ practices

Rowe, Samantha; Olewe, M. A.; Kleinbaum, David G.; McGowan, John E.; McFarland, Deborah A.; Rochat, Roger W.; Deming, Michael S.

doi:10.1093/intqhc/mzl009

Cited by 35 publications

(38 citation statements)

References 12 publications

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“…The Hawthorne Effect is an acknowledged limitation of non-participant structured observation, the key method used in this study [22], [23], [24]. Health workers who are conscious of the fact they were being observed may have altered their behaviour.…”

Section: Discussionmentioning

confidence: 99%

An Evaluation of the Clinical Assessments of Under-Five Febrile Children Presenting to Primary Health Facilities in Rural Ghana

et al. 2011

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BackgroundThe shift to test-based management of malaria represents an important departure from established practice under the Integrated Management of Childhood Illnesses (IMCI). The possibility of false results of tests for malaria and co-morbidity, however, make it important that guidelines in IMCI case assessment are still followed.Methods and FindingsWe conducted a cross-sectional observational study to evaluate current practices in IMCI-based assessment of febrile children in 10 health centres and 5 district hospitals, with follow up of a subset of children to determine day 7–10 post-treatment clinical outcome. Clinical consultation, examination and prescribing practices were recorded using a checklist by trained non-medical observers. The facility case management of 1,983 under-five years old febrile children was observed and 593 followed up at home on days 5–10. The mean number of tasks performed from the 11 tasks expected to be done by the IMCI guidelines was 6 (SD 1.6). More than 6 tasks were performed in only 35% of children and this varied substantially between health facilities (range 3–85%). All 11 tasks were performed in only 1% of children. The most commonly performed tasks were temperature measurement (91%) and weighing (88%). Respiratory rate was checked in only 4% of children presenting with cough or difficulty in breathing. The likelihood of performing “better than average number of tasks” (>6) was higher when the consultation was done by medical assistants than doctors (O.R. = 3.16, 1.02–9.20). The number of tasks performed during assessment did not, however, influence clinical outcome (O.R. = 1.02, 0.83–1.24).ConclusionFacility-tailored interventions are needed to improve adherence to IMCI guidelines incorporating test-based management of malaria. Studies are needed to re-evaluate the continued validity of tasks defined in IMCI case assessment guidelines.

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Section: Discussionmentioning

confidence: 99%

An Evaluation of the Clinical Assessments of Under-Five Febrile Children Presenting to Primary Health Facilities in Rural Ghana

et al. 2011

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“…Previous examinations of the quality of care delivered through CCM have evaluated pilot programmes in limited geographic areas (Kelly et al 2001; Rowe et al 2007a), or have assessed the skills of CCM providers, rather than quality of services received by sick children, through tests of knowledge (Zeitz et al 1993; Ashwell and Freeman 1995), reviews of case registers (Mehnaz et al 1997; Rowe et al 2006; Rowe et al 2007b) or through role plays and case scenarios (Zeitz et al 1993; Kallander et al 2006). Previous observation-based studies of sick child care have evaluated care for a single disease or have observed CCM providers at health facilities rather than their normal practice settings (Zeitz et al 1993; Ashwell and Freeman 1995; Kelly et al 2001; Hadi 2003; Rowe et al 2006; Rowe et al 2007a).…”

Section: Introductionmentioning

confidence: 99%

“…Previous observation-based studies of sick child care have evaluated care for a single disease or have observed CCM providers at health facilities rather than their normal practice settings (Zeitz et al 1993; Ashwell and Freeman 1995; Kelly et al 2001; Hadi 2003; Rowe et al 2006; Rowe et al 2007a). This study uses rigorous, community-based observation methods with ‘gold-standard’ clinical reassessments to evaluate the quality of care for sick children in the context of a CCM programme being implemented at scale.…”

Section: Introductionmentioning

confidence: 99%

Quality of sick child care delivered by Health Surveillance Assistants in Malawi

Gilroy¹,

Callaghan-Koru²,

Cardemil³

et al. 2012

Health Policy and Planning

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Objective To assess the quality of care provided by Health Surveillance Assistants (HSAs)—a cadre of community-based health workers—as part of a national scale-up of community case management of childhood illness (CCM) in Malawi.Methods Trained research teams visited a random sample of HSAs (n = 131) trained in CCM and provided with initial essential drug stocks in six districts, and observed the provision of sick child care. Trained clinicians conducted ‘gold-standard’ reassessments of the child. Members of the survey team also interviewed caregivers and HSAs and inspected drug stocks and patient registers.Findings HSAs provided correct treatment with antimalarials to 79% of the 241 children presenting with uncomplicated fever, with oral rehydration salts to 69% of the 93 children presenting with uncomplicated diarrhoea and with antibiotics to 52% of 58 children presenting with suspected pneumonia (cough with fast breathing). About one in five children (18%) presented with danger signs. HSAs correctly assessed 37% of children for four danger signs by conducting a physical exam, and correctly referred 55% of children with danger signs.Conclusion Malawi’s CCM programme is a promising strategy for increasing coverage of sick child treatment, although there is much room for improvement, especially in the correct assessment and treatment of suspected pneumonia and the identification and referral of sick children with danger signs. However, HSAs provided sick child care at levels of quality similar to those provided in first-level health facilities in Malawi, and quality should improve if the Ministry of Health and partners act on the results of this assessment.

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“…It is possible that both health workers and carers of children may have changed their behaviours because they were being observed. Such Hawthorne effects are well documented [17,18]. It was assumed that the behaviours observed here were ‘best behaviours’ of both the health workers and the carers.…”

Section: Discussionmentioning

confidence: 58%

Management of febrile children under five years in hospitals and health centres of rural Ghana

Webster

Baiden

Bawah

et al. 2014

Malar J

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BackgroundThe case management of febrile children in hospitals’ and health centres’ pre-roll out of the new WHO policy on parasitological diagnosis was assessed. The delivery of artemisinin combination therapy (ACT) at these two levels of the health system was compared.MethodsStructured observations and exit interviews of 1,222 febrile children attending five hospitals and 861 attending ten health centres were conducted in six districts of the Brong Ahafo Region of Ghana. Effectiveness of delivery of case management of malaria was assessed. Proportions of children receiving ACT, anti-malarial monotherapy and antibiotics were described. Predictors of: a febrile child being given an ACT, a febrile child being given an antibiotic and of carers knowing how to correctly administer the ACT were assessed using logistic regression models stratified by hospitals and health centres.ResultsThe system’s effectiveness of delivering an ACT to febrile children diagnosed with malaria (parasitologically or clinically) was 31.4 and 42.4% in hospitals and health centres, respectively. The most ineffective process was that of ensuring that carers knew how to correctly administer the ACT. Overall 278 children who were not given an ACT were treated with anti-malarial monotherapy other than quinine. The majority of these children, 232/278 were given amodiaquine, 139 of these were children attending hospitals and 93 attending health centres. The cadre of health staff conducting consultation was a common predictor of the outcomes of interest. Presenting symptoms and examinations conducted were predictive of being given an ACT in hospitals and antibiotic in hospitals and health centres but not of being given an ACT in health centres. Treatment-seeking factors were predictive of being given an ACT if it was more than seven days since the fever began and an antibiotic in hospitals but not in health centres.ConclusionInterventions to improve adherence to negative parasitological tests are needed, together with guidance on dispensing of antibiotics, but improving the education of carers on how to administer ACT will lead to the greatest immediate increase in the effectiveness of case management. Guidance is needed on implementation of the new test-based treatment for malaria policy in health facilities.

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The influence of observation and setting on community health workers’ practices

Cited by 35 publications

References 12 publications

An Evaluation of the Clinical Assessments of Under-Five Febrile Children Presenting to Primary Health Facilities in Rural Ghana

An Evaluation of the Clinical Assessments of Under-Five Febrile Children Presenting to Primary Health Facilities in Rural Ghana

Quality of sick child care delivered by Health Surveillance Assistants in Malawi

Management of febrile children under five years in hospitals and health centres of rural Ghana

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