Improving Malaria Case Management and Referral Relationships at the Primary Care Level in Ghana: Evaluation of a Quality Assurance Internship

Amos Asiedu; Rachel A. Haws; Akosua Gyasi; Paul Boateng; Keziah Malm; Raphael Ntumy; Lolade Oseni; Gladys Tetteh

doi:10.9745/GHSP-D-23-00050

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FIGURE 1
Selection of CHPS Compounds for the Impact Malaria Community Health Officer Internship and Mentoring Program in Ghana
Abbreviations: CHPS, Community-based Health Planning and Services; HMIS, health management information system; IPTp3+, intermittent preventive treatment of malaria for pregnant women, 3+ doses.
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FIGURE 2
Framework and Process for Implementation of the Impact Malaria Community Health Officer Internship and Mentoring Program in Ghana
Abbreviations: CHO, community health officer; CHPS, Community-based Health Planning and Services; PDSA, plan-do-study-act.
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FIGURE 3
Study Design and Timeline of the Impact Malaria Community Health Officer Internship and Mentoring Program in Ghana
Abbreviations: CHO, community health officer; HMIS, health management information system.

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TABLE 1.

Characteristics of Mentors and Community Health Officers in the Impact Malaria Internship Program in Ghana

	Mentors, No. (%) (N=281)	Community Health Officers, No. (%) (N=520)
Age group, years
20–29	0 (0.0)	228 (43.8)
30–39	28 (10.0)	268 (51.5)
40–49	168 (59.8)	24 (4.7)
50–59	85 (30.2)	0 (0)
Sex
Female	180 (64.1)	255 (49.0)
Male	101 (35.9)	265 (51.0)
Cadre
Medical doctor	73 (26.0)	--
Health information officer	52 (18.5)	--
Medical laboratory scientist	52 (18.5)	--
Malaria focal person	52 (18.5)	--
Midwife	52 (18.5)	78 (15.0)
Enrolled nurse	--	218 (41.9)
Community health nurse	--	146 (28.1)
Nurse	--	78 (15.0)
Years of experience
<1	0 (0)	117 (22.5)
1–5	0 (0)	292 (56.1)
6–10	84 (29.9)	44 (8.5)
11+	197 (70.1)	67 (12.9)

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TABLE 2.

Effect of Internship on Malaria Clinical Competence and Skill Retention for Community Health Officers in Ghana at 3-Month Post-Internship Mentoring Assessment

Clinical Competence Assessment	Pre-Internship Assessment Score Percentage, Mean [SE]	Post-Internship Assessment Score Percentage, Mean [SE]	PP Difference Before-After Internship, Mean (95% CI)	P Value	3-Month Post-Internship Score Percentage, Mean [SE]	PP Difference From Internship End to 3-Month Post-Internship, Mean (95% CI)	P Value
Patient assessment/history taking	86.2 (2.8)	98.2 (1.2)	+12.0 (8.3, 15.1)^{^a}	<.001^{^a}	98.0 (1.0)	+0.2 (−1.1, 2.1)	.642
Severe malaria assessment and referral	44.0 (1.7)	76.0 (1.4)	+32.0 (28.2, 35.8)^{^a}	<.001^{^a}	75.1 (1.5)	−1.1 (−5.3, 3.4)	.681
Assessment of fever	56.9 (1.5)	81.8 (1.2)	+24.9 (20.9, 29.3)^{^a}	<.001^{^a}	80.0 (1.0)	−1.8 (−5.3, 1.1)	.173
Acute respiratory infection	41.1 (1.7)	71.1 (1.4)	+30.0 (24.6, 34.0)^{^a}	<.001^{^a}	65.2 (1.0)	−5.9 (−1.9, −8.8)^{^a}	.003^{^a}
Diarrhea	28.0 (1.0)	47.0 (0.9)	+19.0 (16.2, 22.3)^{^a}	<.001^{^a}	76.0 (1.0)	+28.0 (24.6, 32.3)^{^a}	<.001^{^a}
Medical history	55.9 (1.9)	81.9 (1.5)	+26.0 (22.1, 31.4)^{^a}	<.001^{^a}	79.1 (1.4)	-2.8 (−7.1, 1.2)	.136
Knowledge assessment	57.4 (2.8)	73.2 (0.8)	+15.8 (10.0, 21.3)^{^a}	<.001^{^a}	-	-	-

Abbreviations: CI, confidence interval; PP, percentage point; SE, standard error.
↵a Statistically significant difference.

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TABLE 3.

Comparison of HMIS Malaria Management Indicators in Intervention CHPS Compound Versus Comparison Compound 0–12 Months Before CHO Internship Versus 0–12 Months Post-Internship

	Intervention CHPS Compound (CHO Internship)				Comparison CHPS Compound
National HMIS Indicator	Baseline^{^a} Mean, % (SD)	Post-Intervention^{^b} Mean, % (SD)	PP Difference (95% CI)	P Value	Baseline^{^a} Mean, % (SD)	Post-Intervention^{^b} Mean, % (SD)	PP Difference (95% CI)	P Value
Presumptive treatment	4.3 (0.0022)^{^c} N=111,471	2.1 (0.0012)^{^c} N=63.322	−2.2 (−4.9, −1.5)^{^c}	.001^{^c}	3.4 (0.0165) N=70,749	2.9 (0.0204) N=62,758	+0.4 (−3.4, 2.2)	.239
Nonadherence to negative test results	0.9 (0.0022)^{^c} N=21,053	0.7 (0.0019)^{^c} N=16,830	−0.2 (−4.8, −1.1)^{^c}	.009^{^c}	1.3 (0.0057) N=24,980	0.8 (0.0054) N=17,477	−0.5 (−2.5, −0.1)	.015
IPTp3+ coverage	45.7 (0.0891)^{^c} N=101,672	58.7 (0.0670)^{^c} N=138,440	+13.0 (6.4, 18.7)^{^c}	.000^{^c}	48.1 (0.0961)^{^c} N=105,972	57.9 (0.0450)^{^c} N=134,442	+9.8 (+4.5, +14.6)^{^c}	.000^{^c}
Testing rate for suspected uncomplicated malaria	94.7 (0.0234)^{^c} N=2,292,065	97.3 (0.0130)^{^c} N=2,471,574	+2.6 (+1.1, +6.4)^{^c}	.000^{^c}	95.9 (0.0130) N=2,009,378	96.5 (0.0241) N=2,142,251	+0.5 (−3.4, +2.3)	.187
Percentage of confirmed cases referred	44.3 (0.3210)^{^c} N=33,430	34.3 (0.291)^{^c} N=32,100	−10.0 (−1.8, −18.0)^{^c}	.007^{^c}	48.1 (0.4192) N=21,083	47.2 (0.6202) N=27,237	−1 (−5.2, +4.1)	.294
Appropriate pre-referral treatment (aged<5 years)	64.7 (0.0031)^{^c} N=10,208	79.8 (0.0562)^{^c} N=9,833	+15.1 (+7.1, 22.7)^{^c}	.000^{^c}	70.0 (0.0467) N=11,304	72.3 (0.0762) N=11,874	+2 (−2.1, +4.3)	.096
Confirmed malaria cases treated with ACTs	95.0 (0.1087) N=536,572	100.0 (0.0464) N=1,097,219	+5.0 (−3.8, +13.1)	.090	88.1 (0.0235) N=657,432	92.4 (0.2102) N=945,652	+4 (−2.3, −9.0)	.186

Abbreviations: ACT, artemisinin-based combination therapy; CHO, community health officer; CHPS, Community-based Health Planning and Services; CI, confidence interval; HMIS, health management information system; IPTp3+, intermittent preventive treatment of malaria for pregnant women, 3+ doses; N, numerator of each indicator; PP, percentage point; SD, standard deviation.
↵a 0–12 months before internship.
↵b 0–12 months post-internship.
↵c Statistically significant associations.