Plausible role for CHW peer support groups in increasing care-seeking in an integrated community case management project in Rwanda: a mixed methods evaluation

Anne Langston; Jennifer Weiss; Justine Landegger; Thomas Pullum; Melanie Morrow; Melene Kabadege; Catherine Mugeni; Eric Sarriot

doi:10.9745/GHSP-D-14-00067

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The Bahomwana CHW Peer Support Group meets in Gasambu village, Rwanda, to exchange ideas and challenges in order to accomplish and improve their work.
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Figure.
Care-Seeking From CHWs and Facilities for All iCCM Conditions in Children 0–59 Months, Kabeho Mwana Project vs. Non-Project Districts

Abbreviations: CHWs, community health workers; iCCM, integrated community case management.
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A community health worker and member of a Peer Support Group on a routine home visit.

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Table 1. Care-Seeking for Fever, Diarrhea, and ARI Symptoms and Other MCH Interventions for Kabeho Mwana and Non-Kabeho Mwana Project Districts in 2005 and 2010

	Non-KM Project Districts			KM Project Districts			Difference in the Differences
	2005	2010	Change	2005	2010	Change	Difference in the Differences
	N (%)	N (%)	%	N (%)	N (%)	%	%
Care-Seeking From Any Trained Provider
Diarrhea	803 (16.2)	808 (36.3)	+20.0	292 (8.4)	308 (40.0)	+31.6	+11.6***
Fever	1,485 (31.5)	1,003 (40.8)	+9.3	546 (20.3)	332 (48.7)	+28.4	+19.1***
ARI symptoms	964 (30.5)	233 (47.4)	+16.9	357 (20.9)	85 (57.9)	+37.0	+20.0**
All 3 conditions	2,551 (26.0)	1,570 (40.0)	+14.0	877 (16.3)	541 (46.0)	+29.7	+15.7***
Non-Project Specific Indicators
At least 3 ANC visits in the most recent pregnancy	4,269 (13.7)	5,036 (36.2)	+22.5	1,115 (12.0)	1,274 (32.2)	+20.2	−2.3
Child 12–23 months received DPT3	1,271 (87.0)	1,262 (97.3)	+10.3	343 (88.5)	330 (95.7)	+7.2	−3.1
Child 6–59 months received vitamin A in past 6 months	5,461 (83.7)	6,168 (94.7)	+11.1	1,394 (85.8)	1,589 (85.6)	−0.2	−11.3

Abbreviations: ANC, antenatal care; ARI, acute respiratory infection; DPT3, diphteria, pertussis, and tetanus; KM, Kabeho Mwana; MCH, maternal and child health.
All of the tests are one-tailed. The tests in the last column of Table 1 correspond with the tests of the unadjusted odds ratios given in Table 2.
* P≤.05, ** P≤.01, *** P≤.001.

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Table 2. Odds Ratios for Care-Seeking for Sick Children in Kabeho Mwana Project Districts vs. Non-Project Districts After Controlling for 2005–2010 Gains in Both Types of Districts

Conditions	Unadjusted OR (95% CI)	Adjusted OR^a (95% CI)
Diarrhea	2.47*** (1.47–4.15)	2.56*** (1.47–4.46)
Fever	2.49*** (1.66–3.73)	2.54*** (1.68–3.85)
ARI symptoms	2.53** (1.29–4.95)	2.35** (1.20–4.62)
All 3 conditions	2.31*** (1.66–3.21)	2.24*** (1.60–3.16)

Abbreviations: ARI, acute respiratory infection; CI, confidence interval; iCCM, integrated community case management; OR, odds ratio.
↵a Adjusted to control for the duration of time since implementation of iCCM, the district (as a fixed categorical effect), and whether malaria was endemic in the district. All of the tests are one-tailed.
* P≤.05, ** P≤.01, *** P≤.001.

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Table 3. CHW Contribution to Care-Seeking, Kabeho Mwana Project Districts vs. Non-Project Districts, 2005 and 2010

	2005		2010
	Non-KM Project Districts	KM Project Districts	Non-KM Project Districts	KM Project Districts
Diarrhea	n = 1,103		n = 1,132
Any provider	16.2 (13.3–19.1)	8.4*** (5.6–11.3)	36.2 (32.5–39.8)	40.0 (34.0–46.0)
CHW	0.2 (−0.2–0.60)	1.1 (0.1–2.1)	9.5 (7.3–11.7)	21.8*** (16.1–27.4)
Facility	16.2 (13.3–19.1)	8.4*** (5.6–11.3)	26.7 (23.0–30.3)	18.2^* (13.6–22.9)
Fever	n = 2,046		n = 1,355
Any provider	31.5 (28.7–34.3)	20.3*** (15.9–24.7)	40.8 (37.2–44.4)	48.7^* (43.1–54.3)
CHW	0.4 (0.0–0.8)	1.2 (0.0–2.4)	12.1 (10.1–14.2)	26.1*** (21.0–31.3)
Facility	31.1 (28.3–33.9)	19.1*** (15.0–23.3)	28.6 (25.4–31.9)	22.5^* (18.3–26.8)
ARI Symptoms	n = 1,332		n = 322
Any provider	30.5 (27.2–33.8)	20.9** (16.3–25.5)	47.4 (39.2–55.7)	57.9 (45.9–69.9)
CHW	0.5 (0.0–0.9)	0.4 (−0.2–1.0)	7.7 (4.4–11.0)	27.5*** (16.6–38.3)
Facility	30.0 (26.8–33.2)	20.5** (15.8–25.1)	39.8 (31.8–47.7)	30.4 (20.8–40.1)
All 3 Conditions^a	n = 2,847		n = 2,142
Any provider	26.4 (24.1–27.6)	16.2*** (15.1–22.1)	40.0 (37.1–42.9)	46.0 (37.1–42.9)
CHW	0.6 (0.3–0.9)	1.2^* (0.3–2.0)	4.9 (3.7–6.1)	12.4*** (8.9–15.9)
Facility	25.8 (23.5–28.1)	15.0*** (11.6–18.4)	35.1 (32.–38.1)	33.6 (29.3–38.0)

Abbreviations: ARI, acute respiratory infection; CHW, community health worker; KM, Kabeho Mwana.
↵a Includes children presenting with multiple conditions.
All data are shown as % (95% CI).
P values given are for the difference between rates of care-seeking in KM and non-KM districts in the same year.
↵ * P≤.05, ** P≤.01, *** P≤.001.

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GHSP-D-14-00067 Supplementary Material

Langston et al. doi: 10.9745/GHSP-D-14-00067. Listed in order below are Supplementary Table 1 (percent of women reporting serious problems in accessing health care); Supplementary Table 2 (basic district characteristics included in the regression); and Supplementary Table 3 (percent of under-5 children with a reported illness 2 weeks prior to the survey).

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Supplementary Material - Langston et al. doi: 10.9745/GHSP-D-14-00067
Supplementary Material - Langston et al. doi: 10.9745/GHSP-D-14-00067
Supplementary Material - Langston et al. doi: 10.9745/GHSP-D-14-00067