Improving access to appropriate case management for common childhood illnesses in hard-to-reach areas of Abia State, Nigeria

Studies have demonstrated that trained community health workers can improve access to quality health services for under five children. Under the World Health Organization’s Rapid Access Expansion Progamme, integrated community case management of childhood illnesses (iCCM) was introduced in Abia and Niger States, Nigeria in 2013. The objective of the program was to increase the number of children 2-59 months receiving quality life-saving treatment for malaria, pneumonia and diarrhoea by extending case management through community-oriented resource persons (CORPs). We present findings from household surveys comparing baseline and endline data to assess changes in sick child care-seeking, assessment, and treatment coverage provided over the project period in Abia State.

The World Health Organization -United Nations Children's Fund (WHO-UNICEF) Joint statement on integrated community case management (iCCM), supports iCCM as an equity-focused strategy to improve access to essential treatment services for children under the age of five. 3 The strategy targets treatable diseases that are the main causes of childhood deaths in low and middle-income countriespneumonia, diarrheoa, malaria and malnutrition, using available efficacious treatment. This involves administration of oral antibiotics for pneumonia, zinc and low osmolarity oral rehydration salts (ORS) for diarrheoa and artemisinin-combination therapy for malaria by community health workers (CHWs). 4,5 In November 2013, the WHO Rapid Access Expansion Programme (RAcE) was launched in Nigeria. 6 The program, which pioneered iCCM in the country, supported Abia and Niger States to train and deploy community health workers (CHWs) referred as community-oriented resource persons (CORPs), in underserved hard-to-reach communities of the states. The iCCM programme in Abia State targeted children under five years of age across hard-to-reach communities in 15 out of 17 local government areas (LGAs). We present the results of the changes in care-seeking, diagnostic and treatment coverage, after the introduction of iCCM in Abia state.

METHODS STUDY SETTING
Abia State is in the south eastern region of Nigeria. The state had an estimated population of 3.7 million in 2016. The population is predominantly rural (70%), with the agricultural sector employing a good proportion of the state's workforce. 7 The State Ministry of Health (SMOH) provides overall direction for the health services in the state and is responsible for health staff development and organization; and implementation of secondary health care. The SMOH, through the Abia State Primary Health Care Development Agency (SPHCDA), provides policies and guidelines for primary health care service delivery and supervises its implementation in the 17 LGAs in the state. The primary health care (PHC) system provides basic health services and is often the only source of health care available to persons living in the rural areas. However, over the years, issues of equity and disparity between disease burden and health expenditure have led to sub-optimal utilization of the PHC system. To this end, the SPHCDA was established to improve access and quality of care provided at the PHC level. The SPHCDA, whose mandate is to also provide community health services, led the iCCM programme with support from Society for Family Health (SFH), Nigeria. Using the national iCCM guideline, the iCCM programme was implemented in hardto-reach areas, defined as areas outside the five-kilometer radius of a functioning primary healthcare center that has road accessibility, 24-hour health service provision, and adequate availability of human resources and medical supplies in 15 of 17 LGAs in Abia State.
After the baseline survey, CORPs were selected by community members and members of ward development committee based on the national criteria for CORPs selection. 8 The selected CORPs received a six-day training in iCCM at the Primary Health Centers (PHCs). The national MOH approved iCCM curriculum was used for training the CORPs. The Nigeria iCCM curriculum has been adopted from the WHO "Caring for sick child in the community" training. The CORPs training comprised of didactic and clinical sessions. The clinical sessions, comprise assessment, classification and treatment of malaria, diarrheoa, and pneumonia, screening and referral of children with severe acute malnutrition, and severe illnesses. Following the training, CORPs were provided with medicines-artemisinin-based combination therapy (ACT) for malaria, oral amoxicillin for pneumonia and ORS and zinc for diarrhoea, diagnostics -Rapid Diagnostic Test for malaria and respiratory rate timers for pneumonia and recording and reporting tools and deployed to their respective communities. The CORPs were supervised and mentored by community health extension workers (CHEWs) based at the PHCs. The CHEWs were supervised by LGA iCCM focal persons, who are trained nurses. At the time of the endline survey 1,251 iCCMtrained CORPs were active out of the 1,351 trained at the start of the programme.

CARE SEEKING
Defined as seeking care for malaria, diarrhoea and pneumonia from an appropriate provider, including community-oriented resource person. An appropriate provider was defined as seeking care from a public or private health facilities, a community-oriented resource person, or proprietary and patent medicine vendors.

ASSESSMENT/DIAGNOSIS
Children presenting with fever were tested and diagnosed using a Rapid Diagnostic Test for malaria by a CORP. To assess for fast breathing pneumonia, children with cough/difficult or rapid breathing had their respiratory rate counted by a CORP for one minute using a respiratory rate counting timer. Cases with respiratory rate above the WHO age-specific cut-off point were classified as fast-breathing or pneumonia. (50 breaths or more per minute in a child age 2 months up to 12 months and 40 breaths or more per minute in a child age 12 months up to 5 years are considered fast breathing).

TREATMENT
Children between 6-59 months with a positive RDT for malaria receive artemether-lumefantrine (AL). Children with fast-breathing pneumonia were treated with amoxicillin dispersible tablet. Children aged 2-59 months presenting with diarrhoea were treated with ORS and zinc.

HOUSEHOLD SURVEYS
Baseline and endline cross-sectional cluster-based household surveys were conducted in the iCCM programme areas at the start of the project in May-June 2014 and in February 2017. The aim of the household surveys was to assess changes in sick child care-seeking, assessment, and treatment coverage as well as caregivers' knowledge of childhood illnesses and perceptions of CORP services over the project period. The surveys interviewed primary caregivers of children age 2-59 months who had been sick with diarrhoea, fever, or cough with difficult or fast breathing in the two weeks prior to the survey. Information on background characteristics of the caregivers and children, and care-seeking, assessment, and treatment for the three illnesses was collected.
Improving access to appropriate case management for common childhood illnesses in hard-to-reach areas of Abia State, Nigeria

Journal of Global Health Reports
A 30x30 multi-stage cluster sampling methodology was used for both surveys. Thirty clusters were selected using probability proportional to size. Within each cluster, 10 interviews were conducted for each of the three illnesses (diarrhoea, fever, or cough with difficult or fast breathing) for a total of 30 interviews per cluster. Due to some changes in the project areas between the baseline and endline surveys, the clusters were redrawn at endline with an updated sampling frame that only included communities where the project was implemented.

DATA MANAGEMENT
Data collection for the baseline household survey was completed between May and June 2014 and for the endline household survey in February 2017. All survey team members were trained prior to the conduct of the surveys. The trainings included a pre-test of the survey instruments in one of the LGAs. For the household surveys, written informed consent was sought from each respondent prior to the administration of the questionnaire.
The household survey data were collected using paper questionnaires and entered into a CSPro database developed by the U.S. Census Bureau and ICF International with funding from U.S. Agency for International Development USA. Data were double-entered and checked for consistency. Any discrepancies were checked and resolved.
DATA ANALYSIS Survey data were analyzed using Stata version 14. Frequency estimates and 95% confidence intervals were calculated for all household survey indicators collected. Estimates were adjusted for cluster effects. Pearson's chi-square test was computed to assess significant changes between baseline and endline indicator estimates.

ETHICAL APPROVAL
The household survey protocol was reviewed and approved by the ICF Institutional Review Board and from the National Health Research Ethics Committee in Nigeria.

CHARACTERISTICS OF SICK CHILDREN AND CAREGIVERS
At baseline and endline, there was an equal representation of sick children by sex and an even distribution across the age groups ( Table 1). The most commonly reported illness at both baseline and endline was fever (66.0% and 74.3%, respectively). There was a higher report of all three illnesses at endline compared to baseline. Majority of caregivers were between the age 25-34 (just under 50% in both surveys), had a secondary or higher level of education (68.7% and 75.5% at baseline and endline, respectively), and were currently married or living with a partner as if married (just under 90% in both surveys) (Table 2). Overall, the characteristics of the sick children and caregivers were similar across the baseline and endline household surveys. CAREGIVER KNOWLEDGE OF ILLNESSES Caregiver knowledge of two or more childhood illness danger signs increased significantly, from 65% at baseline to 78% at endline (P<0.01) ( Table 3). Knowledge on the cause and signs and symptoms of malaria, however, remained relatively stable between baseline and endline, at around 70% at baseline and slightly under 70% at endline. Caregiver knowledge of correct malaria treatment (artemisinin-based combination therapy [ACT]) improved significantly between baseline and endline, increasing from 30% at baseline to 54% at endline (P<0.0001). Caregiver knowledge of correct diarrhoea treatment (oral rehydration solution [ORS] and zinc) also increased significantly, from 1% at baseline to 25% at endline (P<0.0001).

CAREGIVER PERCEPTIONS OF ICCM-TRAINED CORP
Overall, most caregivers had good perceptions of the CORPs working in their community by endline, with more than 80% of caregivers reporting that they viewed the CORP as a trusted health care provider, that CORPs provide quality services, and that CORPs are a convenient source of treatment. In addition, at endline, 88% of caregivers reported that they found the CORP at their first visit, demonstrating high accessibility (Table 4).

CARE-SEEKING FOR FEVER, DIARRHOEA, AND COUGH WITH DIFFICULT OR FAST BREATHING
Overall, care-seeking from an appropriate provider, defined as seeking care from a public or private health facilities, a community-oriented resource person, or proprietary and patent medicine vendors increased over the course of the RAcE project from 68.7% to 76.8% (P<0.01); primarily due to increases in care-seeking for children with diarrhoea (P<0.05) and children with cough with difficult or fast breathing (P<0.0001) ( Table 5). Source of care-seeking shifted substantially over the project period; with more caregivers selecting to seek care from CORPs in their communities by endline (48.1%) and fewer seeking care from hospitals (10.8% at baseline to 6.6% at endline), health centers (decreased from 34.0% to 24.8%) and propriety and patent medicine vendors (decreased from 55.1% to 36.2%).

ASSESSMENT OF SICK CHILDREN
The percentage of children with fever in the two weeks preceding the survey who had blood drawn (proxy measure for receipt of an RDT) increased from 9.3% at baseline to 41.0% at endline (P<0.0001) ( Table 6). Among the children with fever that had a blood test, the percentage of caregivers that received the result of the test also improved from 72.2% at baseline to 90.3% at endline (P<0.01). Among the children with fever for which care was sought from a CORP, 77.3% had blood drawn at endline and 93.8% of caregivers reported having received the result of the test. A similar increase was also observed in assessment of cough with difficult or fast breathing; improving from 21.2% to 42.8% over the project period (Table 6). Among the children with of cough with difficult or fast breathing for which care was Improving access to appropriate case management for common childhood illnesses in hard-to-reach areas of Abia State, Nigeria     Receipt of treatment among all cases of confirmed malaria (fever cases that had a positive RDT), diarrhoea, and cough with difficult or fast breathing increased significantly between baseline and endline (Table 7). Among confirmed malaria cases, receipt of ACT within 2 days increased from 25.0% to 66.9% (P<0.01) over the project period. Among confirmed malaria, diarrhoea, and cough with difficult or fast breathing cases for which care was sought from a CORP, 69.8%, 64.7%, and 66.1%, respectively received the appropriate treatment (ACT within 2 days, ORS and zinc, and amoxicillin, respectively) from a CORP at endline. Among the children who sought care from a CORP for the three illnesses at endline, 62.3% received the first dose of treatment in the presence of a CORP, 98.4% of caregivers received counseling on how to administer the treatment (among children who received treatment), and 69.8% of children received a follow-up visit from the CORP ( Table 8). Provision of the first dose of treatment, counseling, or follow-up visits by a CORP was similar across all illnesses. Improving access to appropriate case management for common childhood illnesses in hard-to-reach areas of Abia State, Nigeria  ACT -artemisinin-based combination therapy, na -not applicable, ORS -oral rehydration salts, CORP -community-oriented resource person *The overall indicator was calculated to include the percentage of children with confirmed malaria that received an ACT within two days, children with diarrhoea that received ORS and zinc, and children with cough with difficult or fast breathing that received amoxicillin.

Journal of Global Health Reports
Improving access to appropriate case management for common childhood illnesses in hard-to-reach areas of Abia State, Nigeria Journal of Global Health Reports ORS -oral rehydration salts, ACT -artemisinin-based combination therapy, CORP -community-oriented resource person DISCUSSION This study examined changes in coverage of care-seeking and diagnostic and treatment services for diarrhoea, malaria, and pneumonia over the course of iCCM implementation in Abia state. The results demonstrate substantial improvements in access to appropriate case management of childhood illness between 2013 and 2017. Our results showed that in areas with access to iCCM, CORPs were the main source of care. Overall, care-seeking practices shifted over the course of the project, with more caregivers choosing to access care from a CORP by endline and less seeking care from PPMVs. The observed shift is likely due to proximity of caregivers to the CORPs, perceived quality and cost-savings, as PPMVs charge money for treatment, whereas treatment is provided free of charge by the CORPs. Several studies also have shown lower or sub-standard quality care provided by PPMVs; thus, perceived lower quality of care may also have influenced the shift away from PPMVs to CORPs. [9][10][11][12][13] Overall, caregivers also had good perceptions of the CORP working in their communities, with more than 80% reporting that they view the CORPs as trusted health care providers, that CORPs provide quality services, and that CORPs are a convenient source of treatment. Caregiver knowledge of child illness danger signs and knowledge of the correct treatment for malaria and diarrhoea all improved significantly between baseline and endline in the project areas.
Improvements in the appropriate assessment of children with fever and cough with difficult breathing were also observed over the RAcE project period, with higher coverage observed of administration of RDTs to assess for malaria and respiratory rate counting to assess for pneumonia among CORPs compared to coverage among all providers. Significant improvements in treatment coverage across all iCCM illnesses were also observed; with similarly higher coverage of appropriate treatment provided by CORPs compared to coverage among all providers. Of all iCCM illnesses, coverage of ACT treatment for confirmed malaria experienced the greatest improvement over the project period; though coverage of timely ACT treatment (within 24 hours) was lower among both CORPs and all providers. This signifies that greater efforts to enhance community awareness of the importance of early care seeking for febrile ill-ness in children and the availability of trained and adequately supplied CORPs are needed to improve timely care-seeking. Our results provide evidence that well-supported CORPs can provide iCCM services consistent with country iCCM protocols. Other studies have demonstrated similar results to ours, indicating that when CHWs are trained and equipped, they can positively influence careseeking behavior and improve access to appropriate treatment of common childhood illnesses, especially in hard-toreach areas across sub-Saharan Africa. [14][15][16][17][18][19][20][21] While substantial increases were observed in care-seeking and appropriate case management of childhood illnesses over the life of the RAcE project; the results indicate that there are still areas for further improvement. Providing refresher trainings to CHWs and regular supervision and mentorship, ensuring CHWs have commodities, and providing recognition and other incentives to CHWs are strategies that have been shown to help improve the appropriate care provided by CHWs and their overall satisfaction and motivation for the work they do. [22][23][24][25] When CHWs are welltrained, supplied, and supervised, they can increase access to prompt and appropriate treatment of preventable childhood illnesses. 22,[26][27][28] These findings also highlight the importance of supporting CHWs as results were achieved within a well-supported iCCM program.
There are a few survey limitations to note. First, the survey findings are representative of the project areas as a whole; the survey was not powered to provide lower subnational-level estimates (eg, at the LGA level), and therefore we are not able to report on any differences in coverage across the project areas. Second, some programme areas changed from the initially selected areas at the start of the programme in Abia. These changes caused us to have to redraw the sample for the endline household survey, rather than using the same selected clusters for the baseline survey. Despite these changes, we do not believe this effected the results or the comparability of the baseline and endline surveys, as CORPs had not yet been operating in the programme areas at baseline and the initially selected areas were very similar in sociodemographic characteristics as the final selected areas for the programme. Last, there are known potential biases and limitations with the indicators that assess caregiver recall of malaria diagnostic testing and coverage of appropriate treatment for children with fever and cough with difficult or fast breathing. Improving access to appropriate case management for common childhood illnesses in hard-to-reach areas of Abia State, Nigeria

CONCLUSIONS
The study results demonstrate that CHWs improve access to treatment of diarrhoea, malaria and pneumonia among children under five living in communities located far from health facilities. Across the implementation sites, they provided appropriate treatment and reduced caregiver dependence on non-quality alternatives in the communities. The health system in Nigeria is plagued with acute shortages in healthcare personnel and long distances to health facilities. The availability of CORPs can help address health access issues, especially in the rural areas, and support the Nigeria's policy goal to meet the universal health coverage and the health needs of the Nigerian population.