摘要：Objectives. To characterize community health worker (CHW) performance using an algorithm for managing common childhood illnesses in Siaya District, Kenya, we conducted CHW evaluations in 1998, 1999, and 2001. Methods. Randomly selected CHWs were observed managing sick outpatient and inpatient children at a hospital, and their management was compared with that of an expert clinician who used the algorithm. Results. One hundred, 108, and 114 CHWs participated in the evaluations in 1998, 1999, and 2001, respectively. The proportions of children treated “adequately” (with an antibiotic, antimalarial, oral rehydration solution, or referral, depending on the child's disease classifications) were 57.8%, 35.5%, and 38.9%, respectively, for children with a severe classification and 27.7%, 77.3%, and 74.3%, respectively, for children with a moderate (but not severe) classification. CHWs adequately treated 90.5% of malaria cases (the most commonly encountered classification). CHWs often made mistakes assessing symptoms, classifying illnesses, and prescribing correct doses of medications. Conclusions. Deficiencies were found in the management of sick children by CHWs, although care was not consistently poor. Key reasons for the deficiencies appear to be guideline complexity and inadequate clinical supervision; other possible causes are discussed. In rural areas of developing countries, several reasons support the use of community health workers (CHWs) as a complement to health facilities as a source of medical care for children. Compared with health facilities, CHWs are geographically closer and available when health facilities are closed; moreover, CHWs are community members, and therefore cultural and linguistic barriers that may be present at health facilities are overcome. In addition, CHWs can help ensure that treatment at home is appropriate. For example, studies from several countries documented that when a child had a febrile illness, mothers frequently treated their children with an antimalarial at home rather than seeking care at a health facility. 1– 3 Although treatment was often begun promptly, the dose administered was incorrect (usually too low) 70% to 88% of the time. Providing care through CHWs could improve the dosing of antimalarials administered at home, an approach consistent with World Health Organization (WHO) recommendations. 4 CHWs who use simple diagnostic algorithms based on a small number of clinical signs can detect and treat pneumonia, 1, 5– 8 malaria, 2, 9 and dehydration secondary to diarrhea. 10 Some studies have documented that CHWs trained to manage a single disease can reduce childhood mortality. 8– 11 The singledisease approach is limited, however, because children frequently have symptoms indicating more than one illness. 11– 14 Studies of CHWs taught to manage multiple diseases suggest that, 1 to 4 years after initial training, CHWs retain some of their clinical competency, and that children in the populations served by the CHWs are more likely to be treated for the illnesses targeted by the CHW intervention. 15, 16 However, these studies have important limitations, such as small sample size, nonrepresentative samples of CHWs, and no evaluation of CHW performance in the treatment of actual patients. In 1995, CARE Kenya addressed the need for more comprehensive care at the community level by initiating the Community Initiatives for Child Survival in Siaya project in approximately 200 villages in Siaya District, Kenya. The mortality rate for children younger than 5 years in Nyanza Province, which includes Siaya District, was estimated to be 199 per 1000 live births in 1998. 17 The goals of this project, now implemented in 332 villages covering approximately 140 000 persons, are (1) to improve child survival by training and supporting unpaid CHW volunteers, who are literate and selected by their communities; (2) to provide care for children with acute respiratory infections, diarrhea, and malaria; and (3) to refer severely ill children to health facilities. In addition, CHWs counsel caregivers on the continued care of their sick children at home and on behaviors related to health and disease prevention (e.g., immunizations, family planning, and preventing HIV infection). CHWs were trained to use a simplified version of WHO's Integrated Management of Childhood Illness (IMCI) guidelines. 18 IMCI is a global strategy designed to strengthen health systems, implement clinical guidelines in health facilities, and implement community-based interventions that might include care by CHWs. The algorithm for CARE CHWs (available from N. Kukreja at gro.erac@ajerkuk ) relies on clinical signs and requires minimal equipment (a watch with a second hand) to guide a CHW to a diagnostic classification and an effective treatment. A representative page of the algorithm is shown in Figure 1 ▶ . Like IMCI, CARE uses separate algorithms for children younger than 2 months and aged 2 to 59 months. Open in a separate window FIGURE 1— Section of the community health worker algorithm on the management of cough or difficult breathing for children aged 2 months to 5 years: Siaya District, Kenya. In 1997, 336 CHWs received 3 weeks of initial training from project staff and job aids (clinical registers and flow sheets); in 1998 and 2000, CHWs received refresher training; and throughout the project, CHWs have been supervised. Refresher training lasted for 1 week, was conducted in groups of 8 to 10 CHWs, and included lectures, roleplaying, reviewing videotaped examination findings, and clinical preceptorship at Siaya District Hospital. Note that some changes were made in the algorithm after the start of the program. For example, in 1998, the criteria for the dehydration classifications were revised. Also, the original algorithm provided treatment guidelines (now excluded) if referral was not considered possible. Treatment and counseling job aids were also modified several times. During the project, 3 surveys of CHW performance were conducted to identify clinical skills needing reinforcement during refresher training and to evaluate the project as a whole. Because little has been published on the ability of CHWs to follow a clinical algorithm addressing multiple illnesses, we present results of these evaluations. Experience with programs in which CHWs manage multiple illnesses is particularly relevant today as more countries consider including CHW interventions in their community component of IMCI.
