Ensuring access for the most remote communities: An evaluation of an integrated community case management program in Kono District, Sierra Leone

Background

Integrated community case management (iCCM) through community health workers (CHWs) aims to reduce under five child mortality rates (U5MR) in remote communities. Kono District had a high malaria burden and U5MR. In 2009, iCCM for children aged 2-59 months expanded district-wide. We evaluated the effect of iCCM on mortality, care-seeking, and appropriate treatment by CHWs or government clinic.

Methods

We conducted cluster surveys in 2010 and 2013, powered to detect a 28% decline in U5MR. The 2010 survey used a stepped wedge design consistent with the phased expansion. Clusters were selected by proportional to population size (2010) and using simple random sampling with weighting (2013). Households were selected exhaustively or using systematic random sampling. Caregivers reported on mortality over a one-year period and child morbidity and care-seeking over a two-week period.

Results

In 2010 and 2013, 5,257 and 3,649 households were surveyed, respectively. Between the years, U5MR remained unchanged although the ≥5 mortality rate increased from 0.68 to 0.93 deaths/1,000/month (p=0.03). iCCM remained the first source of care for >50% of children aged under five years. Government clinics declined as the first source of care from 30.0% to 21.7% (p=0.02). Appropriate treatment for fever by CHWs or government clinics increased from 45.5% to 58.2% (p=0.01).

Discussion

As iCCM is the main source of care and contributes to increased appropriate treatment, it is a key strategy for remote communities. A decrease in U5MR was not detected though the study was not powered to detect a relative change smaller than 28%.