Research for Health Environment and Development, P.O. Box 345, Mangochi, Malawi.
District Health Office, P.O. Box 42, Mangochi, Malawi.
BMC Health Serv Res. 2019 Jul 22;19(1):509. doi: 10.1186/s12913-019-4341-5.
Community-Directed Interventions (CDI) is a participatory approach for delivery of essential healthcare services at community level. It is based on the values and principles of Primary Health Care (PHC). The CDI approach has been used to improve the delivery of services in areas that have previously applied Community-Directed Treatment with ivermectin (CDTi). Limited knowledge is available about its added value for strengthening PHC services in areas without experience in CDTi. This study aimed to assess how best to use the CDI approach to strengthen locally identified PHC services at district level.
This was a comparative intervention study carried out over a period of 12 months and involving four health centres and 16 villages assigned to 1) a conventional Essential Health Package (EHP)/PHC approach at health centre level or 2) an EHP/PHC/CDI approach at community level in addition to EHP/PHC at health centre level. Communities decided which intervention components to be included in the intervention. These were home management of malaria (HMM), long lasting insecticide treated nets (LLIN), vitamin A and treatment against schistosomiasis. The outcomes of the two strategies were compared quantitatively after the intervention was completed with regard to intervention component coverage and costs. Qualitative in-depth interviews with involved health professionals, implementers and beneficiaries were carried out to determine the benefits and challenges of applied intervention components.
Implementation of the EHP/PHC/CDI approach at community level as an add-on to EHP/PHC services is feasible and acceptable to health professionals, implementers and beneficiaries. Statistically significant increases were observed in intervention components coverage for LLIN among children under 5 years of age and pregnant women. Increases were also observed for HMM, vitamin A among children under 5 years of age and treatment against schistosomiasis but these increases were not statistically significant. Implementation was more costly in EHP/PHC/CDI areas than in EHP/PHC areas. Highest costs were accrued at health centre level while transport was the most expensive cost driver. The study identified certain critical factors that need to be considered and adapted to local contexts for successful implementation.
The CDI approach is an effective means to increase accessibility of certain vital services at community level thereby strengthening delivery of EHP/PHC services. The approach can therefore complement regular EHP/PHC efforts.
The study was retrospectively registered with the Pan African Clinical Trial Registry TRN: PACTR201903883154921 .
社区导向干预（CDI）是一种在社区层面提供基本医疗服务的参与式方法。它基于初级卫生保健（PHC）的价值观和原则。CDI 方法已被用于改善以前应用伊维菌素社区定向治疗（CDTi）的地区的服务提供。关于在没有 CDTi 经验的地区加强 PHC 服务方面，CDI 方法的附加值的知识有限。本研究旨在评估如何最好地利用 CDI 方法加强地区一级的当地确定的 PHC 服务。
这是一项为期 12 个月的比较干预研究，涉及四个卫生中心和 16 个村庄，分为 1）卫生中心一级的常规基本卫生套餐（EHP）/PHC 方法或 2）卫生中心一级的 EHP/PHC/CDI 方法，以及卫生中心一级的 EHP/PHC。社区决定干预组件包含哪些内容。这些是疟疾家庭管理（HMM）、长效驱虫蚊帐（LLIN）、维生素 A 和血吸虫病治疗。干预完成后，对两种策略的结果进行了定量比较，比较了干预组件的覆盖范围和成本。对参与的卫生专业人员、实施者和受益人进行了深入的定性访谈，以确定所应用的干预组件的益处和挑战。
在 EHP/PHC 服务之上作为附加服务实施社区一级的 EHP/PHC/CDI 方法是可行且可接受的卫生专业人员、实施者和受益人。在 5 岁以下儿童和孕妇的 LLIN 干预组件覆盖方面观察到了统计学上的显著增加。在 5 岁以下儿童的 HMM、维生素 A 和血吸虫病治疗方面也观察到了增加，但这些增加没有统计学意义。EHP/PHC/CDI 地区的实施成本高于 EHP/PHC 地区。最高的成本发生在卫生中心一级，而运输是最昂贵的成本驱动因素。研究确定了一些需要考虑并适应当地情况的关键因素，以确保成功实施。
CDI 方法是一种增加社区一级某些重要服务可及性的有效手段，从而加强了 EHP/PHC 服务的提供。因此，该方法可以补充常规的 EHP/PHC 工作。
该研究在泛非临床试验注册处（PACTR201903883154921）进行了回顾性注册。
