Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, Massachusetts, 02115, USA.
Department of Biostatistics, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, Massachusetts, 02115, USA.
Implement Sci. 2020 Mar 4;15(1):13. doi: 10.1186/s13012-020-0968-1.
In the context of task shifting, a promoted approach to healthcare delivery in resource-poor settings, trained community health workers (CHWs) have been shown to be effective in delivering quality care of malaria for febrile under-5 children. While their effectiveness has been documented, the fidelity of implementation (FOI) has not been adequately studied. By understanding and measuring whether an intervention has been performed with fidelity, researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved. The objective of this study was to assess the FOI of a recommended protocol for malaria care by CHWs in a resource-poor setting in Nigeria.
Thirty-five female CHWs who participated in a 3-day training on home management of malaria among under-5 children were studied. They managed 1,646 children over the implementation period and then underwent evaluation via a one-time hospital-based observation by the trainers. During the evaluation, a pre-tested standard checklist was used to compute performance scores for CHWs; doctors and nurses were selected to serve as the gold standard for comparison. Performance scores (PS) recorded during the evaluation were used to assess adherence and compliance with the recommended treatment protocol.
Of the 4 skill domains assessed, adherence was greatest for compliance with malaria treatment recommendations (94%) and lowest for post-treatment initiation counseling of home-based caregivers (69%). The average overall adherence of 83% was comparable to adherence by gold standard comparators. Mean PS was not found to be significantly associated with CHW demographics. Scores for clinical evaluation among those whose occupation was not healthcare-related were significantly lowered by 0.52 [95% CI (1.05-0.01), p = 0.05]. Compliance with the treatment protocol increased by 23% for every unit increase in total PS (p = 0.07) and doubled for every unit increase in scores for post-treatment initiation counseling of caregivers (p = 0.002).
Studying intervention fidelity stands to identify the shortcomings of implementation and specific areas to target for improvement in future adoption or implementation. This study concludes that future trainings should emphasize clinical evaluation and post-treatment counseling of caregivers by CHWs to ensure the best outcome for children.
在任务转移的背景下，培训社区卫生工作者（CHW）作为资源匮乏环境中提供医疗服务的一种被推广的方法，已被证明在为发热的 5 岁以下儿童提供疟疾优质护理方面是有效的。虽然已经证明了他们的有效性，但实施的保真度（FOI）尚未得到充分研究。通过了解和衡量干预措施是否具有保真度，研究人员和从业者可以更好地理解干预措施的工作方式和原因，以及可以在多大程度上改善结果。本研究的目的是评估在尼日利亚资源匮乏的环境中，CHW 推荐的疟疾护理方案的 FOI。
对 35 名参加过 3 天的 5 岁以下儿童疟疾家庭管理培训的女性 CHW 进行了研究。在实施期间，他们管理了 1646 名儿童，然后由培训师进行一次性医院观察评估。在评估过程中，使用预先测试的标准检查表来计算 CHW 的绩效得分；选择医生和护士作为比较的金标准。评估期间记录的绩效得分用于评估对推荐的治疗方案的遵守情况。
在评估的 4 个技能领域中，对遵守疟疾治疗建议的依从性最高（94%），对家庭护理人员治疗后启动咨询的依从性最低（69%）。83%的平均整体依从率与金标准对照者的依从率相当。CHW 人口统计学特征与平均 PS 无显著相关性。非医疗相关职业者的临床评估得分平均降低 0.52 分[95%CI（1.05-0.01），p=0.05]。总 PS 每增加一个单位，治疗方案的依从性就会增加 23%（p=0.07），对护理人员治疗后启动咨询的依从性增加一倍（p=0.002）。
研究干预措施的保真度有助于确定实施中的不足之处，并确定未来采用或实施中需要改进的具体领域。本研究得出结论，未来的培训应强调 CHW 的临床评估和对护理人员的治疗后咨询，以确保儿童获得最佳结果。
