It is well established that rectal artesunate is a lifesaving intervention. This study identified five continuum of care criteria (5CC Framework) that should feature as part of any RAS implementation guideline: care transitions for the patient; consistency of supplies at delivery sites; comprehensiveness of care received by the patient at the VHC and at referral health centres; connectivity of care between providers; and communication between all points of care. The data to support this recommendation is presented below:
Care transitions for the pediatric patient and caregiver
Cue to action
The transition from homestead to the village health clinic with a sick child often requires a stimulus to trigger a decision-making process, referred to as a cue to action. Project posters provided pictorial information on severe malaria danger signs and indicated where care could be sought. At endline, 80% of the respondents in the exposed arm reported seeing at least one of the 200 study posters. They were displayed in various locations which included meeting places, on prominent trees on well-used paths and on leaders’ houses (Fig. 1). The majority of respondents reported that they were unable to read but responded positively to the pictorially based posters. 92.4% of respondents who had seen the poster understood it, determined by their capacity to recall the key learning content of the poster during interview. These posters became a valued cue to action in the exposed arm over the course of the intervention period. In the control arm, the most significant reported cues to action were knowledge acquired through word of mouth that severe malaria medicines were now available in the village clinic (which was not the case prior to the study) and through knowledge of a death of a child in the village from malaria/danger signs. The knowledge that medicines were available and consistently in stock at the VHC encouraged members of the community to seek healthcare for danger signs, across both arms.
Table 1: Household reported cue to action in response to severe malaria
Cue to action
|
Exposed n=173
|
Unexposed
n =55
|
Comparison p value
|
Exposed
|
Unexposed
|
Comparison p value
|
#
|
%
|
#
|
%
|
|
#
|
%
|
#
|
%
|
|
Posters and pictures mounted in the village/
my community
|
97
|
56.1
|
50
|
90.9
|
<0.001
|
158
|
95.8
|
18
|
32.7
|
<0.001
|
Knowledge of
availability of medicine for danger signs at the VHC
|
51
|
30.0
|
9
|
16.4
|
<0.001
|
96
|
58.2
|
53
|
96.4
|
<0.001
|
The death of a child from malaria/danger
signs in the village
|
86
|
50.0
|
8
|
14.6
|
<0.001
|
109
|
66.1
|
51
|
92.7
|
<0.001
|
Care transitions
Closest primary-care point of care
A successful care transition from homestead to the village health clinic is founded on the desire for residents in the catchment area to access care at the nearest primary-care point. At the study sites, 97% of all respondents knew about the VHC, with 85% having visited their health centre in the past year, primarily due to a child’s illness. The VHC was the first and preferred point of care for severe childhood febrile illness, primarily due to ease/proximity (80% reported they could reach the VHC within 1 hour by foot), adequacy/speed of access and because tertiary health facilities (and even some health centres) have policies restricting self-referrals. Two-thirds of caregivers were seen swiftly, spending only half an hour at the VHC, including waiting time.
Consistency of supplies at delivery sites
VHC readiness – functionality and conduciveness to delivery of RAS
Knowledge that the village health centre is functional and that the necessary commodities are available, motivates people to transition from homestead to the nearest primary point of care. This assessment was made over the course of 276 monitoring visits throughout the duration of the study. The data revealed significant infrastructure challenges at the village health clinics, including inconsistent access or lack of clean water for handwashing, inconsistent supplies of gloves, absence of lighting for night-time care, as well as unreliable access to dry secure storage for commodities. In addition, malaria-related clinical supervision was very low to absent throughout the 12-month study; 93% of the monitoring visits revealed no on-site supervision had taken place during the preceding month. Prior to the launch of the study, RAS was not routinely available in the study VHCs. Knowledge that RAS was now available at the VHC was reported as a cue to seek care among community members. Although the study did not supply the commodity, the study ensured that RAS was always in the VHCs, in both study arms. When, during routine monitoring, it was noted that RAS supplies were diminishing, the HSAs/CHWs were prompted to pull the commodity from the health centre as per district procedures. RAS was administered to 100% of the cases with danger signs presenting at the VHCs. Knowledge that RAS was regularly available (consistency of supplies) proved to be a powerful cue to seek care for a child with danger signs and resulted in the artesunate being administered to every case.
Comprehensiveness of care at the VHC
Care delivery
Another criterion of continuum of care highlighted in this study, relates to the nature of the care provided and whether it was considered ‘comprehensive care’ and appropriate in relation to the presenting symptoms. The toolkit and HSA sensitization training emphasized the need for comprehensive care, defined as – child examined/assessed, RAS administered (correct dose, correct method), referral slip & instructions given – and encouraged HSAs to have the job aid to hand when managing a child with signs of severe malaria. There was strong evidence that children with danger signs (Table 3), the majority of whom had multiple danger signs at one time (Table 4), who were managed by sensitized HSAs with access to the job aid, had a significantly higher chance of receiving comprehensive care. The social behaviour change intervention had a positive impact on correct response and administration of RAS among exposed CHWs/HSAs. This group of CHWs showed higher levels of knowledge and offered a superior quality of care, in comparison to the unexposed CHWs. This kind of simple change requires consistent supervision in order to be sustained.
Table 2: Severe malaria danger signs that presented at the village health clinic
Danger signs
|
%
|
Unable to feed/drink
|
30.1
|
Severe vomiting
|
23.5
|
Altered consciousness
|
19.9
|
Convulsions or history of convulsions
|
11.8
|
Extreme weakness
|
8.1
|
Severe anaemia
|
6.6
|
Table 3: Number of danger signs experienced by children at the time they presented at the VHC
Number of danger signs at a time
|
Count
|
%
|
One (1) danger sign
|
11
|
50.3
|
Two (2) danger signs
|
38
|
42.6
|
Three (3) danger signs
|
31
|
34.8
|
Four (4) danger signs
|
18
|
20.2
|
When comparing the association between the age of the child and the service provided, both the mean and median show that the likelihood of receiving correct care from the HSA is greater among sick children who are younger. In addition, there is evidence that the odds of correct services being offered increases with a decrease in the age of the sick child – odds ratio 0.95) CI: 0.92 – 0.98).
Dosing of rectal artesunate
A key component of comprehensive care is the assurance that the patient will receive the correct dose (Fig. 5). The majority of children were administered the correct dose based on their age. In the exposed arm, 84.5% of the cases were administered the correct dosage, while in the
unexposed arm, 71.9% were given the correct dosage. The tendency was to under-dose and administer one capsule instead of two. As weighing scales were not readily available, the children were not weighed and dosing was, therefore, based solely on estimated age. The HSAs in the intervention sites had access to a dosing table but in 16% of cases the HSAs administered the incorrect dose, solely based on the age of the child. Whether the HSA adjusted the dose downward because they determined that the child’s weight was lower, they underestimated the age of the child, or whether this was a clinical error, was not determined.
Connectivity of care
Role of referral slips
Continuity of care requires a dependable and consistent way of enhancing connectivity of care between providers and the different levels within the health system. The referral slip performed this role, irrespective of the availability of the RASIEC toolkit. All referrals were counter-verified during routine monitoring by checking the referral slip duplicate retained in the referral slip book. The referral was then tracked to the health facility (where the majority were retrieved) and others were retrieved at the homestead during the follow-up interview. The dedicated/condition-specific referral slips proved to be an intervention in both study arms that was well received by HSAs and caregivers alike. Although not officially part of the toolkit, it was perceived as such and caregivers in both arms (84.4% in unexposed; 94.4% in exposed) reported that the referral slip had a ‘positive’ impact on the response they received at the referral health facility. The HSAs reported that the referral slip book was a key tool, as it legitimized, formalized and authenticated their referrals and, as a result, the caregivers took the stipulation to seek advanced care more seriously than with a verbal referral.
Caregiver compliance with referral
The success of connected care depends on caregiver compliance, defined as the extent to which the patient’s behaviour matches the prescriber’s recommendations. The caregiver is expected to comply with the health worker’s recommendation for action which, in this case, is referral for post-RAS treatment. Compliance with referral was extremely high and essentially equal in both arms – over 96% in both. Additional sensitization of the HSA/CHW did not affect whether the caregiver adhered to referral or not. Caregivers reported rapid change in the state of the child soon after RAS was administered. Despite this improvement, caregivers did not delay complying with the referral.
Table 4: Improvement in status of the child soon after RAS administration – caregiver report
RAS administration & response to RAS
(Caregiver report)
|
Exposed
n=56
|
Unexposed
n=33
|
#
|
%
|
#
|
%
|
Child showed improvement soon after VHC (Yes)
|
52
|
92.9
|
31
|
93.99
|
Time taken to reach care after referral
The time it takes to reach care after referral, otherwise known as the transit time between referral and arrival at a health facility, influences how connectivity of care is evaluated. In the case of this study, it was rapid, with 89% reaching the referral centre within the stipulated 24-hour window, and 74% reaching the referral facility in less than 5 hours. Caregivers whose children were treated by sensitized HSAs/CHWs – trained to ‘assess’ - ‘treat’ - ‘refer’ –, displayed a greater response to time pressure but the difference was not significant. The referral slip was a very effective tool in encouraging caregivers to travel with urgency.
Comprehensiveness of care at the referral centre
Care received at the referral centre
It is postulated that the most significant barrier to the success of RAS is the trajectory from the village health clinic to the referral centre. The assumption is that once a child arrives at the referral centre, they will receive the correct post-RAS care. The study did not evaluate the care provided at the referral centre directly, but data was gathered based on the caregiver’s recall of the care his/her child received. Admission for a minimum of 24 hours is expected after RAS administration for signs of severe malaria, to allow for observation during the administration of parenteral injectable artesunate. Of key interest, in relation to WHO guidelines for post-RAS management of severe malaria, was whether the child was admitted (versus treated as an outpatient), and whether the child received some kind of parenteral treatment: intravenous (IV) drip/injection (Table 5).
Table 5: Care (parenteral IV or injection) & admission at the referral facility (caregiver recall)
Number of danger signs
|
IV/Drip or Injection
|
Admitted
|
Total
|
Percent
|
One (1) danger sign
|
No
|
No
|
3
|
3.4%
|
Yes
|
0
|
0.0%
|
Yes
|
No
|
4
|
4.5%
|
Yes
|
4
|
4.5%
|
Two (2) danger signs
|
No
|
No
|
22
|
24.7%
|
Yes
|
1
|
1.1%
|
Yes
|
No
|
7
|
7.9%
|
Yes
|
8
|
9.0%
|
Three (3) danger signs
|
No
|
No
|
21
|
23.6%
|
Yes
|
1
|
1.1%
|
Yes
|
No
|
2
|
2.2%
|
Yes
|
7
|
7.9%
|
Four (4) danger signs
|
No
|
No
|
9
|
10.1%
|
Yes
|
0
|
0.0%
|
Yes
|
No
|
0
|
0.0%
|
Yes
|
0
|
0.0%
|
TOTAL
|
89
|
100.0%
|
Of the 86 caregivers (primarily mothers) who responded to this question, 21 (24.5%) reported that their child was admitted as an inpatient, and that they spent nights sleeping at the hospital (something a caregiver is very likely to recall). Of all the tracked cases who received RAS and complied with referral, only 30% received parenteral care at the referral facility, note that some were administered parenteral treatment on an outpatient basis and did not receive the three doses of injectable artesunate followed by artemisinin-based combination therapy as required by national guidelines. This lack of alignment with severe malaria treatment guidelines to admit the patient to administer post-RAS treatment, revealed the need to further explore this dimension of the continuity of care.