Impact of Strengthening Community Health Services on Utilization of Malaria Prevention and Control Interventions in Migori County

Abstract

Malaria was the leading cause of morbidity and mortality and accounted for 40% and 30-40% of the outpatient attendance in 2011 in Migori and Kwale counties. Some studies have attributed this to inadequate capacity to deliver malaria interventions to all who need them. This study aimed at evaluating the impact of strengthening community health services on utilization of malaria prevention and control intervention in Migori County. A Quasi experimental study design was employed at baseline (zero years) and at endline (after four years) to measure the impact in Migori, with Kwale county as the Control. In the intervention group (Migori), CHVs were trained on malaria prevention and control strategies. A baseline and endline Household Surveys in each of the counties were conducted to act as the pre-data and post data respectively. The difference-in-differences method (DiD) was applied for comparing the outcomes at the intervention and control. A p value of less than 0.05 was considered significant. Health facility data on malaria morbidity were gathered on monthly basis and aggregated annually from four new established Community Health Units each in the intervention and Control sites between January 2013 to December 2016. Stratified random sampling was applied at baseline and endline surveys. The interventions were training of CHVs on community health strategy and community case management of malaria based on national training guidelines. Data were collected on utilization of malaria prevention and control interventions and malaria morbidity at CHUs during baseline and endline surveys. The study got ethical approval from Maseno University Ethical Review Committee. All study participants signed written consent forms. A sample size for each county (Migori and Kwale) was calculated as 384 households per county for both the pre-intervention and post-intervention periods. However, in Migori, a total of 1206 and 578 households were involved in the research in the baseline and endline survey respectively, while in Kwale, a total of 878 and 430 households were involved in the research in the baseline and endline survey respectively. Net ownership among households gave a significant increase (OR of 8.29 (95% CI: 4.82 to 14.28, p < 0.001) in net ownership in the Intervention area. The study found there was a significant increase in nets use the night before the survey among household members with an OR of 7.92 (95% CI: 4.33 to 14.49, p < 0.001), children <5 years (OR of 6.05 (95% CI: 4.27 to 8.57, p < 0.001) and pregnant women (OR of 1.53 (95% CI: 1.11 to 2.10, p = 0.0094) in Migori compared to Kwale. In Migori for > 5 Years, there was a reduction in malaria rates (mean difference = 85.03/1000 population), but not statistically significant (p = 0.06767), CI (-11.49975, 181.55689). For < 5 Years, there was a significant reduction in malaria rates (mean difference = 697.8 /1000, p = 0.01566), CI (250.8067, 1144.7933). In Kwale for >5 Years, there was a slight increase in malaria rates (mean difference = -42.88571/1000, but the change was not statistically significant (p = 0.3912) CI (-179.43945 to 93.66802). For <5 years, there was a slight increase in malaria rates (mean difference = -57.5/1000, but the change was not statistically significant (p = 0.6221), CI ( -391.6629 to 276.6629). The statistical significance of this difference emphasizes the success of the intervention in improving testing accessibility and coverage. The timing of ACT administration also showed significant improvements in Migori with an OR of 1.92 (95% CI: 1.24 to 2.98, p = 0.0035). In conclusion and collectively, these findings provide compelling evidence that the intervention had a meaningful and statistically significant impact on net ownership, use, and the proper hanging of nets across multiple target groups as well as malaria morbidity especially in <5 years. The study found out that the main challenges faced by CHVs were inadequate remuneration, lack of working tools, supplies, transport, motivation as well as poor referral processes while delivering community health services. This study recommends that County Government Departments of Health Services should provide adequate budget allocation to enhance the capacity of CHVs to provide community-based health service. Finally, this study recommends further research to be conducted on the economic evaluation of the community health services as well as cost benefit analysis on the remuneration of CHVs.