Assessing the Quality of Sick Child Care Provided by Community Health Workers

Background
As community case management of childhood illness expands in low-income countries, there is a need to assess the quality of care provided by community health workers. This study had the following objectives: 1) examine methods of recruitment of sick children for assessment of quality of care, 2) assess the validity of register review (RR) and direct observation only (DO) compared to direct observation with re-examination (DO+RE), and 3) assess the effect of observation on community health worker performance.
Methods
We conducted a survey to assess the quality of care provided by Ethiopian Health Extension Workers (HEWs). The sample of children was obtained through spontaneous consultation, HEW mobilization, or recruitment by the survey team. We assessed patient characteristics by recruitment method. Estimates of indicators of quality of care obtained using RR and DO were compared to gold standard estimates obtained through DO+RE. Sensitivity, specificity, and the area under receiver operator characteristic curve (AUC) were calculated to assess the validity of RR and DO. To assess the Hawthorne effect, we compared estimates from RR for children who were observed by the survey team to estimates from RR for children who were not observed by the survey team.
Results
Participants included 137 HEWs and 257 sick children in 103 health posts, plus 544 children from patient registers. Children mobilized by HEWs had the highest proportion of severe illness (27%). Indicators of quality of care from RR and DO had high sensitivity for most indicators, but specificity was low. The AUC for different indicators from RR ranged from 0.47 to 0.76, with only one indicator above 0.75. The AUC of indicators from DO ranged from 0.54 to 1.0, with three indicators above 0.75. The differences between estimates of correct care for observed versus not observed children were small.
Conclusions
Mobilization by HEWs and recruitment by the survey teams were feasible, but potentially biased, methods of obtaining sick children. Register review and DO underestimated performance errors. Our data suggest that being observed had only a small positive effect on the performance of HEWs.

研究背景
随着儿童疾病社区病例管理在低收入国家的推广，亟需对社区卫生工作者（community health workers）提供的照护质量进行评估。本研究旨在达成以下目标：1）探讨用于评估照护质量的患病儿童招募方法；2）对比仅通过登记册审查（register review, RR）、仅直接观察（direct observation, DO）与结合复检的直接观察（direct observation with re-examination, DO+RE）的效度；3）评估观察行为对社区卫生工作者绩效的影响。

研究方法
本研究针对埃塞俄比亚卫生拓展工作者（Health Extension Workers, HEWs）提供的照护质量开展调查。研究对象儿童通过三种途径招募：自发就诊、HEWs动员或调查团队直接招募。本研究按招募方式对患者特征进行了分析。将通过RR、DO获取的照护质量指标估计值，与通过DO+RE获取的金标准估计值进行对比。本研究计算了灵敏度、特异度及受试者工作特征曲线下面积（area under receiver operator characteristic curve, AUC），以评估RR与DO的效度。为评估霍桑效应（Hawthorne effect），本研究将调查团队实施观察的儿童的RR估计值，与未被观察的儿童的RR估计值进行了对比。

研究结果
本研究共纳入103个卫生所的137名HEWs与257名患病儿童，此外还纳入了来自患者登记册的544名儿童。经HEWs动员招募的儿童中，重症病例占比最高（27%）。通过RR与DO获取的照护质量指标对多数指标具有较高的灵敏度，但特异度偏低。RR对应指标的AUC范围为0.47~0.76，仅1项指标的AUC超过0.75；DO对应指标的AUC范围为0.54~1.0，共3项指标的AUC超过0.75。被观察与未被观察儿童的正确照护估计值差异较小。

研究结论
通过HEWs动员与调查团队招募的方式获取患病儿童具备可行性，但可能存在偏倚。登记册审查与DO均低估了绩效差错。本研究数据表明，被观察仅对HEWs的绩效产生了微弱的正向影响。