Testing a simplified tool and training package to improve integrated Community Case Management in Tanganyika Province, Democratic Republic of Congo: a quasi-experimental study

BACKGROUND: Integrated community case management (iCCM) is a strategy to train community health workers (relais communautaires or RECOs in French) in low-resource settings to provide treatment for uncomplicated malaria, pneumonia, and diarrhea for children 2-59 months of age. The package of Ministry of Public Health tools for RECOs in the Democratic Republic of Congo that was being used in 2013 included seven data collection tools and job aids which were redundant and difficult to use. As part of the WHO-supported iCCM program, the International Rescue Committee developed and evaluated a simplified set of pictorial tools and curriculum adapted for low-literate RECOs. METHODS: The revised training curriculum and tools were tested in a quasi-experimental study, with 74 RECOs enrolled in the control group and 78 RECOs in the intervention group. Three outcomes were assessed during the study period from Sept. 2015-July 2016: 1) quality of care, measured by direct observation and reexamination; 2) workload, measured as the time required for each assessment – including documentation; and 3) costs of rolling out each package. Logistic regression was used to calculate odds ratios for correct treatment by the intervention group compared to the control group, controlling for characteristics of the RECOs, the child, and the catchment area. RESULTS: Children seen by the RECOs in the intervention group had nearly three times higher odds of receiving correct treatment (adjusted odds ratio aOR = 2.9, 95% confidence interval CI = 1.3-6.3, P = 0.010). On average, the time spent by the intervention group was 10.6 minutes less (95% CI = 6.6-14.7, P < 0.001), representing 6.2 hours of time saved per month for a RECO seeing 35 children. The estimated cost savings amounts to over US$ 300 000 for a four-year program supporting 1500 RECOs. CONCLUSION: This study demonstrates that, at scale, simplified tools and a training package adapted for low-literate RECOs could substantially improve health outcomes for under-five children while reducing implementation costs and decreasing their workload. The training curriculum and simplified tools have been adopted nationally based on the results from this study.