Developing innovative approaches to improve treatment provision for childhood infection in peri-urban settings: A pilot study in accredited drug shops

肺炎、疟疾和腹泻是非洲5岁以下儿童死亡的主要原因，但如果能够得到诊断和治疗，这些死亡大多数是可以预防的。患有这些疾病的儿童应在患病后24小时内得到诊治，但在离家近的地方往往无法获得负担得起的诊断和治疗。寻求帮助的患者往往是从出售药品但不提供诊断的零售商那里寻求帮助。在这种情况下，许多患有严重疾病的儿童要么接受了错误的治疗，要么他们的疾病严重程度没有得到承认。一个简单的解决方案，称为综合社区病例管理（iCCM），当农村地区的社区卫生工作者（提供卫生服务的志愿者）使用时，在改善这些疾病的诊断和治疗方面显示出令人鼓舞的结果。iCCM战略尚未在城市地区进行测试，但由于非洲城市的人口正在扩大，这一点越来越重要。一般来说，这种城市扩张是无计划的，因此生活条件和卫生条件很差，使儿童面临更大的疾病风险。通过零售点提供更好的服务是确保获得负担得起的基本保健服务的一个可能途径。然而，这是一个有待讨论的问题，即零售商是否能够提供质量和价格可以接受的保健服务。我们计划进行研究，以发展一个以社区为本的机制，提供适合市区的综合社区医疗服务。这项研究将在乌干达城市坎帕拉周围的未规划城市地区进行，选择这个地点是因为它具有快速发展的城市的许多特征：社会经济地位低，无计划的住房，卫生条件差，清洁水供应差，获得医疗服务的机会有限。在研究过程中，我们将与当地利益攸关方（当地社区、药店供应商、卫生工作人员和国家当局）协商，探讨改善城市地区医疗保健服务的两种替代战略中哪一种最可行，并为当地居民和国家卫生当局所接受。在这两项战略中，卫生部将培训社区卫生工作者志愿者或药店小贩，以诊断和治疗三种主要的儿童疾病：肺炎、疟疾和腹泻，并将患有严重疾病或不明疾病的患者转诊到当地保健中心。这项研究的一个主要目的是确定监督和支持社区志愿者和药店供应商的最适当方式，如何将他们纳入当地卫生系统，以及如何确保他们提供的服务质量。我们亦会在10间药房进行一项小型试验研究，以衡量诊断的准确性和训练后所提供服务的质素。药店供应商将被要求记录他们看到的病人的细节，包括症状，诊断和采取了什么行动。这将得到卫生专业人员其他评估方法的支持，以评估药品供应商是否正确使用了iCCM指南和处方药。研究小组还将观察在药店治疗患病儿童时会发生什么，并进行访谈，以了解供应商，患者和当地领导人对经过培训的药店接受的治疗的看法，并探索新方法对患者和药店供应商的好处和成本。我们还将衡量卫生部为支持这一方法所需的费用。收集的数据将用于制定新的干预战略，以改善生活在无规划城市地区的儿童获得治疗的机会，并将在未来的研究中进行测试。

Pneumonia, malaria and diarrhoea are major causes of death in African children under 5 years of age, yet if diagnosis and treatment are available the majority of these deaths can be prevented. Children with these diseases should be seen and treated within 24 hours of becoming ill but affordable diagnosis and treatment are often not available close to home. Patients who do seek help often do so from retailers who sell medicines but do not provide diagnosis. In these situations, many children with serious diseases either receive the wrong treatment or the severity of their illness goes unrecognised. A simple solution, called integrated Community Case Management (iCCM), has shown encouraging results in improving diagnosis and treatment of these diseases when it is used by community health workers (volunteers who provide health services) in rural areas.The iCCM strategy has not been tested in urban areas, but this is increasingly important because the population of African cities is expanding. Generally, this urban expansion is unplanned so living conditions and sanitation are poor, placing children at increased risk of disease. Providing better services through retail outlets is one possible way to ensure access to affordable basic health services. However, this is subject to some debate on whether retailers can provide health services of acceptable quality and price. We plan to conduct a study in order to develop a community-based mechanism to deliver iCCM services that is suitable for urban areas. The study will be conducted in unplanned urban areas surrounding the Ugandan city of Kampala This site was chosen because it has many features of rapidly expanding cities: low socioeconomic status, unplanned housing, poor sanitation, poor provision of clean water and limited access to health services. During the study, we shall consult with local stakeholders (local communities, drug shop vendors, health staff and national authorities) to explore which of two alternative strategies to improve access to health care in urban areas would be most feasible and acceptable to the local population and national health authorities. In these two strategies, either community health worker volunteers (CHWs) or drug shop vendors would be trained by the Ministry of Health to diagnose and treat three key childhood diseases: pneumonia, malaria and diarrhoea, and to refer patients with severe or unknown illness to local health centres. A key aim of the study is to identify the most suitable way to supervise and support community volunteers and drug shop vendors, how to integrate them into the local health system, and how to assure the quality of the services they provide. We shall also conduct a small pilot study in 10 drug shops to measure the accuracy of diagnosis and quality of service provided after training. Drug shop vendors will be asked to record details of patients they see, including the symptoms, diagnosis and what actions were taken. This will be backed up by other methods of assessment by health professionals to assess whether the drug vendor used the iCCM guidelines and prescribed drugs correctly. The research team will also observe what happens when a sick child is treated in a drug shop, and carry out interviews to learn what providers, patients and local leaders thought of the treatments received in trained drug shops, and to explore the benefits and costs of the new approach to patients and drug shop vendors. We shall also measure how much it costs the Ministry of Health to support this approach. The data collected will be used to inform the development of a new intervention strategy to improve access to treatment for children living in unplanned urban areas, which will be tested in future studies.