Background
JCHEWs | CHEWs | CHOs | Nurse Officers | Nurse Midwifes | Medical Officers | |
---|---|---|---|---|---|---|
Training | 2 years | 3 years | 4 years | 3 years | 3 years + | 4 years + |
Roles | 50% time in communities 50% time providing consultations | Consultations and facility management | General and supportive care | General and supportive care + midwifery care | General/family medicine | |
Facilities | Health Posts: Service Area: Village or neighborhood Target population: 500 Hours: 9 am-4 pm Services: Basic Curative Staff: | |||||
X | – | – | – | – | – | |
Primary Health Clinics: Service Area: Villages or communities Target population: 2000–5000 Hours: 24 h Services: Basic + Normal Delivery Staff: | ||||||
X | X | – | X | X | – | |
Primary Health Centers (Ward Health Center): Service Area: Political Ward Target population: 10,000–20,000 Hours: 24 h Services: Basic + Basic Emergency Obstetric Care Staff: | ||||||
X | X | X | X | X | X | |
Clinical Guidelines | National Standing Orders | Standard Treatment Guidelines | ||||
Approx. total fees for training | ~US$100–260 | ~US$150–390 | ~US$200–520 | ~US$150–390 | ~US$1400–2000 | |
Mo. Salary (Approx.) | ~US$ 78 | ~US$104 | ~US$148 | ~US$165 | ~US$193 |
Methods
Sampling
Assessing health worker knowledge
Diagnosis-case presentation | National Standing Orders Definition |
---|---|
Acute diarrhea with severe dehydration- 13 month old boy with diarrhea | Severe condition Main symptoms: Frequent watery stool with weakness, with or without vomiting Examination: Lethargic or unconsciousness, sunken eyes, drinks poorly or unable to drink, skin pinch goes back very slowly Treatment: ORS by mouth if child can drink AND 100 ml/kg Ringer’s Lactate Solution, first 30 ml/kg in 30 min and then 70 ml/kg in 2.5 h. Reassess every 1–2 h. |
Pneumonia- 5 year old girl with a cough | Moderate condition, suspect Pneumonia Main symptoms: Cough with fast breathing Examination: fast breathing (> 40 breath/min), no chest in-drawing, temp >37C, chest not clear, difficulty breathing (danger sign), inability to suck/drink (danger sign) Treatment: Cotrimoxazole 1 Tab (480 mg) bd ×5/7 OR Amoxicillin 250 mg/10mls qds × 5. Give Paracetamol if temp is > 37.5C, ½ tab or 250 mg qds × 5 days. Ask parent to bring child back in 2 days. |
Diabetes Type II - 48 year old man feeling weak, without energy and is often hungry | Severe condition, suspect Diabetes Main symptoms: Passing a lot of urine, getting up more than 4 times at night to pass large quantities of urine but without pain, feel very thirsty and drinks a lot of water/fluid, loss of weight Examination: General weakness, examine urine for increased sugar and blood Treatment: Refer to hospital (in analysis, if Medical Officer: Oral Hypoglycemic or insulin when hypoglycemic are not effective) |
Pulmonary Tuberculosis- 40 year old man suffering from fever and cough for some time | Moderate condition, suspect Pulmonary Tuberculosis Main symptoms: Cough of more than 3 weeks duration with or without chest pain with weight loss and shortness of breadth Examination: Coughing, sputum may or may not have blood, weight loss, breathlessness Treatment: Request for 3 sputum examinations, if at least 2 of 3 are positive, treat for pulmonary TB. Expectations of treatment depend on the receipt of specific TB training, not on specific cadres: if trained on TB management and have necessary drugs: First 2 months daily supervised: combined tablet of RHZE (150 mg + 75 mg + 400 mg + 275 mg). Daily for 6 months: combined tablet of EH(400 mg + 150 mg) OR supervised for 4 months: combined tablet of RH (150 mg + 75 mg). If not trained, refer to the Clinic. |
Malaria with Anemia - 4 year old boy with fever for some time that is now worse | Severe Condition Main symptoms: Fever with any of the following: Vomiting, unable to feed, convulsions or history of convulsions Examination: Temp 37.5 C or above with any of the following: neck stiffness, change in alertness, convulsions, bulging fontanelle, moderate dehydration, lethargic Treatment: Continue feeding. Paracetamol 250 mg stat. Artemether-Lumefantrine 2 tablets twice daily for 3 days OR Artesunate+Amodiaquine 50 mg/135 mg one tablet once daily for 3 days. Oral Chloramphenicol 1.2 ml. |
Results
Sample characteristics
Medical Officer | CHO | Nurse Officer | Nurse Midwife | CHEW | JCHEW | Env Hlth Off/Ass | Comm Hlth Ass | Hlth Att/AuxNurse | Dental Off/Nur/Tech | Total | |
---|---|---|---|---|---|---|---|---|---|---|---|
N | 115 | 256 | 497 | 169 | 1891 | 802 | 110 | 93 | 168 | 37 | 4138 |
Wtd prop | 2.6 | 5.9 | 12.7 | 4.7 | 44.2 | 20.1 | 2.6 | 2.2 | 4.4 | 0.7 | 100 |
Age (years) | 40.5 | 45.0 a | 45.2 a | 36.8 | 40.4 | 35.7 a | 33.6 a | 41.1 | 39.1 | 34.9 | 40.5 |
(CI) | (36.3–44.7) | (43.7–46.3) | (44.1–46.2) | (34.7–38.9) | (39.9–40.8) | (34.9–36.4) | (32.1–35.2) | (39.3–42.9) | (37.6–40.7) | (31.3–38.6) | (36.3–44.7) |
Experience (years) | 13.6 | 20.7 a | 19.1 a | 9.2 | 14.9 | 10.5 | 7.9 a | 15.4 | 12.3 | 9.9 | 13.6 |
(CI) | (9.6–17.6) | (19.0–22.3) | (17.8–20.4) | (6.4–11.9) | (14.4–15.5) | (9.8–11.2) | (6.8–8.9) | (13.3–17.5) | (10.8–13.8) | (6.4–13.4) | (9.5–17.7) |
Female (%) | 20.7 | 62.3 | 86.4 | 99.8 | 71.2 | 65.4 | 37.6 | 81.4 | 89.1 | 70.9 | 71.6 |
Rural (%) | 13.5 | 51.0 | 40.9 | 72.4 | 57.9 | 69.1 | 70.4 | 50.8 | 58.4 | 41.5 | 57.2 |
Total non-ess Q | 63.1 | 37.5a | 36.4 a | 37.3a | 33.4a | 32.7a | 37.7a | 25.1a | 19.7a | 36.8a | 34.3a |
(CI) | (57.0–69.2) | (35.0–40.2) | (34.6–38.3) | (34.2–40.4) | (32.4–34.4) | (31.2–34.3) | (32.0–43.4) | (21.2–28.9) | (17.8–21.6) | (29.3–44.4) | (33.6–35.0) |
Facility Type | |||||||||||
Hlth Po/Di | 3.0 | 6.5 | 2.4 | 3.9 | 10.9 | 12.0 | 17.8 | 20.6 | 15.4 | 7.7 | 9.8 |
Hlth Clin | 35.0 | 15.4 | 20.7 | 10.6 | 26.0 | 28.0 | 22.1 | 11.6 | 6.7 | 36.0 | 23.4 |
Hlth Ctr | 62.0 | 78.1 | 76.8 | 85.5 | 63.1 | 60.0 | 60.1 | 67.8 | 77.9 | 56.3 | 66.8 |
(total) |
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
State | |||||||||||
Anambra | 1.2 | 2.7 | 26.7 | 8.4 | 47.7 | 9.5 | 0.1 | 1.0 | 2.6 | 0.1 |
100
|
Bauchi | 0.2 | 3.7 | 7.5 | 0.7 | 42.7 | 29.3 | 14.4 | 0.7 | 0.8 | 0.0 |
100
|
Bayelsa | 25.9 | 9.6 | 8.7 | 9.6 | 28.4 | 12.4 | 0.2 | 0.2 | 0.3 | 4.8 |
100
|
Cross River | 1.4 | 15.3 | 12.6 | 2.9 | 53.4 | 12.9 | 0.0 | 0.7 | 0.6 | 0.2 |
100
|
Ekiti | 2.8 | 4.1 | 17.9 | 3.3 | 52.2 | 9.8 | 0.1 | 3.7 | 3.4 | 2.8 |
100
|
Imo | 1.3 | 3.3 | 18.0 | 13.6 | 30.4 | 14.4 | 3.4 | 4.1 | 11.5 | 0.0 |
100
|
Kaduna | 4.7 | 11.6 | 14.0 | 2.6 | 46.8 | 18.6 | 1.2 | 0.6 | 0.0 | 0.0 |
100
|
Kebbi | 0.3 | 2.6 | 3.1 | 6.4 | 48.3 | 26.1 | 9.4 | 0.8 | 0.4 | 2.7 |
100
|
Kogi | 0.8 | 7.0 | 12.4 | 0.0 | 53.6 | 21.1 | 0.4 | 3.0 | 1.0 | 0.8 |
100
|
Niger | 1.5 | 2.4 | 4.8 | 1.8 | 51.7 | 37.2 | 0.0 | 0.1 | 0.6 | 0.0 |
100
|
Osun | 4.0 | 7.5 | 17.2 | 2.6 | 31.8 | 11.8 | 0.0 | 6.7 | 17.4 | 1.0 |
100
|
Taraba | 0.2 | 2.4 | 11.1 | 3.8 | 47.3 | 24.1 | 2.6 | 3.2 | 4.3 | 1.1 |
100
|
Cadre differences across outcome measures
N | Consultation Processa | Diagnosisb | Treatmentb | ||||
---|---|---|---|---|---|---|---|
N
|
mean
|
CI
|
%
|
CI
|
%
|
CI
| |
Cadre | |||||||
Medical Officer | 106 | 56.8 | (50.6–63.0) | 72.2 | (64.6–79.7) | 43.5 | (36.3–50.8) |
CHO | 253 | 35.1c | (32.2–38.1) | 53.3c | (48.2–58.3) | 25.1c | (22.0–28.2) |
Nurse Officer | 494 | 35.7c | (33.6–37.8) | 57.1c | (53.7–60.5) | 27.0c | (24.3–29.8) |
Nurse Midwife | 168 | 34.3c | (30.8–37.8) | 56.9c | (51.6–62.2) | 26.2c | (20.7–31.7) |
CHEW | 1886 | 29.2c | (28.2–30.3) | 46.4c | (44.9–47.8) | 20.6c | (19.4–21.9) |
JCHEW | 799 | 27.2c | (25.9–28.4) | 43.1c | (40.8–45.4) | 19.3c | (17.5–21.1) |
Env Hlth Off/Ass | 110 | 26.0c | (22.1–29.8) | 43.4c | (35.8–51.0) | 18.1c | (13.0–23.3) |
Comm Hlth Ass | 92 | 19.8c | (16.1–23.5) | 31.3c | (25.7–36.8) | 13.8c | (10.0–17.7) |
Hlth Att/AuxNurse | 167 | 18.3c | (15.8–20.8) | 30.3c | (26.7–33.9) | 12.0c | (9.4–14.6) |
Dental Off/Nur/Tech | 36 | 24.0c | (17.6–30.4) | 47.0c | (37.6–56.3) | 21.9c | (16.6–27.2) |
All | 4111 | 30.1c | (29.4–30.8) | 47.5c | (46.4–48.6) | 21.7c | (20.8–22.6) |
Regression models
Knowledge of consultation process clinical guidelines
(1) | (2) | (3) | |
---|---|---|---|
Variables | Consultation Process | Diagnostic Accuracy | Treatment |
Medical Officer | [ref] | [ref] | [ref] |
CHO | −0.0584*** | − 0.139* | − 0.0222 |
(0.0223) | (0.0750) | (0.0426) | |
Nurse Officer | −0.0468** | − 0.0914 | − 0.0258 |
(0.0205) | (0.0721) | (0.0423) | |
Nurse Midwife | −0.0557** | −0.113 | − 0.0338 |
(0.0244) | (0.0761) | (0.0442) | |
CHEW | −0.0817*** | −0.183** | − 0.0603 |
(0.0205) | (0.0726) | (0.0404) | |
JCHEW | −0.0956*** | −0.211*** | − 0.0784* |
(0.0207) | (0.0723) | (0.0412) | |
Env Hlth Off/Ass | −0.110*** | −0.276*** | − 0.0649 |
(0.0243) | (0.0783) | (0.0451) | |
Comm Hlth Ass | −0.0998*** | −0.239*** | − 0.120*** |
(0.0229) | (0.0769) | (0.0444) | |
Hlth Att/AuxNurse | −0.0688*** | −0.205*** | − 0.104** |
(0.0220) | (0.0767) | (0.0426) | |
Dent Off/Nur/Tch | −0.115*** | −0.200*** | − 0.0413 |
(0.0239) | (0.0774) | (0.0495) | |
Gender | |||
Female | −0.0153** | −0.0160 | − 0.0140 |
(0.00670) | (0.0144) | (0.0123) | |
Experience | |||
< 8 yrs. experience | 0.000986 | 0.00270 | 0.00313 |
(0.00139) | (0.00283) | (0.00261) | |
8+ yrs. experience | −0.00185 | −0.00383 | −0.00288 |
(0.00162) | (0.00321) | (0.00296) | |
Non-essential questions | |||
Total non-ess Q | 0.00939*** | 0.0100*** | 0.00300*** |
(0.000475) | (0.00101) | (0.000802) | |
Total non-ess Q2 | −2.65e-05*** | −3.72e-05*** | 1.52e-05* |
(4.34e-06) | (8.29e-06) | (8.78e-06) | |
Constant | 0.112*** | 0.352*** | 0.132*** |
(0.0244) | (0.0763) | (0.0435) | |
R-squared | 0.559 | 0.259 | 0.185 |
Rho | 0.5157 | 0.5950 | 0.5241 |
Observations | 4040 | 4040 | 4040 |
Number of facilities | 2086 | 2086 | 2086 |