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International Journal for Quality in Health Care Advance Access originally published online on May 4, 2006
International Journal for Quality in Health Care 2006 18(4):299-305; doi:10.1093/intqhc/mzl009
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International Journal for Quality in Health Care vol. 18 no. 4 © The Author 2006. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

The influence of observation and setting on community health workers’ practices

S. Y. Rowe1,*, M. A. Olewe2,{dagger}, D. G. Kleinbaum1, J. E. McGowan, Jr1, D. A. McFarland3, R. Rochat3 and M. S. Deming4

1 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA, 2 CARE Kenya, Siaya, Kenya, 3 Department of Global Health, Rollins School of Public Health, Emory University, and 4 Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA

Objective. To determine whether results from an evaluation that involved observation of community health workers while they performed patient consultations in a hospital reflected normal everyday practices.

Design. Comparison of two samples of ill-child consultations: (i) consultations performed during an evaluation in which we observed community health workers in a hospital in-patient and outpatient department from February to March 2001 and (ii) consultations performed under no observation in villages and documented in clinical registers within the 90 days before the hospital evaluation.

Setting. Siaya District Hospital and villages in Kenya.

Study participants. Community health workers.

Main outcome measure. Treatment error indicator, defined as the percentage of consultations where at least one recommended treatment (where recommended treatments were those that were indicated based on community health worker assessments of the child’s condition) was not prescribed.

Results. We analyzed data on 1132 consultations (372 from the hospital evaluation and 760 from the community) performed by 103 community health workers. For all types of consultations combined, the difference between treatment error indicators (hospital minus community) was –16.4 [95% confidence interval (CI): –25.6, –7.1].

Conclusions. We found that community health workers made treatment errors less frequently when they were observed in a hospital in-patient or outpatient department than when they were not observed in the community. Evaluations that involve the observation of community health workers in a hospital setting might overestimate the quality of care that they normally give in their villages.

Keywords: case management, child health, community health worker, Hawthorne effect, Kenya, treatment error

Address reprint requests to S. Y. Rowe, Division of Parasitic Diseases, Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop F-22, Atlanta, GA 30341, USA. E-mail: say9{at}cdc.gov

* Present address: Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.

{dagger} Present address: Inter Country Programme for Malaria, World Health Organization, Kampala, Uganda.

Accepted for publication April 1, 2006.


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