The fidelity of implementation of recommended care for children with malaria by community health workers in Nigeria

Implement Sci. 2020 Mar 4;15(1):13. doi: 10.1186/s13012-020-0968-1.


Background: In the context of task shifting, a promoted approach to healthcare delivery in resource-poor settings, trained community health workers (CHWs) have been shown to be effective in delivering quality care of malaria for febrile under-5 children. While their effectiveness has been documented, the fidelity of implementation (FOI) has not been adequately studied. By understanding and measuring whether an intervention has been performed with fidelity, researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved. The objective of this study was to assess the FOI of a recommended protocol for malaria care by CHWs in a resource-poor setting in Nigeria.

Methods: Thirty-five female CHWs who participated in a 3-day training on home management of malaria among under-5 children were studied. They managed 1,646 children over the implementation period and then underwent evaluation via a one-time hospital-based observation by the trainers. During the evaluation, a pre-tested standard checklist was used to compute performance scores for CHWs; doctors and nurses were selected to serve as the gold standard for comparison. Performance scores (PS) recorded during the evaluation were used to assess adherence and compliance with the recommended treatment protocol.

Results: Of the 4 skill domains assessed, adherence was greatest for compliance with malaria treatment recommendations (94%) and lowest for post-treatment initiation counseling of home-based caregivers (69%). The average overall adherence of 83% was comparable to adherence by gold standard comparators. Mean PS was not found to be significantly associated with CHW demographics. Scores for clinical evaluation among those whose occupation was not healthcare-related were significantly lowered by 0.52 [95% CI (1.05-0.01), p = 0.05]. Compliance with the treatment protocol increased by 23% for every unit increase in total PS (p = 0.07) and doubled for every unit increase in scores for post-treatment initiation counseling of caregivers (p = 0.002).

Conclusions: Studying intervention fidelity stands to identify the shortcomings of implementation and specific areas to target for improvement in future adoption or implementation. This study concludes that future trainings should emphasize clinical evaluation and post-treatment counseling of caregivers by CHWs to ensure the best outcome for children.

Keywords: Community health workers; Implementation fidelity; Malaria; Process evaluation; Sub-Saharan Africa.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Antimalarials / administration & dosage
  • Antimalarials / therapeutic use*
  • Artemisinins / administration & dosage
  • Artemisinins / therapeutic use*
  • Caregivers / education
  • Child, Preschool
  • Clinical Protocols / standards*
  • Community Health Workers / standards*
  • Counseling / methods
  • Drug Therapy, Combination
  • Employee Performance Appraisal / standards
  • Female
  • Humans
  • Implementation Science
  • Infant
  • Inservice Training / organization & administration
  • Malaria / drug therapy*
  • Malaria / therapy
  • Microbiological Techniques / methods
  • Middle Aged
  • Nigeria
  • Socioeconomic Factors


  • Antimalarials
  • Artemisinins
  • artemisinin