Journal of Community Health

, Volume 41, Issue 2, pp 376–386 | Cite as

Determinants of Utilization and Community Experiences with Community Health Volunteers for Treatment of Childhood Illnesses in Rural Sierra Leone

  • Aisha I. YansanehEmail author
  • Asha S. George
  • Alyssa Sharkey
  • William R. Brieger
  • Lawrence H. Moulton
  • Fatu Yumkella
  • Peter Bangura
  • Augustin Kabano
  • Theresa Diaz
Original Paper


In 2010, at the same time as the national roll out of the Free Health Care Initiative (FHCI), which removed user fees for facility based health care, trained community health volunteers (CHVs) were deployed to provide integrated community case management of diarrhea, malaria and pneumonia to children under 5 years of age (U5) in Kambia and Pujehun districts, Sierra Leone. After 2 years of implementation and in the context of FHCI, CHV utilization rate was 14.0 %. In this study, we examine the factors associated with this level of CHV utilization. A cross-sectional household-cluster survey of 1590 caregivers of 2279 children U5 was conducted in 2012; with CHV utilization assessed using a multiple logistic regression model. Focus groups and in-depth interviews were also conducted to understand communities’ experiences with CHVs. Children with diarrhea (OR = 3.17, 95 % CI: 1.17–8.60), from female-headed households (OR = 4.55, 95 % CI: 1.88–11.00), and whose caregivers reported poor quality of care as a barrier to facility care-seeking (OR = 8.53, 95 % CI: 3.13–23.16) were more likely to receive treatment from a CHV. Despite low utilization, caregivers were highly familiar and appreciative of CHVs, but were concerned about the lack of financial remuneration for CHVs. CHVs remained an important source of care for children from female-headed households and whose caregivers reported poor quality of care at health facilities. CHVs are an important strategy for certain populations even when facility utilization is high or when facility services are compromised, as has happened with the recent Ebola epidemic in Sierra Leone.


Community health workers/volunteers Utilization Integrated community case management Children under five Sierra Leone 



This study was supported by the Department of Foreign Affairs Trade and Development Canada and administered through UNICEF. We would like to acknowledge all the respondents and village elders who made the study possible CARE, IRC and ABC Development Partners in Kambia district and Save the Children in Pujehun district implemented the intervention. Interviewers recruited by Statistics Sierra Leone conducted the fieldwork for the household survey. Mr. Adam Wolkon and Ms. Jodi Vanden Eng from the Centers for Disease Control and Prevention (CDC) performed PDA programming, training and troubleshooting during data collection. We would like to thank UNICEF Sierra Leone, specifically John Baimba, Kennedy Ongwae and Ngozi Kennedy, who coordinated meetings, implemented contracts, purchased supplies, and provided input during data collection. For the qualitative research, the authors wish to thank: Eoghan Brady, Agnes Kamara, Sheka Bangura, Daniela Bongay, Alie Timbo, Kadie Samai, Bernadette Allieu, Mohamed Feika, Abu Bakarr S. Kamara, John Momoh, Isata Foray, Celina Hansen, Sunday Smith, Dr. K.S. Daoh, Dr. Tom Sesay, Dr. Mohamed A Vandi, Dr. David Bome, Dr. Sartie Kenneh, Ngashi Ngongo, Therese Dooley, Francesca Moneti, Christiane Rudert, Ariel Higgins-Steele, and Shannon McMahon. In addition, we would like to thank the community leaders who facilitated this work, as well as the health providers and community members who generously shared their time, thoughts and experiences.

Authors’ Contributions

AIY—co-investigator of the study; worked on amending study protocol, data collection, manuscript conceptualization, analysis, and lead in writing of the manuscript. ASG—input on study protocol, involved in manuscript conceptualization, substantial input and feedback on manuscript drafts. AS—co-investigator for qualitative study; input on qualitative study findings, substantial input and feedback on manuscript drafts. WRB—feedback and input on study protocol and manuscript drafts. LHM—provided input on the manuscript data analytic plan and feedback on the different drafts of the manuscript. FY—local co-investigator for qualitative study; input on qualitative findings and feedback on manuscript drafts. PB—conducted training of field staff, provided supervision of field staff, input on data analysis and feedback on manuscript draft. AK—overall coordination of qualitative and quantitative studies, input on manuscript drafts. TD—principal investigator of study; protocol development, input on manuscript conceptualization and substantial feedback on manuscript drafts.

Compliance with Ethical Standards

Conflict of interest



  1. 1.
    Ajayi, I., et al. (2008). Feasibility and acceptability of artesimin-based combination therapy for the home management of malaria in four African sites. Malaria Journal, 7, 6–14.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Bakshi, S., et al. (2013). The role of traditional treatment on health care seeking by caregivers for sick children in Sierra Leone: Results of a baseline survey. Acta Tropica, 127, 46–52.CrossRefPubMedGoogle Scholar
  3. 3.
    Brenner, J., et al. (2011). Can volunteer health workers decrease child morbidity and mortality in Southwestern Uganda? An impact evaluation. PloS one, 6(12), e27997.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Briand, S., et al. (2014). The international Ebola emergency. New England Journal of Medicine, 371, 1180–1183. doi: 10.1056/NEJMp1409858.CrossRefPubMedGoogle Scholar
  5. 5.
    Diaz, T., et al. (2013). Healthcare seeking for diarrhoea, malaria and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: Results of a cross-sectional survey. BMC Public Health, 13, 157–168.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Doctor, H. (2011). Does living in a female-headed household lower child mortality? The case of rural Nigeria. Rural and Remote Health, 11, 1635. (Online).PubMedGoogle Scholar
  7. 7.
    Fauci, A. (2014). Ebola-underscoring the global disparities in health care resources. New England Journal of Medicine, 371, 1084–1086. doi: 10.1056/NEJMp1409494.CrossRefPubMedGoogle Scholar
  8. 8.
    Government of Sierra Leone. (2010). Millennium development goals progress report. Freetown, Sierra Leone: UNDP.Google Scholar
  9. 9.
    Haines, S., Sanders, D., Lehmann, U., Rowe, A. K., Lawn, J. E., Jan, S., et al. (2007). Achieving child survival goals: Potential contribution of community health workers. Lancet, 369, 2121–2131.CrossRefPubMedGoogle Scholar
  10. 10.
    Health for All Coalition, & Save the Children. (2011). Free Health Care in Sierra Leone one year on: National public and stakeholder’s perceptions of the Free Health Care Initiative. Freetown, Sierra Leone.Google Scholar
  11. 11.
    Kalyango, J. N., et al. (2012). Increased use of community medicine distributors and rational use of drugs in children less than five years of age in Uganda caused by integrated community case management of fever. The American Journal of Tropical Medicine and Hygiene, 87(5 Suppl), 36–45. doi: 10.4269/ajtmh.2012.11-0733.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kalyango, J. N., Rutebemberwa, E., Alfven, T., Ssali, S., Peterson, S., & Karamagi, C. (2012). Performance of community health workers under integrated community case management of childhood illnesses in eastern Uganda. Malaria Journal, 11, 282. doi: 10.1186/1475-2875-11-282.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Kisia, J., et al. (2012). Factors associated with utilization of community health workers in improving access to malaria treatment among children in Kenya. Malaria Journal, 11, 248–254.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Koon, A. D., Goudge, J., & Norris, S. A. (2013). A review of generalist and specialist community health workers for delivering adolescent health services in sub-Saharan Africa. Human Resources for Health, 11, 54–62.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Lewin, S., Munabi-Babigumira, S., Glenton, C., Daniels, K., Bosch-Capblanch, X, et al. (2010). Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. The Cochrane Database of Systematic Reviews 4Google Scholar
  16. 16.
    Miller, N., et al. (2014). Integrated community case management of childhood illnesses in Ethiopia: Implementation strength and quality of care. The American Journal of Tropical Medicine and Hygiene, 6(91), 424–434.CrossRefGoogle Scholar
  17. 17.
    Mukanga, D., et al. (2012). Access, acceptability and utiilzation of community health workers using diagnostics for case management of fever in Ugandan chidren: A cross-sectional study. Malaria Journal, 11, 121–130.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Nanyonjo, A., Makumbi, F., Etou, P., Tomson, G., & Kallander, K. (2013). Perceived quality of care for common childhood illnesses: Facility versus community based providers in Uganda. PLoS ONE, 8(11), 1–10.CrossRefGoogle Scholar
  19. 19.
    Onah, M., & Govender, V. (2014). Out-of-pocket payments, health care access and utilisation in South-Eastern Nigeria: A gender perspective. PLoS ONE, 9(4), e93887. doi: 10.1371/journal.pone.0093887.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Onwujekwe, O., Dike, N., Ojukwu, J., Uzochukwu, B., et al. (2006). Consumers stated and revealed preferences for community health workers and other strategies of the providison of timely and appropriate treatment of malaria in southeast Nigeria: an analysis of activities, costs and outcomes. Malaria Journal,. doi: 10.1186/1475-2875-5-117.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Onwujekwe, O., Uzochukwu, B., Ojukwu, J., et al. (2007). Feasibility of a community health worker strategy for providing near and appropriate treatment of malaria in southeast Nigeria: An analysis of activites, costs and outcomes. Acta Tropica, 101, 95–105.CrossRefPubMedGoogle Scholar
  22. 22.
    Perez, F., Ba, H., Dastagire, S., & Altmann, M. (2009). The role of community health workers in improving child health programmes in Mali. BMC International Health and Human Rights, 9, 28–39.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Perry, H. B., & Zulliger, R. (2012). How effective are community health workers: An overview of current evidence with recommendations for strengthening community health worker programs to accelerate progress in achieving the health-related millennium development goals. Baltimore: Johns Hopkins Bloomberg School of Public Health.Google Scholar
  24. 24.
    QGIS, Quantum GIS Development Team. (2014). Quantum GIS Geographic Information System. Open Source Geospatial Foundation Project.
  25. 25.
    Rutebemberwa, E., Kadobera, D., Katureebe, S., Kalyango, J. N., Mworozi, E., & Pariyo, G. (2012). Use of community health workers for management of malaria and pneumonia in urban and rural areas in eastern Uganda. The American Journal of Tropical Medicine and Hygiene, 87(Suppl 5), 30–35. doi: 10.4269/ajtmh.2012.11-0732.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Save the Children. (2011) No child born to die: Closing the gaps.
  27. 27.
    Scott, K., McMahon, S., Yumkella, F., Diaz, T., & George, A. (2013). Navigating multiple options and social relationships in plural health systems: A qualitative study exploring healthcare seeking for sick children in Sierra Leone. Health Policy and Planning, 29(3), 292–301.CrossRefPubMedGoogle Scholar
  28. 28.
    Seidenberg, P. D., et al. (2012). Impact of integrated community case management on health-seeking behavior in rural Zambia. The American Journal of Tropical Medicine and Hygiene, 87(5 Suppl), 105–110.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Stata Corp. (2009). Stata statistical software. Release 12. College Station, TX: Stata Corp LP.Google Scholar
  30. 30.
    Statistics Sierra Leone. (2004). SSL projections—Population per district, 2004 Census. Freetown: Statistics Sierra Leone.Google Scholar
  31. 31.
    Statistics Sierra Leone, ICF Macro. (2009). Sierra Leone demographic and health survey 2008. Calverton, Maryland: Statistics Sierra Leone (SSL) and ICF Macro.Google Scholar
  32. 32.
    UN Inter-agency Group for Child Mortality Estimation. (2014). Levels and Trends in Child Mortality Report 2014: UNICEF.Google Scholar
  33. 33.
    UNICEF Sierra Leone. (2011). List of peripheral health units (PHUs) in districts. In DISTRICTS.xlsx LOPi (ed). Freetown, Sierra Leone.Google Scholar
  34. 34.
    UNICEF WCARO. (2011). Case study on narrowing the gaps for equity: Sierra Leone removing health care user fees to improve prospects for mothers and children. UNICEF West and Central Africa Regional Office.Google Scholar
  35. 35.
    Yansaneh, A., et al. (2014). Influence of community health volunteers on care seeking and treatment coverage for common childhood illnesses in the context of free health care in rural Sierra Leone. Tropical Medicine & International Health, 19(12), 1466–1476. doi: 10.1111/tim.12383.CrossRefGoogle Scholar
  36. 36.
    Yeboah-Antwi, K., et al. (2010). Community case management of fever due to malaria and pneumonia in children under five in Zambia: A cluster randomized controlled trial. PLoS Medicine, 7(9), e1000340. doi: 10.1371/journal.pmed.1000340.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Aisha I. Yansaneh
    • 1
    Email author
  • Asha S. George
    • 1
  • Alyssa Sharkey
    • 2
  • William R. Brieger
    • 1
  • Lawrence H. Moulton
    • 1
  • Fatu Yumkella
    • 3
  • Peter Bangura
    • 4
  • Augustin Kabano
    • 5
  • Theresa Diaz
    • 2
  1. 1.Department of International Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreUSA
  2. 2.Knowledge Management and Implementation Research Unit, Programme Division, Health SectionUNICEFNew YorkUSA
  3. 3.Dalan Development ConsultantsFreetownSierra Leone
  4. 4.Statistics Sierra LeoneFreetownSierra Leone
  5. 5.Health Section, Child Survival DivisionUNICEF Sierra LeoneFreetownSierra Leone

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