Research proposal

FACTORS ASSOCIATED WITH MANAGEMENT OF PNEUMONIA

AMONG CHILDREN BY VILLAGE HEALTH TEAMS IN ABIM DISTRICT

BY

Acronyms and Abbreviations

ARI             Acute Respiratory Infection Timer.

UNICEF      United Nations Children’s Emergency Fund.

VHT            Village Health Team.

WHO           World Health Organisation.

Operational definitions

Term                                       Definition

Correct treatment Defined as giving antibiotics for fast breathing as per the Sick

Child Job Aid (SCJA).

Management of Pneumonia Defined as history taking, examination, diagnosis and providing

correct treatment or referring if the child has severe pneumonia.

by their own community to promote the health and wellbeing of all village members, working in close relationship with the formal health care system.(WHO, 2006).

Abstract

Background: Pneumonia is the 2^nd leading cause of death in children under 5 years of age in Uganda. Pneumonia deaths could be prevented if Village Health Teams (VHTs) knew how to manage pneumonia correctly. The objective of the study was to determine factors associated with management of pneumonia among under-five year children by VHTs in Abim district.

Methods: This was a cross sectional mixed methods study that investigated management of pneumonia by VHTs.  Data was collected from 374 VHTs using a training video, questionnaires and case vignettes. The proportion of VHTs that correctly manage pneumonia was determined. Modified Poisson regression was used to investigate factors associated with management of pneumonia in children by VHTs. Four (4) key informants’ interviews with health workers (VHT focal persons) of health centres II, III and five focus group discussions with community members were conducted.  

Results: The study found that 15.51% of VHTs correctly manage children with pneumonia in the district as per the Sick Child Job Aid. In addition, the study reported that 73.8% of the VHTs could count within +/- 5 count of an expert. The study found that educational level [Adj. PR 2.06; 95% CI: (1.18-3.61) p-value 0.011], having a VHT register [Adj. PR 0.54; 95% CI (0.300.98) p-value 0.041] and drug stock outs [Adj. PR 4.24; 95% CI (1.37-13.13) p-value 0.012] were significantly associated with management of pneumonia. The qualitative component identified refresher training, equipment and supplies and support supervision as main health facility factors influencing management of pneumonia among children by VHTs. Similarly community perception that VHTs cannot manage a child with pneumonia, drug stock outs, and trust were the community factors influencing VHT management of pneumonia.

Conclusion: A low proportion of VHTs in the district manage children with pneumonia as per the Sick Child Job Aid. Strategies to improve provision of VHT registers and drugs, support supervision, refresher trainings and recruitment of educated individuals into the VHT structure are necessary to improve management of pneumonia. Communities should also be sensitised on roles and responsibilities of VHTs in management of pneumonia.

CHAPTER ONE

1.0 INTRODUCTION AND BACKGROUND.

1.1 Introduction.

Pneumonia accounts for 15% of all childhood deaths and kills more children than any other infectious disease worldwide; with an estimated 935,000 deaths of children under five per year attributable to this infection. Sub Saharan Africa and South East Asia account for 70% of the reported 935,000 deaths.(Bagonza, 2014).  In Uganda; pneumonia is the 2nd leading cause of death in children under 5 years of age. (MoH, 2016)

Pneumonia affects children and families everywhere, but it is most prevalent in South Asia and Sub-Saharan Africa. Pneumonia is one of the biggest health problems faced by children who live in South Asia and Sub-Saharan Africa. Children can be protected from pneumonia; it can be prevented with simple interventions, and treated with low-cost, low-tech medication and care. (Joy Phumaphi & Judd, 2004). However due to shortage of health workers in Uganda, children who have pneumonia do not get prompt medication; resulting in high pneumonia morbidity and mortality.(MoH, 2016). To bridge the health worker shortage, Village Health Teams (VHTs) were incorporated as an effective part of the workforce for delivering community management of pneumonia. Studies have shown that community management of pneumonia can result in a 70% reduction in mortality from pneumonia in 0–5year-old children. (Theodoratou et al., 2010).

Although VHTs manage pneumonia at community level using the Integrated Community Case Management (ICCM) strategy, the proportion of VHTs that can correctly manage pneumonia is not known; this is the knowledge gap.(Rabbani et al., 2016). It is important to know the proportion of VHTs that can correctly manage pneumonia at community levels. By knowing the

1

proportion of VHTs that correctly manage a child with pneumonia, it will allow estimation of the proportion of children that receive correct pneumonia management. This information on proportion of children that receive correct pneumonia treatment will be used to inform programs on VHT management of pneumonia that will reduce pneumonia mortality and morbidity.

1.2 Background

The Village Health Team (VHT) is a non-statutory community structure selected by the people themselves to manage all matters related to health and cross-cutting issues. VHTs are chosen by their own communities to promote health and wellbeing of all village members. (MoH, 2015).

The basic functions of VHTs include community information management, health promotion and education, mobilization of communities for utilization of health services and health action, simple community case management and follow up of major killer diseases (malaria, diarrhoea, pneumonia and emergencies, care of new-born and distribution of health commodities (MoH, 2015). Government of Uganda introduced the VHT structure and roll out to districts was in a phased manner.

Abim district introduced the VHT structure in 2011. Abim district has a total of 618 VHTs, spread in 35 parishes and 309 villages. Each village in the district has 2 VHT members.  The district trained VHTs on ICCM in 2014. The aim of ICCM is to improve correct use of lifesaving treatments by making them available, assuring their delivery, good quality, and mobilising demand for them. (MoH, 2010).

In the ICCM program, VHTs manage simple childhood illnesses namely malaria, non-severe pneumonia and diarrhoea.  In managing pneumonia, VHTs are required to screen for fast breathing using a respiratory timer with cut offs shown in table 1 below; and manage as per the guidelines in the SCJA. For children 2–11 and 12–59 months, a respiratory rate of above 50 breaths per minute and above 40 breaths per minute respectively indicates suspected pneumonia.

Key challenges in VHT management of pneumonia include weak linkages between the health facilities and VHTs, lack of funding mechanism from the government, poor mechanisms for monitoring and supervision, lack of health personnel and poor coordination of partners and program inputs (Katamba, 2013). Due to these challenges, VHTs continue to perform poorly.

Table 1 Showing algorithm for management of pneumonia in children by Village Health Teams.

CHAPTER TWO

2.0 LITERATURE REVIEW

Proportion of VHTs who correctly manage pneumonia among children

In a study from Kenya, the mean percentage of assessment, classification and treatment procedures performed correctly for each child with pneumonia was 79.8% (range 13.3 to100%). (Rowe et al., 2007). Out of the 187 children who required at least one treatment or referral to a health facility in that study, only 38.8% were prescribed all treatments (including referral) recommended by the guidelines(Rowe et al., 2007). However take note of the large confidence interval, this shows that the study could have been biased.

Previous studies conducted in Uganda reported varying levels of VHT management of childhood illnesses; from 11.7% to 89%. Bagonza (2014) reported that 21.7% of VHTs managed childhood illnesses correctly while Wanduru et al (2016) reported that only 11.7% of VHTs managed pneumonia as per the SCJA. Kallander (2006) reported that 71% of VHT respiratory counts were within +/-5 breaths/min from the gold standard, while Mukanga (2011) reported that 40% of VHT respiratory counts were within +/- 5 breaths/min. (Mukanga et al., 2011). The figures are all different and yet all these studies were done in Uganda. The differences in figures could be due to the fact that different criteria were used for measuring management of childhood illnesses.

Individual Factors associated with management of pneumonia by Village Health Teams Age: Studies have shown that older VHTs manage childhood illness much better than their younger counterparts. In particular studies show that VHTs who are above 40 years old managed childhood illnesses  better than VHTs less than 40 years old. (Kawakatsu, Sugishita, Kioko,

Ishimura, & Honda, 2012). This may be attributed to experience gained working for many years when compared to their younger colleagues. It was found, that older VHTs have more knowledge about childhood illnesses and were more likely to follow treatment guidelines.

Education: Education and health care behaviour have a strong relationship. The education level of a VHT has a direct effect on following treatment guidelines specified in the Sick Child Job Aid. Studies have shown that VHTs who have attained secondary education or higher are more likely to manage pneumonia as per the guidelines when compared to their colleagues with only  primary level of education or those with no formal education.(Sommanustweechai et al., 2016; Wanduru et al., 2016).  Educated VHTs have the ability to comprehend treatment guidelines; they can gain access to health promotional messages and can interpret the messages and apply correct procedures.

Gender and Marital Status: Marital status has been indicated as a significant factor that affects VHT management of pneumonia. Studies have shown that being female, unmarried were associated with correct management of childhood illnesses. (Bagonza, 2014; Kambarami et al., 2016). Married female VHTs face a lot of challenges while carrying out VHT activities; she has to get permission from her husband to provide services to sick children, some of whom may stay in distant places and might require treatment at night. It is also important to note that Married men are more likely to provide correct management as compared to their unmarried younger males. It is thought that a married older man, is more stable and will less likely move away from a given village, compared to a younger male, who will move away to look for jobs, partners etc.

(Kok, Dieleman, et al., 2015).

Wealth: Education is linked to wealth; wealthy persons are more educated when compared to poorer persons. One study showed that wealthy VHTs provided better management of childhood illnesses compared to their poorer colleagues. (Kok, Dieleman, et al., 2015). It is assumed that VHTs who are wealthy may not necessarily need money for motivation from government; given that the money VHTs receive for motivation in Uganda is small. Most VHTs are paid around 10,000 UGX per review meeting; this amount of money is not enough to motivate a wealthy person, but to poor persons especially in villages, it’s a reasonable amount. The wealthy VHTs can be said to be self-motivated; they may also be offering services to get community recognition for other benefits like respect, good name and so forth. Wealthy VHTs also have more time to dedicate to VHT activities, their poorer colleagues have to divide time between VHT work and looking for means to earn money for their family needs.

Health Facility Factors associated with management of pneumonia by Village Health Teams

Knowledge and Refresher training; Findings from a cluster randomised trial by Sing et al (2016) and other studies showed that acquisition and sharing of knowledge, and seeing healthrelated knowledge put into action were more important motivators than transport allowances or the hope of gaining employment.(Hadi, 2001; Kalyango et al., 2012; Kimbugwe et al., 2014; Singh, Negin, Orach, & Cumming, 2016; Sommanustweechai et al., 2016). When VHTs put what they learnt into practice for instance building tippy taps, having dish-racks and purifying water in their homes they became role models in the community. This motivated them since the community viewed them as important persons. This is also the core of the VHT program; all VHTs should have knowledge and skills to manage childhood illnesses. The training should be carried out for a sufficient time so that all VHTs understand key concepts. To reinforce grasping of these concepts, there is need for constant refresher trainings.  

Equipment and supplies: In addition to knowledge, you also need all the equipment and supplies for you to be able to put the knowledge into practice. Several studies have shown that having drugs, register books, respiratory timers and referral forms affect management. It is obvious that without drugs, you cannot treat any child; the same is true if you lack register books, respiratory timers etc.(Kalyango et al., 2012; Sommanustweechai et al., 2016; Strachan et al., 2015).  

Support Supervision: Studies have showed that VHTs who had regular close supervision and received feedback after supervision managed childhood illnesses better on average compared to other VHTs who were not supervised.(Hadi, 2001; Kok, Dieleman, et al., 2015; Strachan et al.,

2015; Wanduru et al., 2016). Regular support supervision is good because they are avenues were VHTs receive professional help in areas they are not competent with. Receiving feedback after support supervision is beneficial to the VHTs too because they get knowledge on what to do and what not to do. This feedback builds their confidence in doing their duties.

Relationship with health facility: Several studies report this finding, having good relationships between the VHT and health facility is actually important for correct management of childhood illnesses.(Hadi, 2001; Kalyango et al., 2012; Mays et al., 2017). When VHTs have good relationships with more experienced and learned health workers, they are able to learn more and participate in health facility activities which build their self-confidence. In addition, their participation in health facility activities endears them to community members who give a lot of respect to them. This motivates them to perform even better.

Incentives and Motivation: Lastly related to all the above is the motivation schemes in place. VHT work is largely voluntary in Uganda. VHTs are not paid for their work. They must carry on with their other socio economic activities for survival while at the same time offering free services to the whole community. Studies have shown that even though they work freely, if given incentives; it motivates them to manage childhood illnesses better.(Kimbugwe et al., 2014; Mays et al., 2017; Sommanustweechai et al., 2016; Wanduru et al., 2016). Motivation can also be in other forms, like involving VHTs in health facility activities, appreciating their work and giving them certificates for exceptional work.

Community Factors associated with management of pneumonia by Village Health Teams

Community Respect and Support: VHTs management of childhood illnesses is linked to community respect and support. (Bagonza, 2014; Kalyango et al., 2012; Kimbugwe et al., 2014;

Strachan et al., 2015). Indeed lack of community support led to collapse of the VHT structure in Luwero district.(Turinawe et al., 2015). The structure collapsed because community members refused to support VHTs who were imposed on them by Local Council One chairpersons. To improve community respect and support; VHTs should be included in community activities and functions. They should be recognised in community meetings, they should also be involved in any other government activity within that community. VHTs should also become role models and should not be drunkards.  

Patient Characteristics: In a cross sectional study in Siaya district Kenya, patient characteristics were found to be strongly associated with VHT management of childhood illnesses. (Rowe et al., 2007). A crying child, restless child made it difficult for VHTs to properly screen the children for pneumonia. The study was conducted in a hospital setting, had a small sample size and the dosage was not evaluated. They also used recall as a method of data collection and not all factors were investigated.

Indices used for measuring VHT management of childhood illnesses:

There is no standardized approach to asses VHT management of pneumonia. Different studies created their own methods to assess management of pneumonia. Some of the studies used the following methods for assessment.

Review of VHT register books: In a Random Controlled Study carried out in Zambia, data was collected by review of VHT register books for up to six months (Hamer et al., 2012). Assessments were based on reviews of VHT medical records and not direct observation of VHTs doing their work. Though being a Randomised Control Trial (RCT); effective follow up was not done on children, the research assistants only saw the children after 5-7 days from the time a child was treated. For pneumonia specifically the study did not track the dose of AL or amoxicillin prescribed and were unable to determine whether age or weight appropriate dosing was performed. Relying on review of VHT register books is likely to create information bias because most of their books are incorrectly filled.

Video Probes: Kallander et al (2006) study collected data by studying children with clinically verified pneumonia and use of video probes. Technicalities of using videos in the field for data collection proved difficult, and the Kallander study was conducted in a hospital setting, not in a VHTs home. A hospital setting is different from a VHTs normal environment.

Observations: In Mukanga et al (2011) study, two paediatricians observed VHTs’ assessment, classification and prescription of treatment, at health facilities. The study had the following limitations; observers were not blinded to results and the indicators were weighted making analysis more complex. The study was also facility based, with an environment different from the usual work setting of VHTs and the study was carried out immediately after training, which is not ideal in real life normal routine VHT activities.

Composite Scores: Bagonza et al (2014) used composite scores for assessing management of childhood illnesses; however the scores were not linked to technical assessment of VHT competence. In that study; if a VHT did some work in the past one week he scored 4 points, if he did any activity in the past 2 weeks he scored 3 points. Those who scored zero points did not do any activity in the past 4 weeks. A VHT may have carried out activities in the past week (earned 4 points) but in reality he/she gave wrong drugs to children. The scores used and subsequent results do not reflect any skill or competence. The results must therefore be interpreted with caution.

Composite Scores and Case Scenarios: Phillip Wanduru et al (2016) assessed management of childhood illnesses by combining scores from knowledge assessment and case management using case scenarios. Case scenarios were conducted with a medical officer observing VHTs in their management of children suspected of having malaria, pneumonia, or diarrhoea in a health facility. This method was good because it collected data without using registers or asking VHTs to recall past events. It was however facility based and each VHT managed a different child. Each VHT managed a different child because sick children who had come to the clinic were picked at random from the health facility on that particular study day.  As a result, prescriptions differed from one child to another because the diagnoses were different. Accordingly, some VHTs had to do more tasks when prescribing than others, and this created a level of nonuniformity in scoring.

Conclusion: VHT management of childhood illnesses is thought to be affected by some of the factors listed above. However all the reviewed studies had design weakness, affecting their generalizability. To address all the challenges in the above reviewed studies, this study will be more robust and rigorous. The study will be conducted in a VHTs home, several years after initial ICCM training. To address issues of non-uniformity in scoring, all study participants will answer the same case vignettes and all study participants will use the same standard video to assess their ability to count breaths per minute of a child. To minimise information bias, no review of VHT registers will be carried out.

CHAPTER THREE

3.0      STATEMENT OF THE PROBLEM, JUSTIFICATION AND CONCEPTUAL FRAMEWORK

3.1 Statement of the problem

Data from Health Management Information System forms 105 and 108 shows that a total of

7442 children were diagnosed with pneumonia at both outpatient and inpatient departments in Abim health facilities for three financial years from 2015 to 2017. In this period, 15 children died in the inpatient department with pneumonia. The pneumonia crude mortality rate for the district is 6.8%. (MoH, 2017). VHTs in communities are responsible for early identification, treatment and/or referral of pneumonia cases at community level. The role of VHTs in reducing pneumonia related morbidity and mortality is critical.

Although VHTs role in managing pneumonia is critical, pneumonia related morbidity and mortality remains high, the proportion of VHTs that can correctly manage pneumonia is not known. A study by Bagonza et al (2014) on general management of childhood illnesses of VHTs in the ICCM program concluded that only 21.7% of VHTs performed optimally in the integrated community case management programme. Also between (2% to 35%) of normal U5 children receive antibiotics for treatment of a non-existent pneumonia (Graham et al., 2016; Mukanga et al., 2011). These studies relied majorly on review of VHT treatment data, some had small sample sizes, most were done in a health facility setting and each of the studies had their own independent methods of measuring management of childhood illnesses. Furthermore Abim is found in Karamoja region, which has very poor health indicators. VHTs from Abim have a different context when compared to VHTs from the areas these previous studies were conducted from.

Lack of knowledge on the proportion of VHTs who can correctly manage pneumonia at community level prevents effective evaluation of community pneumonia treatment programs. It is thought that VHTs fail to manage sick children because of lack of supervision, illiteracy, drug stock outs and community pressure. (Druetz, Siekmans, Goossens, Ridde, & Haddad, 2015). Districts have tried to improve VHT supervision, provision of refresher trainings and ensuring no drug stock outs. VHTs were given bicycles, t-shirts as measures of motivation. Though these measures are good, a lot more needs to be done to improve VHT management of childhood

illnesses.

This study therefore seeks to understand the extent to which VHTs can correctly manage pneumonia at community level. The information gained will help the district plan for appropriate strategies to reduce pneumonia related childhood morbidity and mortality.

3.2 Justification

The study revealed the proportion of VHTs that can correctly manage pneumonia in Abim district. It estimated proportion of children that receive correct management of pneumonia. This information will provide an opportunity for the health workers and district health officers to know and understand how many VHTs can provide correct management of pneumonia.

This study also identified significant individual, community and health facility related factors that affect VHT management of pneumonia. The information on factors affecting VHT management of pneumonia will be used by stakeholders to improve VHT community management of pneumonia. This information will lead to reduction in pneumonia specific morbidity and mortality in the district. The study is in line with the ministry of health’s ICCM policy that advocates for measuring management of childhood illnesses of VHT integrated community case management activities.   Furthermore, the findings of this study will also help identify the gaps, and suggest appropriate interventions. Researchers and students may use the research findings for academic work.

3.3 Conceptual framework

Figure 1: Conceptual framework of health facility, community and individual factors associated with VHT management of pneumonia

Adapted from A qualitative assessment of health extension workers’ relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance (Kok, Kea, et al., 2015)

3.3.1 Conceptual Framework Narrative.

The conceptual framework shows that VHTs management of children with pneumonia is influenced by health facility factors, community factors and individual characteristics of the VHTs.

Management of pneumonia is influenced by individual characteristics such as level of education, economic status and marital status of the VHT. VHTs with low levels of education find it difficult to manage pneumonia because they find it challenging to interpret the information in their SCJAs. Mostly poor VHTs are also illiterate. In addition the age, sex and marital status of a VHT affect his/her scores in management of pneumonia. Female VHTs, who are unmarried, are more available and correctly manage sick children as compared to male, unmarried VHTs, who in most cases are preoccupied with other economic activities other than community work.

Management of pneumonia is also influenced by health facility factors such as support supervision, trainings the VHTs had undergone, workload, availability of drugs and supplies and involvement of the VHTs in health facility activities among others. Lack of pneumonia drugs, respiratory timers and referral forms for example undermine VHTs management of pneumonia. VHTs that have registers are known to perform better than their counter parts that do not have registers. However the size of the catchment area affects a VHTs management of childhood illnesses. VHTs who manage more than 30 households performed poorly than their counterparts who managed fewer households. VHTs with few households may not use registers compared to VHTs with many households in their catchment areas. Work load is a big contributor to VHT management of childhood illnesses.

On the other hand, management of pneumonia is also influenced by community and patient characteristics. Community characteristics such as respect from the community, inclusion of VHTs in community programs amongst others and community support affects management. Patient characteristics like a restless child, a crying child or children with other medical complications affect a VHTs management of pneumonia.

This is not a study about the effects of pneumonia management but its highlighting the above factors among others, as predictors of VHTs management of children with pneumonia.

CHAPTER FOUR

4.0 RESEARCH QUESTIONS, HYPOTHESIS AND OBJECTIVES

Research Question

What factors are associated with management of pneumonia among under-five year children by VHTs in Abim district?

4.1 Research Questions

1. What proportion of VHTs correctly manage pneumonia among children?
2. What individual factors are associated with correct management of pneumonia among under-five year old children by VHTs?
3. What health facility factors are influencing correct management of pneumonia among under-five year children by VHTs?
4. What community level factors are influencing correct management of pneumonia among under-five year children by VHTs?

4.2 General objective

To determine factors associated with management of pneumonia among under-five year children by VHTs in Abim district.

4.3 Specific objectives

1. To determine the proportion of VHTs who correctly manage pneumonia among children.
2. To determine individual factors associated with correct management of pneumonia among under-five year children by VHTs.
3. To examine health facility factors influencing correct management of pneumonia among under-five year children by VHTs.
4. To explore community factors influencing correct management of pneumonia among under-five year children by VHTs.

CHAPTER FIVE

5.0METHODOLOGY

5.1 Study site

The study was conducted in Abim district. Abim district was chosen because it is located in

Karamoja region. Karamoja region has consistently demonstrated the nation’s lowest scores on key development and health indicators (Wilunda et al., 2015). Over 70% of the population experiences critical food insecurity. (Wilunda et al., 2015). Over 90% of people in Karamoja are classified as poor and vulnerable as opposed to just under 11% in Kampala. (Irish-Aid, 2016). The sub-region has a literacy level of only 12% compared to a 71% national average. There is low access and utilisation of basic health services- averaging 24% compared to the national rate of 72%. (Irish-Aid, 2016). Maternal morality and infant mortality rates are significantly higher than the rest of the country (750 verses 438 per 100,000 live births and 105 verses54 per 1,000 live births respectively). (Irish-Aid, 2016). Abim district has a land area of 2,337 square kilometres and lies between latitude 2^o 30’ N and 2^o 30’ N and Longitude 30^o 45’ E and 31^o 10’ E, It is bordered by Kotido district in the north, Moroto and Amuria district in the east, Otuke district in the South west, Agago district in the west, Amudat district in the south and the entire

Eastern borderline is shared with Kotido and Napak. It has an average altitude of 100 metres to 1,800 meters above sea level. The district was part of what was formerly called Karamoja province, which became functional on the 1st July 2006. The district has one county called Labwor. The district is composed of 1 Town council (Abim town Council) and 5 Sub counties including; Abim, Alerek, Lotukei, Morulem and Nyakwae. The District is constituted of 32 Parishes and 309 villages. According to the 2011 CIS exercise the total number of households in the district was 15,569. Abim T.C had the least number of household (1,226) while Lotukei Sub County had the highest number of households (4,215). According to the 2014 census the population of Abim is 107,966(Statistics, 2016).

5.2 Study population

VHTs of Abim district were studied.   The actual respondents were VHTs, health workers and community members. The study unit was a VHT member.

5.3 Study Design

This was a cross sectional study that employed both quantitative and qualitative methods of data collection. Both quantitative and qualitative research methods enabled triangulation of results which improved on internal validity of the study (Moffatt, White, Mackintosh, & Howel, 2006).

5.4 Sample Size

Objective 1 and 2

Proportion of VHTs that correctly manage pneumonia among children and associated individual factors.

Sample size was calculated using the formula for determining sample size for cross sectional studies

n = (Zα+Z1-β) 2 PQ

δ²                                     

Where

• is the estimated proportion of VHTs who manage pneumonia correctly, calculated at 30%.

(Mukanga et al., 2011).

• = (1-P)

Z_α is the level of confidence set at 95 %( 1.96)

Z_1-β is the power of the study, set at a power of 80% (0.84) δ² is the precision or maximum acceptable error set at 5% or 0.05, for a one sided test When computed a sample size of 659.

However, Abim had only 618 VHTs (finite population) so I adjusted it using the formula

Where N is the estimated population from which the sample was drawn which is 618 (total VHTs of Abim)

n is the previously calculated sample size n’ is the adjusted sample size. After calculations, the sample size is 319. After addition of nonresponse rate of 17% the final sample size is 374.  

Community and health facility factors influencing management of pneumonia among under-five year children by VHTs 

Four (4) key informants’ interviews with in-charges of health centre IIs and IIIs were conducted. Also five focus group discussions with community members, one focus group per parish in the study area were conducted. The in-charges of the health facilities were selected to give key informant interviews because they directly supervised the VHTs therefore they were the best suited to provide data on how the VHTs managed pneumonia. The community members were selected for the focus group discussions because they are direct beneficiaries of the VHT activities. They were most suited to give feedback on the management of pneumonia services they received.

5.5 Sampling Procedure

Proportion of VHTs that correctly manages pneumonia and associated individual factors.

Abim district has 618 VHTS, in 6 sub counties and 32 parishes. Using a ballot, three sub counties of the 6 were sampled. In the 3 selected sub counties, the sampling frame (Lists of VHTs managing childhood illnesses) was obtained from health facilities, the lists showed VHTs according to the parishes they belonged to.  Using computer generated lists, 374 VHTs (2 from each of 187 villages) was selected.  The eligible VHTs were located through their supervisors and local council leaders. To ensure credibility of the study, VHTs were not informed of who was involved in the study. Random visits of the selected VHTs were done. This was to reflect real life situation as close as the study design permitted.

Inclusion Criteria for objectives 1 and 2

Eligible respondents were VHTs who had been recruited into the ICCM programme for more than six months by the time of the study and gave informed consent.

Exclusion Criteria for objectives 1 and 2

VHTs who were sick or drunk were excluded. A sick VHT was excluded because he/she is not healthy to participate in the interview, similarly drunk VHTs were excluded from data collection; because when drunk, a person’s decision making ability is compromised. A drunk VHT was determined by observation and illogical speech.

Inclusion criteria for objectives 3 and 4

The health workers selected were VHT Health Facility focal persons; who had worked in the health facility for more than 3 months. For the focus group discussion, community members who were residents of the village were interviewed.

Exclusion criteria for objectives 3 and 4

Health workers who were not VHT focal persons and too committed were excluded. In addition, community members who were drunk and not willing to consent were excluded.

5.6 Study Variables.

5.6.1 Dependent variable.

The dependent variable was correct management of pneumonia by a VHT. The Sick Child Job Aid was used in this study as a reference document for correct management of pneumonia by VHTs.

5.6.2 Independent variables.

The independent variables were: individual, health facility and community factors.

5.7 Data collection.

Proportion of VHTs that correctly manages pneumonia among children and associated individual factors.

Data was collected by using questionnaires, training video and case Vignettes.

Questionnaires: All VHTs answered the questionnaire. The questionnaire collected their demographic and other data that was used to answer study objectives.

Training Video: Data was collected by observing and recording the respiratory count of each VHT against a training video. The video used for the study was of a 6 months old child called wumbi. The video used for data collection is a certified MoH training video used for ICCM training nationally. The video was used to test a VHTs ability to count the breaths per minute of a sick child. The breath per minute count of wumbi (expert count) is 66 breaths per minute.  The breaths per minute of counts of each VHT were then recorded on the data collection forms. A VHT was said to know how to count breaths per minute correctly if his/her count was within +/5 of 66 breaths per minute count of wumbi. Any VHT counts above or below the +/- 5 breaths margin was recorded as a VHT not being able to count correctly. All the VHTs were asked to state the respiratory cut offs used to screen for pneumonia in children with cough for children of the following age categories a) 0 – 7 days, b) 2 -11 months and c) 12-59 months. This was done to test whether they knew how to differentiate between fast and normal breathing using an ARI timer. This was done to test their ability to screen children.  

Case Vignettes: Each respondent was then given case vignettes of under five year old children named Job, Musa and Rose. They were asked to screen, classify and treat the three children using the breaths per minute, age and conditions of each of the cases.  

Job had fast breathing (55 bpm) and two danger signs. According to the VHT ICCM manual, a child with one danger sign must be referred immediately or given pre referral treatment. Job had cough for more than 21 days, and was vomiting everything given. Any VHT who answered that Job had fast breathing when classifying got a mark. The correct management for Job was referral. A VHT got a mark for answering that Job was supposed to be referred (with or without pre referral treatment), any other answer was incorrect.

Musa had fast breathing (55 bpm), with no danger sign. All VHTs who answered that Musa needed to be treated with amoxicillin was given a mark. If a VHT answered that Musa needed referral got zero marks because the VHT manual clearly states that a child of Musaʹs condition can and should be managed by a VHT.

Rose had mild cough with no fast breathing. All VHTs who answered that Rose was breathing normally when classifying got a mark. Under the section of treatment, any VHT who said Rose did not need to be given amoxicillin was given a mark. According to the ICCM manual, a child of Rose nature required no treatment, but that VHTs should give advice to the caregiver on alternative cough remedies, like taking honey amongst others.

The VHTs were then asked to prescribe treatment for each of the three cases. For each of the three cases a VHT was required to correctly classify and prescribe correct treatment.

A VHT that correctly screened, correctly classified and provided correct treatment for all cases was recorded as having managed pneumonia. Any wrong classification or prescription disqualified a VHT and he/she was recorded as having not managed pneumonia. The proportion of VHTs that counted the breaths per minute (within +/- 5) was also determined.

Community and health facility factors influencing management of pneumonia among under-five year children by VHTs.

The key informant and focus group discussions were conducted with health workers and community members respectively. The interviews were conducted using key informant and focus group discussion guides. The interviews were audio recorded by the interviewer (principal investigator) in addition to note taking. The qualitative data collection continued until saturation was reached. We reached saturation by the 4^th KI and 5^th FGD. We reached saturation because from both the KI and FGDs, no new information was received. All study participants in the different locations were giving the same information; so we stopped conducting any more interviews.

5.7.1 Training of research assistants

Four research assistants, who were certified district VHT ICCM trainers were selected and trained for two days on data collection procedures like approach on administering the questionnaire, collection of right information, following ethics involved in research, respect to clients and obtaining their informed consent among others.

5.7.2 Tools for data collection.

Some parts of the questionnaire were adopted from a study in eight districts in central Uganda (Mubiru et al., 2015). This was adjusted to fit the context of this study, the questionnaire was translated to Leb thur and back translated to English to ensure the meaning was not lost hence preserving reliability and validity of the tool.

The key informant and focus group discussion guide for qualitative data was used to explore health facility and community factors influencing VHT management of pneumonia.

5.7.3 Pre-testing

The data collection tools; questionnaires, in-depth interview and key informant guides were pretested in Oyaro parish that was not included in the study. Each of the research assistants used a questionnaire, training video and case vignettes to collect data from VHT members not in the study. After the pre-test, the research assistants and the principal researcher had a debriefing meeting in Abim hospital to clear out inconsistencies.  Adjustments were made to the case vignettes and questionnaires to make it simpler for data collectors to collect correct information. The Video was fine; it did not need any adjustments. The final data collection instruments were then prepared for actual collection of study data from respondents. .

5.7.4 Field editing of data

The research assistants were supervised by the principal investigator. The principal investigator also conducted data collection. The principal investigator conducted meetings at the end of each day of data collection with the research assistants to edit data for completeness and accuracy.  

5.8 Data Management and Analysis

5.8.1 Measurement

Correct management of pneumonia was measured by observing how many VHTs could correctly screen a child for pneumonia, correctly classify and then prescribe correct treatment in all the three children described in the case vignettes. Three case vignettes and a training video were used to assess and determine the proportion of VHTs who could manage a child with pneumonia.

Individual scores of each VHT were used to determine the proportion of VHTs that could correctly manage pneumonia. A VHT had to correctly screen, correctly classify and prescribe correct treatment for all three case vignettes to be classified as having ability to correctly manage a child with pneumonia. If a VHT could correctly screen for pneumonia but gave wrong treatment, or wrongly classified, or any wrong screening, classification or treatment/referral for any one of all three children, it meant he /she provided wrong management.

5.8.2 Computer packages used and Data analysis

Data were entered into excel data capture sheet and analyzed using StataSE13 statistical software. The percentage agreement statistic was used to estimate the proportion of VHTs that could correctly count breaths per minute of a child with fast breathing, compared to the expert count in the training video. The data was entered into Microsoft excel and then exported to

STATA 13 for analysis.  The respiratory rate counts of each VHT was classified either as within the allowed +/- 5 breaths per minute margin or not (above or below the margin). Those VHTs whose respiratory counts were within the allowed margin were considered to be having the skill to count breaths per minute.

Outcome variable: An outcome dependent variable was created in stata. The variable was called Management of pneumonia. The dependent variable had two levels of measurement that is correct management of pneumonia and wrong management of pneumonia. Correct management of pneumonia was coded 1, while wrong management of pneumonia was coded 0. To be coded 1(Correct management of pneumonia) a VHT had to correctly screen, correctly classify and correctly treat all three children in the case vignettes. All VHTs who had any either one wrong screening, classification or treatment score or all wrong scores was coded 0 (Wrong management of pneumonia). Modified Poisson regression was used, because the prevalence of the outcome was higher than 10%. (Martinez et al., 2017). If logistic regression was used for prevalence above 10%, it would overestimate the Odds ratios, leading to erroneous conclusions.

Objective 1: The proportion of VHTs that could correctly manage pneumonia was determined using frequencies and percentages.

Objective 2: Tests for association between the dependent and independent variables was carried out to answer objective 2. In bivariate analysis, cross tabulations was done. Each independent factor was cross tabulated with the outcome. Chi2 values, row and column totals was determined at 5% level of significance. . After the tabulations, each independent factor was investigated using modified Poisson regression to find out if it was associated with the outcome, it reported unadjusted prevalence ratios.

At Multivariate analysis, all factors that reported a chi2 p value less than 0.2 at bivariate analysis level was used for model building. The significance level was set at 5%. The study also included priori confounders (age, gender) that had p values above 0.2 but was shown to be important according to reviews of literature. Forward model building strategy was used.

Modified Poisson regression was used to establish significant factors associated with a VHTˊs management of a child with pneumonia.

Objectives 3: Both quantitative and qualitative data was used to answer objective 3.  Objective 4:  Objective four was answered using qualitative data. Qualitative data, data was analysed manually using content analysis. Transcription was done by the principal investigator who also consulted the notes for verification of data. Transcripts from audio recordings were the basis for content analysis. Transcripts were read several times to get a clear understanding of emerging issues that were coded. Similar codes were grouped into categories and later themes were generated from the categories. Quotes that represented the theme were used for report writing. In addition, similar questions were used for both key informants and in-depth interviews. This was majorly for triangulation of data. The data was used to supplement quantitative data hence helping to explain more the facility and individual factors that influenced management of pneumonia by VHTs.

5.9 Ethical Considerations

Approval for the study was obtained from the institutional review board of Makerere university school of Public Health Higher Degrees Research and Ethics Committee (HDREC). Permission to conduct research was obtained from the office of the District Health Officer Abim. Written informed consent was obtained from study participants. The information gathered was kept confidentially and transcripts for qualitative and filled questionnaires were kept by the principal investigator. The study participants were given identification numbers for anonymity so that they would not easily be identified by anybody who was involved in the study and also to create confidence and freedom as they answered questions.

5.10 Dissemination

The results were submitted as a dissertation in partial fulfilment of the requirement of a ward of master’s degree in Public Health of Makerere University.  Copies of the report will be submitted to Makerere University School of Public Health, Irish AID Kampala and office of the District Health Officer Abim. The study will be published in a peer reviewed scientific journal.

CHAPTER SIX

6.0 RESULTS

6.1 Socio demographic characteristics of Village Health Team members.

A total of 374 VHTs were interviewed from three sub-counties in Abim district, of which

56.42% (211/374) of them were male as shown in table 2. The mean age of the VHTs was 35.57 years with a standard deviation of 10.54; the youngest VHT was aged 19 years and the oldest aged 70 years. In addition, 67.91% (254/374) of the VHTs were Catholics, and 94.39% (353/374) were married. Also, 39.30% (147/374) attended primary school and 91.18% (341/374) of them were peasants. In addition, 10.70% (40/374) of the VHTs had no respiratory timers.

Table 2: Socio demographic characteristics of Village Health Team members.

6.2 Proportion of Village Health Team members that correctly manage pneumonia among children.

Table 3 below shows the different levels of management of pneumonia among respondents. All the 374 VHTs participated in making their own independent respiratory counts. Out of the 374 VHTs, only 2.4% (9/374) of the VHTs counts were equal to that of the video (66 breaths per minute). On further analysis, 73.8% (276/374) of the VHT counts were within the allowable +/-

5 bpm of the video count of 66 bpm. Furthermore, 24.33% (91/374) VHTs counts were less than +/-5 bpm margin and 1.87 % (7/374) of VHT counts was above the margin. Table 3 below shows how each VHT performed when answering the case vignettes and video counts.

Table 3: Village Health Team management of pneumonia scores in answering case vignettes and video counts.

Average performance in percentages(%)  for screening, classifying and treating Job, Musa and Rose

Screening 55.44

Classification 44.21

Treatment 38.41

Dependent variable (Proportion of VHTs that can manage a child with pneumonia.)

6.3 Individual factors associated with Village Health Team management of pneumonia.

The study findings in table 4 below show that only educational level was significantly associated with management of pneumonia [Unadjusted Prevalence Ratio of 2.03; 95% CI: 1.16 – 3.58) p value of 0.014]. The prevalence ration of management of pneumonia amongst VHTs with secondary level of education or higher was higher than VHTs with only primary level of education or no education.

Table 4: Individual factors associated with management of pneumonia by Village Health Team members.

Key: *p < 0.05, **p < 0.01, ***p < 0.001

6.4 Health facility factors associated with management pneumonia by Village Health teams.

Table 5 below shows health facility factors associated with VHT management of pneumonia. The findings show that receiving feedback after support supervision [Unadj PR 0.61; 95% CI: 0.38-0.99) p value 0.046], drug stock outs [Unadj PR 4.15; 95% CI: 1.33-12.89) p value 0.014] and having a VHT register [Unadj PR 0.51; 95% CI: 0.28-0.94) p value 0.031] were significantly associated with management of pneumonia. The prevalence ratio of management of pneumonia amongst VHTs who received feedback after support supervision was lower than that of VHTs who did not receive feedback after support supervision. The prevalence ratio of management of pneumonia amongst VHTs who reported drug stocks outs was higher than VHTs who had drugs. The prevalence ratio of management of pneumonia amongst VHTs who had registers was lower than that of VHTs who did not have registers.

Table 5 Health Facility factors associated with management of pneumonia by Village Health Team members.

Key: *p < 0.05, **p < 0.01, ***p < 0.001

6.5 Factors that are associated with VHT management of children with pneumonia.

As shown in table 6 below, and after adjusting for confounders, this study found that educational level; having a VHT register and drug stock outs were associated with management of pneumonia. Receiving feedback was marginally significant at bivariate, but at multivariate level, it wasn’t significant. VHTs that had secondary education were found to be significantly associated with correct management of pneumonia; Adjusted Prevalence ratio [Adj. PR 2.06; 95% CI: (1.18-3.61) p-value 0.011]. The prevalence ratio of correct management of pneumonia amongst VHTs with secondary education was higher than that amongst VHTs with primary education or no formal education. The prevalence ratio of correct management of pneumonia amongst VHTs with registers was lower than that amongst VHTs without registers. VHTs that reported drug stock outs were associated with correct management of pneumonia [Adj. PR 4.24; 95% CI (1.37-13.13) p-value 0.012].  The prevalence ratio of correct management of pneumonia amongst VHTs who reported drug stock-outs was higher than that amongst VHTs who had drugs.

Table 6: Independent factors associated with management of pneumonia by Village Health Teams.

Key: *p < 0.05, **p < 0.01, ***p < 0.001

Cross tabulations shows that amongst VHTs who correctly managed pneumonia, 15.52% (9/58) lacked registers compared to 84.48% (49/58) with register books. Amongst VHTs who had registers 38.60% (132/342) had primary education or no education compared to 61.40% (210/342) who had secondary education or tertiary. Amongst VHTs who correctly managed pneumonia, 75.85% (44/58) had secondary education level or tertiary compared to 21.14% (14/58) that had primary education level or no education. Amongst VHTs who had drug stock outs 39.67% (121/305) had primary level education or no education compared to 60.33% (184/305) who had primary school educational levels.

6.6 Health facility factors influencing  management of pneumonia by Village Health Teams.

From the qualitative data, respondents (the health workers) interviewed demonstrated proper understanding of pneumonia management. All the four respondents acknowledged that VHTs in their catchment areas treated children with pneumonia.

The theme generated was barriers of management of pneumonia

For this theme of barriers of management of pneumonia, categories with codes like; level of education, support supervision, equipment and supplies, refresher trainings and incentives were generated.  

Barriers of management of pneumonia by VHTS

The barriers were generated based on the emerging issues that were coded and categories reported below were generated.

Level of Education: Health workers agreed that naturally VHTs with a secondary level of education or higher performed better than those with primary level of education or those that had never gone to school as shown in the following quotes.  

“It’s very hard to teach uneducated VHTs. You see during selection of these VHTs, the guidelines are very clear. The guidelines state that only a person who can read and write should be selected into the VHT structure. However some villages had difficulty in selecting a suitable person, so they send one who can say some English words. In other cases the LC 1 chairperson selects his own person, who does not meet the criteria. If you look at the register books of the uneducated VHTs, it’s full of mistakes. Some of the uneducated VHTs use other educated non VHTs to fill their register books, making many mistakes”-Health Worker.

Support Supervision: The health workers said that the district last supervised the VHTs in August 2016; they had been largely left without any clear routine supervision activities from the district. There are no frequent monthly meetings so making supervision and monitoring hard.  

Refresher trainings: The health workers interviewed agreed that VHTs irrespective of whether replaced another or old; need constant refresher training to improve their management of pneumonia scores. The health workers likened VHT refresher trainings to Continuous Medical Education (CME sessions) health workers practise; VHTs too they said, need constant refresher trainings to keep them informed on correct procedures. This they said was very important because VHTs had low levels of education forgot concepts easily and some of them were constantly being replaced due to death or because they stopped working as VHTs due to several reasons.

Incentives for VHTs: VHTs during their training were promised that they would be given some financial incentives during monthly meetings. However for the last 2 years, there was hardly any payment from the district to them. The VHTs only received some money from other partners. During the study period, only CAfH (Community Action for Health), an NGO, implementing nutrition activities was paying VHTs. CAfH works with only one; out of the two VHTs in a village, leaving the other VHT idle. Lack of incentives according to health workers has demotivated the VHTs, and led to poor management scores.  

Screening and treatment: The respondents said that VHTs do not screen children; they do not know the respiratory cut off points and what to treat with amoxicillin.

 “VHTs are not accurate in screening children for pneumonia and treatment, others do not know fast breathing cut off points, they just treat any child with cough (with or without pneumonia) with amoxicillin” Health worker.

VHT Health facility Supervisors: Health workers said that the VHT training manual is different from the training they received in medical schools. The ICCM program introduced colour coated drugs, ARI timers and other procedures that were not taught in medical schools.

This they said confuses them and they do not know how to supervise VHTs.   

“When a VHT comes to you for consultation and drug refill for example; she will say give me blue Coartem, or yellow Coartem, we do not know the dosage and what advice to give them. You see, when we were in medical school, we were not taught on colour coated drugs, respiratory timers and ICCM in general. So most of us do not fully understand this ICCM program, this makes it hard for us to supervise the VHTs effectively. The next time they train VHTs on ICCM, the ICCM trainers should also train all health workers in the district so as to be able to supervise the VHTs accordingly” Health worker.

Equipment and Supplies: Some VHTs lacked respiratory timers, others had filled up forms.

Stock outs of amoxicillin exist in the whole district varying from weeks up to even four months. VHTs also lacked referral tools. Most of the medicine kits (wooden boxes) for keeping ICCM drugs that were supplied by UNICEF are spoilt, so most VHTs are not storing their drugs appropriately. Drugs should be kept inside medicine kits, but they are now kept out of the kits.

6.7 Community factors influencing  management of pneumonia by Village Health Teams.

From the qualitative data, respondents (community members) interviewed demonstrated knowledge of pneumonia. Community members identified pneumonia, as a disease that “goes with cough” makes a child develop fever, and it makes the child breath very fast.

The theme generated during the community FGD was barriers of management of pneumonia

To generate this them, categories with codes like VHTs cannot treat pneumonia, drug stock outs, rationing of drugs, trust and drunkenness were generated.

Barriers of management of pneumonia by VHTS

The barriers were generated based on the emerging issues that were coded and categories reported below were generated.

Drug Stock outs and rationing of drugs: Most respondents agreed that stock outs of VHT drugs exist; some said the stock out lasts only one month while others said the stock outs exists for more than 2 months, some even up to a period of 4 months. The community members said that when VHTs get drugs from the health facility, the drugs get used up within a few days. The respondents said that due to the persistent drug shortages, some VHTs had resorted to “rationing” drugs so as to ensure that at least more community members get drugs. A child who was supposed to get drugs for 5 days will only be given drugs for 2 days; the balance of his drugs is given to another child. This was being done to ensure that each sick child got at least some drugs, even if it was not the complete dosage. This is bad because children are not getting fully cured, they are being under dosed.  

VHTs cannot treat pneumonia: The majority of all respondents strongly admitted that VHTs cannot treat children with pneumonia. They said that VHTs had ARI timers but that it was used for measuring cough, wether the cough was very bad or good. After a brief health education session, explaining to them that VHTs use ARI timers to test for pneumonia (which they correctly identified as a child with hard breathing and cough), the community members still refused to accept that VHTs could treat a child with pneumonia. This implies that VHTs may not be treating pneumonia cases, because children with suspected pneumonia cases are taken to distant health facilities/clinics. This could perhaps explain the high morbidity and mortality rates. “No; VHTs don’t drugs for pneumonia. We know VHTs have amoxicillin but it’s a drug for mostly cough and sometimes body pain. Pneumonia can only be treated with injections and water on drip (IV fluids) . How do you allow a school drop out  to inject your child?”-Community Umlonge East  Village

Trust and Respect: Respondents agreed that if a VHT is not trusted, they will not take their children to him/her for treatment. As a suggestion for getting more trust and respect from the community, the respondents said that a VHT should be a person who knows how to use drugs and write referral letters. When a woman takes a sick child to a VHT, they said; he should educate the woman on how to make the baby swallow the drugs. VHTs should also be a role model from his own home. A VHTs home should be clean, with a latrine. VHTs should have their own time for attending to patients. They should also be available all the time, not VHTs who are very mobile

Drunkenness: According to the community members; some of the VHTs are very good drunkards. Additionally the drunk VHTs are also very proud; they (VHTs accused of being drunk) say that even if we are drunkards, you (community) have no right to remove us from work. As community members we feel defeated. This leads to mothers preferring to travel long distances to health facilities or they stay with their sick children until when it is too late.  

“There are those who when drunk, they insult you, refuse to treat your child or he will just throw drugs to you and asks you to select the ones you think will treat your child” – Morulem Sub County

CHAPTER SEVEN

7.0 DISCUSSION

7.1 Proportion of VHTs who correctly manage pneumonia among children.

This study found that only 15.51% of VHTs could provide correct management of pneumonia to children at all times in Abim district as per the SCJA. The findings of the study agree with

Wanduru et al (2016) who reported that only 11.7% of VHTs managed pneumonia as per the SCJA. Bagonza et al (2014), reports that only 21.7% of VHTs could manage children with pneumonia. These similar challenges were reported by (Kalyango et al., 2012). VHTs in the district performed poorly due to lack of supervision and refresher trainings. This is true because VHTs reported that their respective health facilities and the district had only conducted about 3 support supervision activities in the last two years prior to the survey. The VHTs reported that although some refresher trainings were conducted by partners between 2016 and 2017, none of the trainings were related to pneumonia. In addition, some VHTs were treating children with danger signs instead of referring them. This suggests that children are not being screened, children without pneumonia are being given pneumonia drugs and genuinely sick children are receiving low dosage of drugs contrary to the guidelines in the MoH/ICCM manual (MoH, 2010). The implication of low proportion of VHTs who can treat is that VHTs are contributing to drug wastage and antibiotic resistance with no reductions in pneumonia specific morbidity and mortality.

In addition to the above, this study also found that 73.8% of the VHTs counts were within +/- 5 of a count by experts in the training video. The findings of the study agree with that by Kallander et al (2006) who reported that 71% of the VHT counts were within ±5 breaths/min from the gold standard. The findings also agree with Mukanga et al (2011), who reported 85% in agreement with the paediatrician (j = 0.665, P < 0.001). These results show that VHTs can count the breaths of a sick child, however the challenge they have is classifying wether a child has fast breathing or not, taking into consideration the age of the child. The implication of these findings is that more emphasis should be put on training VHTs on how to classify fast or normal breathing; specifically on how to interpret respective respiratory rate cut offs for different age groups.

7.2 Individual factors associated with correct management of pneumonia among under-five year children by VHTs.

Secondary level of education; having a VHT register and drug stock outs were significantly associated with management of pneumonia. The findings of this study are consistent with findings by Sing et al (2016), Sommanustweechai et al (2016) Strachan et al., (2015) Kalyango et al (2012), Bagonza et al., (2014) Kawakatsu et al., (2012) and Wanduru et al., (2016).

Secondary level of education: VHTs with secondary level of education understand English and can read any IEC material that they are given. VHTs with secondary level of education can also understand key concepts in management of childhood illnesses when compared to their colleagues with primary level of education or no formal education. Emphasis should be placed on recruitment of individuals into the ICCM structure who can read and write.

VHT Registers: Similarly VHT registers affect VHT management of pneumonia. This is true because during support supervision and normal routine VHT work, the register is used as a tool to assess management of pneumonia of individual VHTs. Supervisors can easily identify weaknesses and take corrective action by scrutinizing a VHTs register. Some VHTs lack registers because they are filled up, lost, stolen or they are new VHTs who replaced another VHT that went away with all the tools meant for VHT work.  Since the prevalence ratio of having registers is less than 1, it means having a register is therefore protective, when relating to the outcome.  This implies that availability of registers is important for the success of the ICCM program.

Drug Stock outs: VHTs who reported drug stock outs provided correct management of pneumonia when compared to their colleagues that reported no drug stock outs. It is logical to reason that a VHT who provided correct management of pneumonia cured his/her patients as compared to those provided wrong management. As a consequence, because communities know that their (VHTs providing correct management) drugs work, they easily take their child to that VHT providing correct treatment rather than the one providing wrong treatment. It is also possible that communities take their children to particular VHTs because they are available and more trusted than their other colleagues. As a result, VHTs with drug stock outs provided correct treatment , while their colleagues who did not provide correct treatment had drugs because they managed less sick children. The implication of the finding is that drug stock outs affect VHT performance; so MoH should ensure all VHTs have sufficient drugs. To mitigate drug wastage, strict adherence to ICCM pneumonia treatment guidelines should be followed by all VHTs. The government should include drug tracking forms so that all drugs given out by VHTs should correspond with patient diseases and the number of patients treated

7.3 Health facility factors influencing correct management of pneumonia among under-five year children by VHTs.

Support Supervision: The findings of this study agree with .(Hadi, 2001; Kok, Dieleman, et al., 2015; Strachan et al., 2015; Wanduru et al., 2016). Supervision is a tool that is used by health facility VHT focal persons to monitor and evaluate VHT management of childhood illness.  The feedback from supervision visits is used to take corrective action where necessary. It is possible that only a low proportion of VHTs are managing childhood illnesses because of lack of supervision. The implication is that ICCM targets are not being met.  

Knowledge and Refresher training; the findings of this study agree with.(Hadi, 2001;

Kalyango et al., 2012; Kimbugwe et al., 2014; Singh et al., 2016; Sommanustweechai et al., 2016). Refresher trainings help reinforce knowledge from the initial ICCM training that VHTs attended. Medical workers attend mandatory continuous medical education sessions, the same needs to be applied to VHTs. The implication is that maybe after every six months; VHTs should attend refresher trainings on management of childhood illnesses including pneumonia. The refresher sessions need not to be long and expensive. DHOs office should explore ways of always conducting refresher trainings for VHTs, for this is directly linked to performance.

Incentives: The study found that lack of incentives was affecting VHT pneumonia management scores. The findings agree with (Kimbugwe et al., 2014; Mays et al., 2017; Sommanustweechai et al., 2016; Wanduru et al., 2016). VHT work is voluntary in Uganda. VHTs are not paid for their work. Without incentives, most VHTs are left with no option rather than to commit only some small portion of their time to community work. They are involved in other economic activities to put food on their tables. The implication is that; a modest pay should be given to

motivate VHTS.

Equipment and Supplies: This study also found lack of equipment and supplies as a factor affecting VHT management of pneumonia. The study is consistent with (Kalyango et al., 2012; Sommanustweechai et al., 2016; Strachan et al., 2015). It is obvious that without tools to perform and refine your skills, your knowledge with time diminishes. It’s important that the district health officer ensures that all needed drugs/register books and other tools for working are given to VHTs.

Relationship with health facility: Both the quantitative and qualitative study did not find having good relationships with the health facility staff as an important predictor of VHT management of pneumonia. This is true because some community members reported that there is poor working relationship between the health workers and the VHTs. Health workers always sends patients to VHTs, but these VHTs most times do not have drugs. This is true because the health facility VHT supervisors do not understand ICCM in full, health facilities are not conducting support supervision and VHT have drug stock outs. The implication is that there is a gap between the VHTs and the health workers.

7.4 Community factors influencing correct management of pneumonia among under-five year children by VHTs.

Trust and Respect: Respondents agreed that if a VHT is not trusted, they will not take their children to him/her for treatment, this finding agrees with (Bagonza, 2014; Kalyango et al., 2012; Kimbugwe et al., 2014; Strachan et al., 2015 . Strategies to improve community trust on VHTs should be explored. Closely related to trust is drunkenness. VHTs should not be drunkards. They should be role models that the community can respect and trust.

Drug Stock outs and rationing of drugs: This finding is also supported by quantitative data. It is tragic to note that due to the persistent drug shortages, some VHTs had resorted to “rationing” drugs so as to ensure that at least more community members get drugs. This implies that children are being under dosed.

VHTs cannot treat pneumonia: I think closely related to rationing of drugs; Community members think VHTs cannot treat pneumonia. Community members do not trust VHTs to treat their children with pneumonia. This is an interesting finding that has major implications for the success of management of pneumonia by VHTs. The implication is that children with suspected pneumonia are not being brought to the VHTs. It means the core objective of making drugs easily available within communities is being defeated. There is no use of having drugs that community members believe do not treat their sick children. Communities said they would rather take their children with pneumonia to distant government health facilities than take to VHTs. However this practise is bad because sometimes the community members may take their children to distant facilities when it is too late and yet their own VHTs could have saved the life of their child. This finding needs urgent attention, for this is the core of the community management of pneumonia.

Patient Characteristics: Both quantitative and qualitative study did not find this factor influencing VHT management of pneumonia.

Study Limitations.

The video recording did not depict real life scenario of a child sick. The video shows a child who had fast breathing, but the child was not crying or restless. In normal life situations, a child cries, is restless and has a lot of interrupted breathing. Although the video was not depicting real life scenarios, the fact that the VHTs were able to count is proof that under real life situations they are able to count, within the allowed +/- 5 margin. In addition this study did not assess the number of households each of the respondents served in his/her catchment area. Although it was good to assess workload, the study aimed at estimating proportion of VHTs that provided correct management.

Strengths of the study

A VHTs ability to screen, classify and treat a child with non-severe pneumonia was assessed using training video and case vignettes. The study was powered, with sufficient sample size of VHTs to be able to detect the true effect in the target population.

8.0 CONCLUSION

Objective 1: A low proportion of VHTs in the district correctly manage pneumonia as per guidelines in the SCJA. ..

Objective 2: Educational level, having a VHT register and having drug stock outs are factors significantly associated with management of pneumonia among under-five year children by VHTs in Abim district.  

Objective 3: Refresher training, equipment and supplies and support supervision are health facility factors influencing management of pneumonia by VHTs.  

Objective 4: Community factors influencing management of pneumonia by VHTs were; community perception that VHTs cannot manage a child with pneumonia, drug stock outs and

trust.

9.0 RECOMMENDATIONS

Objective 1

1. VHTs should be adequately trained, supervised, monitored and evaluated by the District

Health Management team on pneumonia screening, classification and treatment.

Objective 2

1. A minimum of secondary level of education should be used as a standard for recruitment of individuals into the VHT structure by the District Health Team. In situations where the village lacks a person with secondary level of education, persons who had reached upper primary or attended adult literacy classes should be enrolled into the structure
2. The District Health office should provide VHTs with register books, pneumonia drugs and all other equipment and supplies needed for management of pneumonia.

Objective 3

1. Health facilities should conduct monthly review meetings, support supervision activities and have necessary equipment and supplies for VHTs to access for work.
2. Health workers should be trained on the ICCM manual by ICCM trainers such that they can provide on spot coaching and guidance to VHTs on a regular basis.

Objective 4

1. The District Health Office should sensitise community members on the roles and responsibilities of VHTs including management of pneumonia.
2. Community leaders should build their communities trust and respect for their own VHTs by involving VHTs in community activities, selecting role models as VHT members.

Recommendations for further research do recommend studying  how mothers follow treatment guidelines , whether they give full dose and at appropriate times as specified by the

VHTs.

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APPENDICES

Appendix 1: Consent Form for the Key Informant/Focus Group Discussion

Good morning/Good afternoon Sir/Madam; I am OJORO VALENTINE pursuing a master’s degree in Public Health at Makerere University. I am conducting a study to determine factors associated with VHTs management of children with pneumonia in Abim district. Your health facility and you particularly have been chosen to participate in this study since you have knowledge and experience in this area.

Procedure: The key informant interview/FGD will not take more than 45 minutes and will be conducted by the principal investigator. You are therefore asked to share information on factors that influence VHT management of children with pneumonia. The recorder will be used and some notes will also be taken.

Benefits: The information will provide the evidence for formulating better strategies to improve management of pneumonia by VHTs. The study will involve interviewing staff. Confidentiality will be observed by use of codes not names and the information will also be kept and only accessible to the research team.

I will be grateful if you agree to participate in the interview

The researcher has explained the purpose of the study and I have understood that the information in the study will be kept confidential and the study will help improve management of pneumonia by VHTs.

Contacts; In case you get a problem related to the study contact me OJORO VALENTINE on 0772547285 or if you need to contact someone outside this study please call Dr Suzan Kiwanuka on 0772886377

Inquiries/questions: Would you like to ask any question about the study? May I begin the interview now? If you agree to be interviewed please sign, or place your thumb print below

Health facility number …………………..  Key informant Signature …………………….

Date of interview ……………………………………

Appendix 2: Key Informant interview Guide for health workers

Name of the health unit……………………………………………..

Health facility grade…………………………….      Date…………

Ownership of the facility……………………………………………

VHTs manage pneumonia in your catchment area. In your opinion;

1. What are the some of the health problems affecting this community? What are those problems that VHTs manage? (Probe for common illness, illnesses that VHTs manage)
2. In your opinion, Comment on VHT training prior to managing the community health problems. (Probe for: evidence of training, frequency of refresher trainings, how replacement VHTs are trained).
3. As a health worker (VHT focal person), what is your comment on the VHT management of pneumonia? (Probe for accuracy in screening, treatment, referral, and workload?) What have you done in the past 6 months to improve this?
4. How do you know if a VHT is performing optimally in management of pneumonia? (Probe for wether s (he) checks registers, how are they checked? In a meeting? Frequency, who calls the meetings, any payments made? How much? By who? Does he give feedback? Availability of amoxicillin and respiratory timers, register books, SCJA).
5. Do all VHTs know how to use the respiratory timers (probe for if alarm scares children when using the timer, if the timer does not show what it is counting, or if sound confuses

VHTs, how to replace batteries)

6. How are VHTs who perform poorly in management of pneumonia helped to improve?
7. Comment on the cooperation between VHTs and the health facility staff(are they

involved in health facility activities, conflict resolution)

Conclusion

8. Of all things discussed what do you see as the most important?
9. Have we missed anything in relation to management of pneumonia by VHTs

Thank you.

Appendix 3: Focus Group Discussion Guide for community members

Name                                                                      of                               the

Parish……………………………………………..Village……………………………………

The ministry of health allows VHTs to treat sick children below 5 years with pneumonia. In your opinion

1. What are the some of the health problems affecting this community? What are those problems that VHTs manage? (Probe for common illness, illnesses that VHTs manage)
2. What do you understand by the term pneumonia
3. Comment on whether your child healed after being treated by VHTs. (, did their children heal from pneumonia attack, if not why? do they buy more drugs from clinics or take the child later to a health facility? Do they have drugs throughout the year when their children are sick? Or are their incidences when the VHT tells them that they do not have drugs?).
4. What factors in your opinion affects VHTs in managing children with pneumonia. (probe if they trust a VHT to treat their children, do they respect their VHTs)
5. How should VHTs earn respect and trust in your community? (probe if VHTs are included in community programs citing examples)

Conclusion

6. Of all things discussed what do you see as the most important?
7. In summary were the key issues discussed?
8. Have we missed anything in relation to management of pneumonia by VHTs?

Appendix 4: Consent Form for the structured questionnaire

Good morning/Good afternoon Sir/Madam; I am OJORO VALENTINE pursuing a master’s degree in Public Health at Makerere University. I am conducting a study to determine factors associated with VHTs management of children with pneumonia in Abim district. You

particularly have been chosen to participate in this study and your contribution is vital.

Procedure: The interview will not take more than 45minutes and will be conducted by the principal investigator or research assistant. You are therefore asked to share information on this subject.

Benefits: The information will provide the evidence for formulating better strategies to improve management of pneumonia by VHTs. The study will involve interviewing clients.

Confidentiality will be observed by use of codes not names and the information will also be kept under lock and key. I will be grateful if you agree to participate in the interview

The researcher has explained the purpose of the study and I have understood that the information in the study will be kept confidential and the study will help improve on management of pneumonia by VHTs.

In case you get a problem related to the study and you need to contact me call 0772547285 or if you need to contact someone outside this study please call Dr Suzan Kiwanuka on 0772886377

Inquiries/questions: Would you like to ask any question about the study? May I begin the interview now? If you agree to be interviewed please sign, or place your thumb print below

Health facility number …………………..  Participants Signature ……………………

And      identification   number:           …………………….Or Participants     Thumb print……………………… (If not able to sign)

Interviewers Signature: ……………………  Date of interview …………………

Appendix 5: Questionnaire for VHTs

Adapted from ICCM facilitators guide(Uganda, 2010)

Questionnaire for VHTs 

01: General Information

02: Socio-Demographic characteristics of VHT

Appendix 6: Case Vignettes

adopted from VHT ICCM facilitators manual(Uganda, 2010)

Case 1: Job

Job is 9 months old. His mother says Job has cough and has been coughing for more than 21 days. The VHT counted 55 breaths per minute. Job vomits everything he eats even the food given last night.

Case 2: Musa

Musa is 37 months old.  Musa was brought to the clinic today because he has a stomach ache, feels hot and is coughing for two days. The VHT assessed the child for cough. The VHT counted 55 breaths a minute.

Case 3: Rose

Rose is 6 months old. Her mother brought her to the clinic because Rose has a cough. The VHT assessed her cough. The mother said Rose had the cough for 14 days. The VHT counted 45 breaths per minute. Rose did not have diarrhoea, and she did not have fever.

Answer sheet for Case Vignettes.

Appendix 7: Consent Form for the Key Informant/Focus Group Discussion (Luo)

Apwoyo coo/ apwoyo rio apwony a bedo Ojoro Valentine atye kakwano koc na me

Irwom me master ilengo me kabedo wa i Makerere University. Atye i ekweda me neno jami na lukere kitic na datare me kin paci gwoko ki ethino na tye in tuo Pneumonia i Distrik me Abim

Ot yath wu na dit me Abim eyaro i akina ot yathi napol rwok me bedo i ekweda ni

Kite na ngech wu tye n’olagoro ikothi gin obedo ni komanni.

Yothi: Yoon a pire tek in ekweda/FGD ba obitero dakika na kalo 45 eka ngat na bi timo ekweda ni bibedo ngat na tye ki ngec na thuth i ekweda.

Ekwai do ni imi ngec nalukere ki jami na piri teko itic ka datare me kin paci i kom ethino na tuo Pneumonia.

Ebino tic ki gi coc me neno ni jami na enywoko ecoyo piny

Ber ka ekwweda: Ngec ki lok ni bi mio caden me yobo yothi nabeco me tic ikom Pneumonia k’ethino. Ekweda ni tho obid bedo ki kare me penyo etic moko imung na nongo nyingi ba ebino ketho kaya leng kun jo nabitic ki lok me ekweda ni obibedo rok me ekweda keken.

Cwinya bibedo yom rwok ka iye bedo itimo ekweda ni kun idok i apeny

Atim ekweda ni do otyeko yaro pethi me ekweda man Kama leng eka thon aniang nil ok me ekweda man ebityo keda imung eka thon obiyobo tic ka datar me kin paci rwok me itic ikom Pneumonia.

Kit me kube; Onyo inwongo peko na luke ki ekweda man, cubere koda OJORO VALENTINE i nama cim 0772547285

Mito niang igimo/Apeny: Imito penyo apeny mo ikom ekweda ni? Do aromo cako ki apeny do?

Ka iye do i apeny me ekweda cor/thik cingi kany

Nama me ot yath …………………………………… Amio ngec ………………………………….

Nino dwe me ekweda …………………………………………………………

Appendix 8: Key Informant interview Guide for health workers (Luo)

Nying ot yath ……………………………………………………..

Rom ka ot yath …………………………………………….. Nino dwe …………………………..

Aloc me ot yath …………………………………………………………………..

Kit na datar me yot kom tyo kode ikom Pneumonia i kabedo ni. I thama ni piri keni;

1. I thama ni piri keni, ikobo ngo ikom pwonyere ka datar me ki paci i tic ikom peki na mako kabedo ni na lukere ki yot kom. (Tem kitek me penyo: Caden me pwonyere, pi kare narom mene ene doki ebedo i pwonyere me cono wic, kite me pwonyo ele datar me kin paci)
2. Kothi peki mene ene mako ka bedo ni nalukere ki lokkom yot kom? Kothi mene ene datar me kin paci twero tic iye? (Tem kitek me penyo kothi tuoe mene na pol, tuoe na datar me kin paci twero mako)
3. Calo akub datar me kin paci, ikobo ngo ikite netyo kode ikom Pneumonia? (Tem kitek me kwanyo akalakala ikite me poko, tuco, kobo tic? I ka coke? Ikara arom mene, nga lwongo kacoke, cul mo ne aculo? Cilling adi? Ki bot ngat? En mio rukuca ige? Bedo tye ka amoxicillin ki gi pimo yeyo, register book, SCJA)
4. Ca datare me kin paci ducu ngeo tic ki gi pimo yeyo (Tem kitek me penyo ka oduru ka cawa poo kom ethino ka eciko cawa me tic, ka cawa ba nyutho ngo na tye ka kwano, nyo dwone oduru rubo wi datar me kin paci, kite me loko makar.
5. Iyothi mene me ene ni datare me kin paci naba tyo gini naber itic ikom Pneumonia ekonyo gi
6. Ikobo ngo ikubere ikin datar me kin paci eka etic me ot yath (Gimo tho eketho gi itic me ot yath, laro lok)

Giko

7. Ikin jami ni ki duc na egwako ni, mene ene ineno calo pire tek rwok?
8. Ikengo gimo na lukere ki datar me kin paci tic ikom Pneumonia

Apwoyi

Appendix 9: Focus Group Discussion Guide for community members (Luo)

Nying parish ………………………………………………. Caalo ……………………………………

Athuko me yot kom yeo datar me kin paci me tuco ethin natuo Pneumonia natye mwaka abic dok kede ping.

Itama ni

1. Kothi peki mene ene mako ka bedo ni nalukere ki lokkom yot kom? Kothi mene ene datar me kin paci twero tic iye? (Tem kitek me penyo kothi tuoe mene na pol, tuoe na datar me kin paci twero mako)
2. Kob mono ka athini ocang inge nwongo kony ki both datar me kin paci. (Ethino gi obino ocang ki tuo Pneumonia, ka ba ocang pingo? Gin mono wilo yen mapol ki ot catho yat nyo tero ethino iyo nge o ot yath? Gi mono tye ki yen imwaka olu ka ethino gi tuo? Nyo bedo athura ka datar me kin paci okobo ni yen ope.
3. Kothi ngo mo ithama ni na cero datar me kin paci tic ikom tuo Pneumonia. (Tem kitek me ngeo ka geno gini datar me kin paci me tuco ethino, gin woro mo datar gi mo tin

paci).

4. Tye mono yon a ithamo na datar me kin paci romo nwongo ki woro eka gen ka kabedo gi?(Tem kitek me ngeo ka datar me kin paci bedo gini tho iyoba me kabedo gi kun inyutho apor).

Giko

1. Ikin jami ni ki duc na egwako ni, mene ene ineno calo pire tek rwok?
2. Ikengo gimo na lukere ki datar me kin paci tic ikom Pneumonia

Apwoyo

Appendix 10: Consent Form for the structured questionnaire (Luo)

Apwoyo coo/rio apwony; an OJORO VALENTINE tye katiom coc me lengo me kabedo wa ki Makererere University.

Atye ka timo ekweda me ngeo gaa naluko tic datar me kin paci ikom tuo Pneumonia i Distrik me Abim

Yothi: Yoon a pire tek in ekweda obitero dakika na kalo 45 eka ngat na bi timo ekweda ni bibedo ngat na tye ki ngec na thuth i ekweda nyo akony ekweda.

Ekwai do ni imi ngec nalukere ki jami na piri teko itic ka datare me kin paci i kom ethino na tuo Pneumonia.

Ebino tic ki gi coc me neno ni jami na enywoko ecoyo piny

Ber ka ekwweda: Ngec ki lok ni bi mio caden me yobo yothi nabeco me tic ikom Pneumonia k’ethino. Ekweda ni tho obid bedo ki kare me penyo etic moko imung na nongo nyingi ba ebino ketho kaya leng kun jo nabitic ki lok me ekweda ni obibedo rok me ekweda keken.

Cwinya bibedo yom rwok ka iye bedo itimo ekweda ni kun idok i apeny

Atim ekweda ni do otyeko yaro pethi me ekweda man Kama leng eka thon aniang nil ok me ekweda man ebityo keda imung eka thon obiyobo tic ka datar me kin paci rwok me itic ikom Pneumonia.

Kit me kube; Onyo inwongo peko na luke ki ekweda man, cubere koda OJORO VALENTINE i nama cim 0772547285

Mito niang igimo/Apeny: Imito penyo apeny mo ikom ekweda ni? Do aromo cako ki apeny do?

Ka iye do i apeny me ekweda cor/thik cingi kany

Nama me ot yath …………………………………… Amio ngec ………………………………….

Nama me nwongere ………………………………….Nyo ka namo cing……………………..

(Ka baromo cono cinge)

Cing akweda ………………………………………… Nino dwe me ekweda……………………….

Appendix 11: Questionnaire for VHTs (Luo)

Karatac me apeny pi Datar me kin paci   

01: Ngec kom ngat acel acel

02: Kitta Datar me kin paci kwo kede eka kanya en kwo iye

Appendix 12 Case Vignettes (Luo)

Adapted from VHT ICCM facilitators manual (Uganda 2010)

Lok 1: Yubu

Yubu tye dweth 9. Ywoyo kilo 9.5. Lietho me kome tye 39.5^oC. Nama wi otgi 15, Kabedo me tye: Icaalo me Buyamba, Ddwaniro parish, Kawenpe sub county. Ayaame okobo ni en ochado for cabit 1. Ba woolo. Yubu obedo ki araka idi wor n’okato, ngoko jami duc na en camo naka thon dek emio idi wor n’okato ni.

Lok 2: Musa

Muca tye dwethe 37. En ywao kilo 15.3. Lietho me kome tye 38.5^oC Nama me wi otgi 32 Caalo me Kapeeka, Ddwaniro parish, Kywankwanzi sub-county. Ekelo Muca i ot yath tin pi adwaayic, winyo lietho, aburu ki aoya koma eka thon woolo. Gin okobo ni en obedo kawinyo lietho pi nino aryo. Datar me kin paci onwongo ni athin tye ki awoona, Enyodo okobo ni ene obedo ka woolo pi nino aryo. Datar me kin paci okwano nyweo 55 i dakika acel.

Lok 3: Rose

Rose tye dwethe abicel. En ywao kilo 4. Lietho me kome tye 37^oC. Ayaame okelo en i ot yath pien onongo Rose tye ka awana. Datar me kin paci oneno awana me. Ayaame okobo ni Rose owoolo pi nino 30. Datar me kin paci okwano nyweo 52 i dakika acel. Rose onongo ope ka cado eka thon en onongo ape ki lietho. Peko me it hope, ayaame okobo. Datar me kin paci ba obino onwongo anyuth moro na rac. Datar me kin paci onwongo peko ka Rose kun tye ki SCJA eka okobo Rose i ot yath.

Karatac me agam me lokkom Vignettes