PROJECT BRIEF
This study aimed to provide valuable evidence on the rational use of antibiotics at the community level to inform future implementation of integrated community case management, helping to ensure that hard-to-reach and remote populations continue to have access to lifesaving treatments and to preserve the utility of medicines worldwide.
Project outline
Pneumonia accounts for approximately 15 percent of all childhood deaths and kills more children than any other infectious disease globally. With an estimated 935,000 deaths of children under five per year attributable to pneumonia, its prevention and control is a global priority essential to achieving Milllenium Development Goal 4 – to reduce child mortality by two-thirds by 2015. The World Health Organization and UNICEF estimat that a considerable proportion of childhood pneumonia deaths could be averted through implementation of a number of key interventions.
Community-level interventions have a key role to play in improving the accessibility, uptake and appropriate use of health services, especially for poor and marginalised populations. One such intervention is the integrated community case management (iCCM) strategy for malaria, pneumonia, diarrhoea and newborn health, which is currently being rolled out across sub-Saharan Africa, Asia and South America. The overall aim is to support and strengthen community-based case management of malaria, pneumonia and diarrhoea by providing free diagnostics and treatment to children under five, training, job aids and supervision to community health workers (CHWs), as well as communication for behavioural change to the community as a whole.
Although interventions such as iCCM have great potential to reduce the burden of pneumonia, especially in hard-to-reach populations, concerns remain regarding the use of antibiotics at community level and the development of antibiotic resistance. With training, supervision and the use of effective job aids, CHWs offer a valuable opportunity to improve the rational use of antibiotics in resource-poor settings. However, evidence on current practice by CHWs and adherence to treatment by caregivers is limited.
Through COMDIS-HSD, a research programme consortium funded by the UK government, Malaria Consortium explored this issue in Zambia to inform action to prevent the development of resistance while continuing to provide community-level treatment for marginalised populations for a major cause of childhood mortality. The project was built upon Malaria Consortium’s implementation of iCCM in Luapula province, which was funded by the Canadian International Development Agency (now known as DFATD).
The cross-sectional study took place in two districts of Luapula province and had three main components:

1. Observation of community health worker consultations to determine if CHWs were able to correctly diagnose and prescribe treatment for children with suspected pneumonia, including innovative methodology to assess the accuracy of respiratory rate assessment.
2. Follow-up visits with caregivers of children who were prescribed antibiotics to determine adherence to treatment, through questionnaires and pill counts.
3. Focus group discussions and key informant interviews with CHWs and caregivers to supplement quantitative findings and explore behaviours, attitudes and possible influences on the rational use of antibiotics at the community level.