Proactive Community Case Management to improve care seeking for febrile illness in Sierra Leone: A community randomized controlled trial.

BackgroundPrompt treatment seeking for febrile illness is a critical step in the care cascade for malaria. In wide areas of sub-Saharan Africa there are critical gaps in coverage of prompt care. Integrated Community Case Management (iCCM) has been shown to be a burden reducing intervention that can influence malaria transmission and reduce overall disease burden and increase care access. Studies have not determined whether the delivery of iCCM through passive or proactive means provide ancillary benefits such as sustainable improvements in care-seeking behavior. This study was designed to determine if ProCCM could deliver sustainable increases in care seeking behavior even after a short period of implementation had ended. MethodsA three-arm community randomized trial was conducted in Pujehun district, Sierra Leone from May 2024 until it was interrupted by the U.S. government in January 2025. The trial compared communities with up to four rounds of ProCCM and stock out support, to stock out support and iCCM alone, or to only iCCM alone (Standard Practice). Forty-six Primary Health Care Units (PHCU) were grouped into 45 clusters and randomized (1:1:1) to one of the three arms using restricted randomization. Treatment seeking rates were measured using cross-sectional household surveys at baseline (before randomization) and at one month post intervention. A final survey was planned at four months after intervention end but was interrupted by U.S. Government actions. FindingsIn the first survey post intervention, 250 of 391 febrile children sought care promptly in the preceding two weeks. Household education, asset ownership, access to water, household construction and use of malaria prevention were similar across arms. There was a significantly higher rate of prompt care-seeking for febrile illness in groups exposed to ProCCM as compared to the other arms. Among the hardest to reach populations, odds of care seeking increased nearly 3x (O.R. 2.78 (95% C.I. 1.03-7.85) p=0.05). Post-intervention beliefs about the availability, quality and community norms of care-seeking for fever were all higher in the ProCCM arm relative to the controls. InterpretationProCCM delivered in short periods can improve care seeking for febrile illness in hard-to-reach populations by modifying community perceptions of community health workers availability and competence, when drugs and diagnostics for malaria care are available. We were unable to assess the sustainability of these gains due to interruption of PMI funding. FundingUSAID/PMI Funding through PATH/PMI Insights supported the original study and data collection. All analytic and post-data collection work supported by Tulane University.