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Supportive supervision to improve the quality and outcome of outpatient care among malnourished children: a cluster randomised trial in Arua district, Uganda
  1. Marzia Lazzerini1,
  2. Humphrey Wanzira1,
  3. Peter Lochoro2,
  4. Richard Muyinda2,
  5. Giulia Segafredo2,
  6. Henry Wamani3,
  7. Giovanni Putoto2
  1. 1WHO Collaborating Centre, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
  2. 2Doctors with Africa, CUAMM, Kampala, Uganda
  3. 3Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University, Kampala, Uganda
  1. Correspondence to Dr Marzia Lazzerini; marzia.lazzerini{at}


Introduction Suboptimal quality of paediatric care has been reported in resource-limited settings, but little evidence exists on interventions to improve it in such settings. This study aimed at testing supportive supervision (SS) for improving health status of malnourished children, quality of case management, overall quality of care, and the absolute number of children enrolled in the nutritional services.

Methods This was a cluster randomised trial conducted in Arua district. Six health centres (HCs) with the highest volume of work were randomised to either SS or no intervention. SS was delivered by to HCs staff (phase 1), and later extended to community health workers (CHWs) (phase 2). The primary outcome was the cure rate, measured at children level. Quality of case management was assessed by six pre-defined indicators. Quality of care was assessed using the national Nutrition Service Delivery Assessment (NSDA) tool. Access to care was estimated with the number of children accessing HC nutritional services.

Results Overall, 737 children were enrolled. In the intervention arm, the cure rate (83.8% vs 44.9%, risk ratio (RR)=1.91, 95% CI: 1.56–2.34, p=0.001), quality of care as scored by NSDA (RR=1.57, 95% CI: 1.01–2.44, p=0.035) and correctness in complementary treatment (RR=1.52, 95% CI: 1.40–1.67, p=0.001) were significantly higher compared with control. With the extension of SS to CHWs (phase 2), there was a significant 38.6% more children accessing care in the intervention HCs (RR=1.26, 95% CI: 1.11–1.44, p=0.001) compared with control.

Conclusion SS significantly improved the cure rate of malnourished children, and the overall quality of care, SS to CHWs significantly increased the crude number of children enrolled in the nutritional services. More studies should confirm these results, and evaluate the cost-effectiveness of SS.

  • supportive supervision
  • malnutrition
  • children under 5 years
  • quality of care
  • randomised controlled trial

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  • Handling editor Stephanie M Topp

  • Contributors LM conceived the study idea, in collaboration with HW, MR, GP, GS, WH and PL. LM, HW and MR lead the design and acquisition of data, LM and HW conducted the analysis and interpreted the data. LM and HW lead the drafting of manuscript, all authors were involved during critical revision for important intellectual content. All authors read and approved for the final manuscript to be published and are accountable for all aspects of the work.

  • Funding Research discussed in the publication is funded by the World Food Programme (Office of Evaluation), the UK aid through the Department for International Development (DFID) and the International Initiative for Impact Evaluation (3ie). The views expressed in the report are not necessarily those of WFP, DFID or 3ie. The funding body had no role in the design of the study, data collection, analysis, and interpretation and writing the final manuscript.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the Makerere University School of Public health ethical committee: protocol number 391, Uganda National Council of Science and Technology (UNCST): HS number 2059, and the ethical committee of the IRCCS Burlo Garofolo, Italy: protocol number 521/2016.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data may be obtained from a third party and are not publicly available.

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