Does Length of Service Predict Adherence to the iCCM Diarrhoea Case Management Protocol? A Structured Observational Study of Community Health Promoters in Turkana County, Kenya

Diarrhoeal disease remains a major childhood health concern in Kenya’s arid and semi-arid lands, where Community Health Promoters (CHPs) deliver integrated community case management (iCCM). This cross-sectional study assessed observed adherence after a six-month SMS reinforcement period and examined whether protocol deviation differed by CHP length-of-service category. Trained observers recorded 102 CHP-caregiver encounters involving children younger than 5 years with diarrhoea in Turkana West Sub-County; each encounter involved a unique CHP. Full adherence required the actual completion of all 12 applicable protocol components. Because only five encounters contained a deviation, Firth’s penalised logistic regression compared CHPs recorded in the 1–5-year service category with those in the two longer-service categories combined. Ninety-seven of 102 encounters (95.1%) were fully adherent, and weighted mean item-level adherence was 98.4%. CHPs in the recorded 1–5-year category had higher unadjusted odds of protocol deviation (OR = 42.23, 95% CI [5.41, 329.49], p < .001), an estimate interpreted cautiously given that it rests on only five observed deviation events. Adherence was high in this post-intervention observational study, but sparse events, non-probability sampling, and absence of baseline or comparison data limit precision and preclude causal attribution to service duration or the SMS intervention.