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Community health workers adherence to referral guidelines: evidence from studies introducing RDTs in two malaria transmission settings in Uganda

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ABSTRACT

Background: Many malaria-endemic countries have implemented national community health worker (CHW) programmes to serve remote populations that have poor access to malaria diagnosis and treatment. Despite mounting evidence of CHWs’ ability to adhere to malaria rapid diagnostic tests (RDTs) and treatment guidelines, there is limited evidence whether CHWs adhere to the referral guidelines and refer severely ill children for further management. In southwest Uganda, this study examined whether CHWs referred children according to training guidelines and described factors associated with adherence to the referral guideline.

Methods: A secondary analysis was undertaken of data collected during two cluster-randomized trials conducted between January 2010 and July 2011, one in a moderate-to-high malaria transmission setting and the other in a low malaria transmission setting. All CHWs were trained to prescribe artemisinin-based combination therapy (ACT) and recognize symptoms in children that required immediate referral to the nearest health centre. Intervention arm CHWs had additional training on how to conduct an RDT; CHWs in the control arm used a presumptive diagnosis for malaria using clinical signs and symptoms. CHW treatment registers were reviewed to identify children eligible for referral according to training guidelines (temperature of ≥38.5 °C), to assess whether CHWs adhered to the guidelines and referred them. Factors associated with adherence were examined with logistic regression models.

Results: CHWs failed to refer 58.8% of children eligible in the moderate-to-high transmission and 31.2% of children in the low transmission setting. CHWs using RDTs adhered to the referral guidelines more frequently than CHWs not using RDTs (moderate-to-high transmission: 50.1 vs 18.0%, p = 0.003; low transmission: 88.5 vs 44.1%, p < 0.001). In both settings, fewer than 20% of eligible children received pre-referral treatment with rectal artesunate. Children who were prescribed ACT were very unlikely to be referred in both settings (97.7 and 73.3% were not referred in the moderate-to-high and low transmission settings, respectively). In the moderate-to-high transmission setting, day and season of visit were also associated with the likelihood of adherence to the referral guidelines, but not in the low transmission setting.

Conclusions: CHW adherence to referral guidelines was poor in both transmission settings. However, training CHWs to use RDT improved correct referral of children with a high fever compared to a presumptive diagnosis using sign and symptoms. As many countries scale up CHW programmes, routine monitoring of reported data should be examined carefully to assess whether CHWs adhere to referral guidelines and take remedial actions where required.

Electronic supplementary material: The online version of this article (doi:10.1186/s12936-016-1609-7) contains supplementary material, which is available to authorized users.

No MeSH data available.


Related in: MedlinePlus

Profile of children analysed in the moderate-to-high transmission setting. *Referral outcome missing for ten children
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Fig2: Profile of children analysed in the moderate-to-high transmission setting. *Referral outcome missing for ten children

Mentions: The analysis examined whether CHWs in each transmission setting adhered to referral guidance in children who presented with a high fever (temperature ≥38.5 °C); this indicator of adherence to referral guidelines was selected because axillary temperature was the only sign routinely recorded by CHWs for all children. Therefore, the recorded temperature was used to identify children who should, irrespective of the RDT result, have been referred according to the training guidelines and examine whether these children were actually referred by CHWs (Fig. 2). The study did not have an independent assessment of the other 11 severe signs and symptoms for referral. Data was analysed from the treatment registers completed by CHWs between January 2011 and July 2012, after CHW supervision was scaled back.Fig. 2


Community health workers adherence to referral guidelines: evidence from studies introducing RDTs in two malaria transmission settings in Uganda
Profile of children analysed in the moderate-to-high transmission setting. *Referral outcome missing for ten children
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC5121932&req=5

Fig2: Profile of children analysed in the moderate-to-high transmission setting. *Referral outcome missing for ten children
Mentions: The analysis examined whether CHWs in each transmission setting adhered to referral guidance in children who presented with a high fever (temperature ≥38.5 °C); this indicator of adherence to referral guidelines was selected because axillary temperature was the only sign routinely recorded by CHWs for all children. Therefore, the recorded temperature was used to identify children who should, irrespective of the RDT result, have been referred according to the training guidelines and examine whether these children were actually referred by CHWs (Fig. 2). The study did not have an independent assessment of the other 11 severe signs and symptoms for referral. Data was analysed from the treatment registers completed by CHWs between January 2011 and July 2012, after CHW supervision was scaled back.Fig. 2

View Article: PubMed Central - PubMed

ABSTRACT

Background: Many malaria-endemic countries have implemented national community health worker (CHW) programmes to serve remote populations that have poor access to malaria diagnosis and treatment. Despite mounting evidence of CHWs’ ability to adhere to malaria rapid diagnostic tests (RDTs) and treatment guidelines, there is limited evidence whether CHWs adhere to the referral guidelines and refer severely ill children for further management. In southwest Uganda, this study examined whether CHWs referred children according to training guidelines and described factors associated with adherence to the referral guideline.

Methods: A secondary analysis was undertaken of data collected during two cluster-randomized trials conducted between January 2010 and July 2011, one in a moderate-to-high malaria transmission setting and the other in a low malaria transmission setting. All CHWs were trained to prescribe artemisinin-based combination therapy (ACT) and recognize symptoms in children that required immediate referral to the nearest health centre. Intervention arm CHWs had additional training on how to conduct an RDT; CHWs in the control arm used a presumptive diagnosis for malaria using clinical signs and symptoms. CHW treatment registers were reviewed to identify children eligible for referral according to training guidelines (temperature of ≥38.5 °C), to assess whether CHWs adhered to the guidelines and referred them. Factors associated with adherence were examined with logistic regression models.

Results: CHWs failed to refer 58.8% of children eligible in the moderate-to-high transmission and 31.2% of children in the low transmission setting. CHWs using RDTs adhered to the referral guidelines more frequently than CHWs not using RDTs (moderate-to-high transmission: 50.1 vs 18.0%, p = 0.003; low transmission: 88.5 vs 44.1%, p < 0.001). In both settings, fewer than 20% of eligible children received pre-referral treatment with rectal artesunate. Children who were prescribed ACT were very unlikely to be referred in both settings (97.7 and 73.3% were not referred in the moderate-to-high and low transmission settings, respectively). In the moderate-to-high transmission setting, day and season of visit were also associated with the likelihood of adherence to the referral guidelines, but not in the low transmission setting.

Conclusions: CHW adherence to referral guidelines was poor in both transmission settings. However, training CHWs to use RDT improved correct referral of children with a high fever compared to a presumptive diagnosis using sign and symptoms. As many countries scale up CHW programmes, routine monitoring of reported data should be examined carefully to assess whether CHWs adhere to referral guidelines and take remedial actions where required.

Electronic supplementary material: The online version of this article (doi:10.1186/s12936-016-1609-7) contains supplementary material, which is available to authorized users.

No MeSH data available.


Related in: MedlinePlus