Abstract

BackgroundMany 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.MethodsA 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.ResultsCHWs 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.ConclusionsCHW 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 materialThe online version of this article (doi:10.1186/s12936-016-1609-7) contains supplementary material, which is available to authorized users.

Highlights

  • 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

  • Data analyses The analysis examined whether CHWs in each transmission setting adhered to referral guidance in children who presented with a high fever; this indicator of adherence to referral guidelines was selected because axillary temperature was the only sign routinely recorded by CHWs for all children

  • Child characteristics During the 19-month study period (January 2011–July 2012), 18,497 children with a history of fever were seen by 180 CHWs in the moderate-to-high transmission

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Summary

Introduction

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. In many sub-Saharan African countries where malaria is endemic, community health workers (CHWs) have received renewed interest to deliver primary healthcare in areas with poor access to public health services, and CHW programmes to treat common childhood infections of malaria, pneumonia and diarrhoea (known as integrated community case management (iCCM)) have been introduced in over 25 countries with the aim of reducing under-five mortality [1, 2]. CHW training usually includes guidance on when children should be referred to a fully qualified health worker, few studies have examined CHW adherence to these referral guidelines [3, 5,6,7]. Guidelines can serve to: (1) support CHWs to make appropriate referral decisions; (2) encourage caregivers to seek further care from health facilities; and, (3) ensure CHWs do not risk managing illnesses they are not trained for, and limit adverse outcomes that may arise if children do not receive attention from qualified health workers. The lack of evidence on referral has been highlighted as a priority for further research to inform the implementation and scale-up of iCCM globally [12,13,14,15]

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