Dataset Information

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

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.

SUBMITTER: Lal S

PROVIDER: S-EPMC5121932 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Malaria remains a major public health threat accounting for 30.4 % of disease morbidity in outpatient clinic visits across all age groups in Uganda. Consequently, malaria control remains a major public health priority in endemic countries such as Uganda. Experiences from other countries in Africa that revised their malaria case management suggest that health workers adherence may be problematic.A descriptive, cross-sectional design was used and collected information on health system, health workers and patients. Using log-binomial regression model, adjusted prevalence risk ratios (PRRs) and their associated 95 % confidence intervals were determined in line with adherence to new treatment guidelines of parasitological diagnosis and prompt treatment with artemisinin combination therapy (ACT).Nine health centres, 24 health workers and 240 patient consultations were evaluated. Overall adherence to national malaria treatment guidelines (NMTG) was 50.6 % (122/241). It was significantly high at HC III [115 (53 %)] than at HC IV (29 %) [PRR = 0.28 (95 % CI 0.148 0.52), p = 0.000]. Compared to the nursing aide, the adherence level was 1.57 times higher among enrolled nurses (p = 0.004) and 1.68 times higher among nursing officers, p = 0.238, with statistical significance among the former. No attendance of facility malaria-specific continuing medical education (CME) sessions [PRR = 1.9 (95 % CI 1.29 2.78), p = 0.001] and no display of malaria treatment job aides in consultation rooms [PRR = 0.64 (95 % CI 0.4 1.03), p = 0.07] was associated with increased adherence to guidelines with the former showing a statistical significance and the association of the latter borderline statistical significance. The adherence was higher when the laboratory was functional [PRR = 0.47 (95 % CI 0.35 0.63)] when the laboratory was functional in previous 6 months. Age of health worker, duration of employment, supervision, educational level, and age of patient were found not associated with adherence to new treatment guidelines.Adherence to malaria treatment guidelines in Uganda is sub-optimal. There is an urgent need for deliberate interventions to improve adherence to these guidelines. Possible interventions to be explored should include: provision of job aides and improved access to laboratory services. There is also a need for continuous medical educational sessions for health workers, especially those at higher-level facilities and higher cadres, on adherence to guidelines in management of fever, including management of other causes of fever.

Project description:BackgroundSeveral malaria endemic countries have implemented community health worker (CHW) programmes to increase access to populations underserved by health care. There is considerable evidence on CHW adherence to case management guidelines, however, there is limited evidence on the compliance to referral advice and the outcomes of children under-5 referred by CHWs. This analysis examined whether caregivers complied with CHWs referral advice.MethodsData from two cluster (village) randomised trials, one in a moderate-to-high malaria transmission setting, another in a low-transmission setting conducted between January 2010-July 2011 were analysed. CHW were trained to recognise signs and symptoms that required referral to a health centre. CHW in the intervention arm also had training on; malaria rapid diagnostic tests (mRDT) and administering artemisinin based combination therapy (ACT); CHW in the control arm were trained to treat malaria with ACTs based on fever symptoms. Caregivers' referral forms were linked with CHW treatment forms to determine whether caregivers complied with the referral advice. Factors associated with compliance were examined with logistic regression.ResultsCHW saw 18,497 child visits in the moderate-to-high transmission setting and referred 15.2% (2815/18,497) of all visits; in the low-transmission setting, 35.0% (1135/3223) of all visits were referred. Compliance to referral was low, in both settings < 10% of caregivers complied with referral advice. In the moderate-to-high transmission setting compliance was higher if children were tested with mRDT compared to children who were not tested with mRDT. In both settings, nearly all children treated with pre-referral rectal artesunate failed to comply with referral and compliance was independently associated with factors such as health centre distance and day of referral by a CHW. In the moderate-to-high transmission setting, time of presentation, severity of referral were also associated with compliance, whilst in the low-transmission setting, compliance was low if an ACT was prescribed.ConclusionsThis analysis suggests there are several barriers to comply with CHWs referral advice by caregivers. This is concerning for children who received rectal artesunate. As CHW programmes continue scale-up, barriers to referral compliance need to be addressed to ensure a continuum of care from the community to the health centre.Trial registrationThe study was registered with ClinicalTrials.gov. Identifier NCT01048801 , 13th January 2010.

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