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

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.

Danger signs and management of suspected severe malaria cases at community level and in referral health facilities: an operational study in the Democratic Republic of the Congo

“…This does not match with evidence from another study (36). Additional factors on our experience and reported in the literature are logistics, finances of the patients, communication skills, perceived quality of care, lack of time and need to care for other children and an improvement in the child's condition (36,38,40,41).…”

“…RAS administration was significantly associated with increased odds of completing referral, which is similar with result from another study in Uganda (37).This may be explained in our study by the sensitization of caretakers and health worker during trainings prior to RAS rollout. However, our findings were different from another study in Uganda, which found that nearly all children treated with pre-referral RAS failed to comply with referral (38). Transport did not show an association with referral completion; eight in ten caretakers went by foot to a RHF, which was consistent with results from a study conducted in Afghanistan, where the majority of caretaker successfully completed referral by foot (39).…”

Caregivers’ compliance with referral advice: evidence from two studies introducing mRDTs into community case management of malaria in Uganda

“…The findings from these studies in Uganda and elsewhere show that community based referral systems operate less than optimally at each stage of the referral process. In the first stage, CHW often do not refer children with referral signs and symptoms to the nearest health centre [ 23 , 33 , 34 ]. In the second stage, caregivers often fail to comply with CHW referral advice and do not seek care from health centres [ 13 – 16 ].…”

Quality of clinical assessment and management of sick children by Health Extension Workers in four regions of Ethiopia: A cross-sectional survey

“…Lack of referral notes might have affected the continuity of care as information was not forwarded [27,28]. Non-adherence to referral guidelines was also observed among community health workers in Uganda [29] and Ghana [30] while a reasonable number of referrals supported with referral slips was observed among community health workers in Pakistan [27]. Most caregivers were advised on home-based sick child care and continued feeding.…”