Task shifting of triage to peer expert informal care providers at a tertiary referral HIV clinic in Malawi: a cross-sectional operational evaluation

Abstract

BackgroundHIV treatment models in Africa are labour intensive and require a high number of skilled staff. In this context, task-shifting is considered a feasible alternative for ART service delivery. In 2006, a lay health cadre of expert patients (EPs) at a tertiary referral HIV clinic in Zomba, Malawi was capacitated. There are few evaluations of EP program efficacy in this setting. Triage is the process of prioritizing patients in terms of the severity of their condition and ensures that no harmful delays occur to treatment and care. This study evaluates the safety of task-shifting triage, in an ambulatory low resource setting, to EPs.MethodsAs a quality improvement exercise in April 2010, formal triage training was conducted by adapting the World Health Organization Emergency Triage Assessment and Treatment Triage Module Guidelines. A cross sectional observation study was conducted 2 years after the intervention. Triage assessments performed by EPs were repeated by a clinical officer (gold standard) to assess sensitivities, specificities, positive and negative predictive values for EP triage scores. Proportions were calculated for categories of disposition by stratifying by EP and clinician triage scores.ResultsA total of 467 patients were triaged by 7 EPs and re-triaged by clinical officers. With combined triage scores for emergency and priority patients we report a sensitivity of 85% and specificity of 74% for the EP scoring, with a low positive predictive value (41%) and a high negative predictive value (96%). We calculate a serious miss rate of EP scoring (i.e. missed priority or emergency patients) as 2.2%. Admission rates to hospital were highest among those patients triaged as emergency cases either by the EP’s (21%) or the clinicians (83%). Fewer patients triaged as priority by either EPs (5%) or clinicians (15%) were admitted to hospital, however these patients had the highest prevalence of same day lab testing and/or specialty referral.ConclusionsOur study provides reassurance that in the context of adequate training and ongoing supervision, task-shifting triage to lay health care workers does not necessarily lead to less accurate triaging. EPs have a tendency to be more conservative in over-triaging patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2291-3) contains supplementary material, which is available to authorized users.

Health interventions among mobile pastoralists: a systematic review to guide health service design

“…In one example, members of nomadic Fulani communities were trained in antimalarial administration, increasing appropriate treatment of uncomplicated malaria from 2% to 82% over a one‐year study period [16]. Reports expressed optimism regarding the potential of joint efforts between formal and informal health providers, which have been shown to be effective in other low‐resource settings [41,42]. While limited investigation has been conducted among pastoralists, preliminary research suggests this may be a promising avenue and that attitudes towards such partnerships are favourable [43,44].…”

Are treatment supporters relevant in long-term Antiretroviral Therapy (ART) adherence? Experiences from a long-term ART cohort in Uganda

“…The greater likelihood of women being treatment supporters than men is in keeping with the role women have played in caring for people living with HIV, throughout the epidemic (Schatz & Ogunmefun, 2007; Schatz & Seeley, 2015; Seeley et al, 1993; Taylor, Seeley, & Kajura, 1996), and in linking relatives, often men, to care (Ahmed et al, 2018; Kawuma, Seeley, Mupambireyi, Cowan, & Bernays, 2018). With the roll out of universal testing and treatment, to provide access to treatment for all people living with HIV, women as treatment supporters may play a crucial role in the provision of HIV-care as health care providers and counsellors manage increasing workloads (Church et al, 2017; Landes et al, 2017). Task shifting to such lay care providers may be essential to support many people living with HIV to link to care (Kennedy, Yeh, Johnson, & Baggaley, 2017; Ruzagira, Baisley, Kamali, & Grosskurth, 2018; Ruzagira, Grosskurth, Kamali, & Baisley, 2017) and stay in care (Hall et al, 2017).…”

Perceptions of patients regarding diabetes-related health communication strategies in the Free State, South Africa

“…Peer support and education, although unstructured and informal, seemed to be a common technique used in transmitting health information among patients with diabetes within various communities in the Free State. Likewise, in the field of HIV management, the concept of 'expert patients' has supported health care workers in delivering health information related to adherence and selfcare for other HIV-positive patients (Landes et al 2017). Such approaches may need to be devised and strengthened in areas of high disease burdens like South Africa.…”