title: Acceptability and effectiveness of the storekeeper-based TB referral system for TB suspects in sub-districts of Lilongwe in Malawi.
abstract: BACKGROUND
  Early access to tuberculosis diagnosis and treatment remains a challenge in developing countries. General use of informal providers such as storekeepers is common. The aim of this study was to determine the effectiveness and acceptability of a storekeeper-based referral system for TB suspects in urban settings of Lilongwe, Malawi.
  
  
  METHODS
  The referral system intervention was implemented in two sub-districts. This was evaluated using a pre and post comparison as well as comparison with a third sub-district designated as the control. The intervention included training of storekeepers to detect and refer clients with chronic cough using predesigned referral letters along with monitoring and supervision. Data from a community based chronic cough survey and an audit of health centre records were used to measure its effectiveness. Focus group discussions and in-depth interviews were carried out to document acceptability of the intervention with the different stakeholders.
  
  
  RESULTS
  Following the intervention, the mean patient delay appeared lower in the intervention than comparison areas (2.14 weeks (SD 5.8) vs 8.8 weeks (SD 15.1)). However, after adjusting for confounding variables this difference was not significant (p = 0.07). After the intervention the proportion of the population diagnosed with smear positive TB in the intervention sites (1.2 per 1000) was significantly higher than in the comparison area (0.6 per 1000, p<0.01) even after adjusting for sex and age. Qualitative findings suggested that (a) the referral letters triggered health workers to ask patients to submit sputum for TB diagnosis (b) the approach may be sustainable as the referral role was linked to the livelihood of the storekeepers.
  
  
  CONCLUSIONS
  The study suggests that the referral system with storekeepers is sustainable and effective in increasing smear positive TB case notification. Studies that assess this approach for control of other diseases along with collection of specimens by storekeepers or similar providers are needed.
authors.affiliation: Research for Equity and Community Health Trust, Lilongwe, Malawi. bertha@africa-online.net
authors.forename: Bertha Nhlema
authors.initials: BN
authors.lastname: Simwaka
authors.forename: Sally
authors.initials: S
authors.lastname: Theobald
authors.forename: Annie
authors.initials: A
authors.lastname: Willets
authors.forename: Felix M L
authors.initials: FM
authors.lastname: Salaniponi
authors.forename: Patnice
authors.initials: P
authors.lastname: Nkhonjera
authors.forename: George
authors.initials: G
authors.lastname: Bello
authors.forename: Stephen Bertel
authors.initials: SB
authors.lastname: Squire
mesh_terms: D000328:Adult; D003132:Commerce / Q000193:education / Q000458:organization & administration*; D003371:Cough / Q000175:diagnosis; D003906:Developing Countries; D005260:Female; D017144:Focus Groups; D006801:Humans; D008295:Malawi; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation / Q000458:organization & administration*; D013183:Sputum / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis*; D014505:Urban Population