title: A mixed methods study of a health worker training intervention to increase syndromic referral for gambiense human African trypanosomiasis in South Sudan.
abstract: BACKGROUND
  Active screening by mobile teams is considered the most effective method for detecting gambiense-type human African trypanosomiasis (HAT) but constrained funding in many post-conflict countries limits this approach. Non-specialist health care workers (HCWs) in peripheral health facilities could be trained to identify potential cases for testing based on symptoms. We tested a training intervention for HCWs in peripheral facilities in Nimule, South Sudan to increase knowledge of HAT symptomatology and the rate of syndromic referrals to a central screening and treatment centre.
  
  
  RESULTS
  We trained 108 HCWs from 61/74 of the public, private and military peripheral health facilities in the county during six one-day workshops and assessed behaviour change using quantitative and qualitative methods. In four months prior to training, only 2/562 people passively screened for HAT were referred from a peripheral HCW (0 cases detected) compared to 13/352 (2 cases detected) in the four months after, a 6.5-fold increase in the referral rate observed by the hospital. Modest increases in absolute referrals received, however, concealed higher levels of referral activity in the periphery. HCWs in 71.4% of facilities followed-up had made referrals, incorporating new and pre-existing ideas about HAT case detection into referral practice. HCW knowledge scores of HAT symptoms improved across all demographic sub-groups. Of 71 HAT referrals made, two-thirds were from new referrers. Only 11 patients completed the referral, largely because of difficulties patients in remote areas faced accessing transportation.
  
  
  CONCLUSIONS
  The training increased knowledge and this led to more widespread appropriate HAT referrals from a low base. Many referrals were not completed, however. Increasing access to screening and/or diagnostic tests in the periphery will be needed for greater impact on case-detection in this context. These data suggest it may be possible for peripheral HCWs to target the use of rapid diagnostic tests for HAT.
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Jennifer J
authors.initials: JJ
authors.lastname: Palmer
authors.affiliation: Medical Emergency Relief International, Nimule, South Sudan.
authors.forename: Elizeous I
authors.initials: EI
authors.lastname: Surur
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Francesco
authors.initials: F
authors.lastname: Checchi
authors.affiliation: Islamic Relief, Islamabad, Pakistan.
authors.forename: Fayaz
authors.initials: F
authors.lastname: Ahmad
authors.affiliation: International Medical Corps, London, United Kingdom.
authors.forename: Franklin Kweku
authors.initials: FK
authors.lastname: Ackom
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Christopher J M
authors.initials: CJ
authors.lastname: Whitty
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D002648:Child; D002675:Child, Preschool; D003140:Communicable Disease Control / Q000379:methods*; D004501:Education, Medical / Q000379:methods*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D011361:Professional Competence; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013397:Sudan / Q000453:epidemiology; D014353:Trypanosomiasis, African / Q000175:diagnosis* / Q000453:epidemiology / Q000473:pathology / Q000517:prevention & control*; D055815:Young Adult