title: Referral Patterns of Community Health Workers Diagnosing and Treating Malaria: Cluster-Randomized Trials in Two Areas of High- and Low-Malaria Transmission in Southwestern Uganda.
abstract: Malaria-endemic countries have implemented community health worker (CHW) programs to provide malaria diagnosis and treatment to populations living beyond the reach of health systems. However, there is limited evidence describing the referral practices of CHWs. We examined the impact of malaria rapid diagnostic tests (mRDTs) on CHW referral in two cluster-randomized trials, one conducted in a moderate-to-high malaria transmission setting and one in a low-transmission setting in Uganda, between January 2010 and July 2012. All CHWs were trained to prescribe artemisinin-based combination therapy (ACT) for malaria and recognize signs and symptoms for referral to health centers. CHWs in the control arm used a presumptive diagnosis for malaria based on clinical symptoms, whereas intervention arm CHWs used mRDTs. CHWs recorded ACT prescriptions, mRDT results, and referral in patient registers. An intention-to-treat analysis was undertaken using multivariable logistic regression. Referral was more frequent in the intervention arm versus the control arm (moderate-to-high transmission, P < 0.001; low transmission, P < 0.001). Despite this increase, referral advice was not always given when ACTs or prereferral rectal artesunate were prescribed: 14% prescribed rectal artesunate in the moderate-to-high setting were not referred. In addition, CHWs considered factors alongside mRDTs when referring. Child visits during the weekends or the rainy season were less likely to be referred, whereas visits to CHWs more distant from health centers were more likely to be referred (low transmission only). CHWs using mRDTs and ACTs increased referral compared with CHWs using a presumptive diagnosis. To address these concerns, referral training should be emphasized in CHW programs as they are scaled-up.
authors: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors: Sham
authors: S
authors: Lal
authors: Vector Control Division, Ministry of Health, Kampala, Uganda.
authors: Richard
authors: R
authors: Ndyomugenyi
authors: Department of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.|Department of International Health, Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
authors: Pascal
authors: P
authors: Magnussen
authors: Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors: Kristian S
authors: KS
authors: Hansen
authors: Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors: Neal D
authors: ND
authors: Alexander
authors: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors: Lucy
authors: L
authors: Paintain
authors: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors: Daniel
authors: D
authors: Chandramohan
authors: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors: Siân E
authors: SE
authors: Clarke
mesh_terms: D000293:Adolescent; D000962:Antimalarials / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D003150:Community Health Workers; D005260:Female; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology*; D008297:Male; D012017:Referral and Consultation; D014454:Uganda / Q000453:epidemiology
chemical_list: D000962:Antimalarials