title: Community health workers adherence to referral guidelines: evidence from studies introducing RDTs in two malaria transmission settings in Uganda.
abstract: BACKGROUND
  Many 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.
  
  
  METHODS
  A 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.
  
  
  RESULTS
  CHWs 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.
  
  
  CONCLUSIONS
  CHW 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.
authors.affiliation: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK. sham.lal@lshtm.ac.uk.
authors.forename: Sham
authors.identifier: http://orcid.org/0000-0002-3650-1398
authors.initials: S
authors.lastname: Lal
authors.affiliation: C/O Vector Control Division, Ministry of Health, Kampala, Uganda.
authors.forename: Richard
authors.initials: R
authors.lastname: Ndyomugenyi
authors.affiliation: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
authors.forename: Lucy
authors.initials: L
authors.lastname: Paintain
authors.affiliation: MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Neal D
authors.initials: ND
authors.lastname: Alexander
authors.affiliation: Institute of Public Health, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Kristian S
authors.initials: KS
authors.lastname: Hansen
authors.affiliation: Faculty of Health and Medical Sciences, Institute of International Health, Immunology and Microbiology & Institute of Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Pascal
authors.initials: P
authors.lastname: Magnussen
authors.affiliation: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
authors.forename: Daniel
authors.initials: D
authors.lastname: Chandramohan
authors.affiliation: Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
authors.forename: Siân E
authors.initials: SE
authors.lastname: Clarke
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D002846:Chromatography, Affinity / Q000706:statistics & numerical data; D003150:Community Health Workers; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence; D006302:Health Services Research; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D008297:Male; D016032:Randomized Controlled Trials as Topic; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D014454:Uganda