Can lay community health workers be trained to use diagnostics to distinguish and treat malaria and pneumonia in children? Lessons from rural Uganda

Abstract

Summaryobjective To determine the competence of community health workers (CHWs) to correctly assess, classify and treat malaria and pneumonia among under-five children after training.methods Consultations of 182 under-fives by 14 CHWs in Iganga district, Uganda, were observed using standardised checklists. Each CHW saw 13 febrile children. Two paediatricians observed CHWs' assessment, classification and prescription of treatment, while a laboratory scientist assessed CHW use of malaria rapid diagnostic tests (RDTs). The validity of CHWs' use of RDTs to detect malaria and respiratory timers to diagnose pneumonia was estimated using a laboratory scientist's RDT repeat reading and a paediatrician's repeat count of the respiratory rate, respectively.results From the 182 consultations, overall CHWs' performance was adequate in taking history (97%), use (following procedures prior to reading result) of timers (96%) and use of RDTs (96%), but inadequate in classification (87%). Breath readings (classified as fast or normal) were 85% in agreement with the paediatrician (j = 0.665, P < 0.001). All RDT readings were in agreement with those obtained by the laboratory scientist. Ninety-six per cent (85 ⁄ 89) of children with a positive RDT were prescribed an antimalarial drug, 40% (4 ⁄ 10) with fast breathing (gold standard) were prescribed an antibiotic and 91% (48 ⁄ 53) with both were prescribed both medicines.conclusion Community health workers can be trained to use RDTs and timers to assess and manage malaria and pneumonia in children. We recommend integration of these diagnostics into community case management of fever. CHWs require enhanced practice in counting respiratory rates and simple job aides to enable them make a classification without thinking deeply about several assessment results.keywords community health worker, performance, integrated community case management for malaria and pneumonia, diagnostics, rapid diagnostic test, respiratory rate timer, Uganda

Clinical outcomes among febrile children aged 2 to 59 months with negative malaria rapid diagnostic test results in Mchinji District, Malawi

“…15 While this may have resulted from ongoing training and mentoring related to the mRDT and rectal artesunate project, it also illustrates that, when they are appropriately trained, community-level CHWs can deliver services of comparable quality to those delivered by facility-level health workers. 20 There were some limitations for this study; first, although the findings of this study suggested a significantly high clinical response to only antipyretics for children who were mRDT-negative, it is possible that some parents or guardians might have given their sick children medications sourced elsewhere, which might have had an effect on the outcome of the study. Although all enrolled children reportedly did not receive antimalarials within 14 days prior to enrolment, there was no way of corroborating this information.…”

Success or failure of critical steps in community case management of malaria with rapid diagnostic tests: a systematic review

“…Correct interpretation was high for the direct assessment of RDTs; 96 to 100% of tests and 95.1 to 100% of CHWs, provided that CHWs were trained properly [18,19,21,32]. In photographic assessments, which have the inherent risk of selection bias as the number of ambiguous tests is relatively high, well-trained CHWs also scored high numbers of correctly interpreted tests, although more mistakes were made in reading faint positive and invalid tests [18,19].…”

“…The way CHWs executed RDTs was judged on several items, but differences in number and definition of items further impaired comparison [18-21,32]. Nevertheless CHWs were found to correctly conduct RDTs if properly trained; 90 to 100% of steps were successfully executed in two studies that used the same WHO checklist, Hawkes et al .…”

Development of a novel device for objective respiratory rate measurement in low-resource settings

“…Previous studies conducted in Africa have shown that RR assessed by CHWs is inaccurate 10 11. In a recent Ugandan study, CHWs counting the RR resulted in correct diagnosis and treatment of only 40% of all cases of childhood pneumonia 11. An instrument to facilitate accurate RR measurement at the village level could improve pneumonia diagnosis and case management.…”