Can illustrated instructions and training help community health workers use malaria tests?

Details

The introduction of artemisinin combination therapy (ACT) increased interest in parasite-based malaria diagnosis and the use of rapid diagnostic tests (RDTs), especially in rural areas with limited microscopy. With donor support, national malaria control programmes are procuring large quantities of RDTs. In many sub-Saharan African countries, shortages of facilities and trained personnel mean that restricting RDTs to facilities would exclude a significant proportion of people with fever. Volunteer community health workers (CHWs) could offer an alternative, but most countries in the region prohibit them from handling blood, and little was known about their ability to use RDTs safely and effectively.

The Zambia-based study asked whether CHWs could prepare and interpret RDTs safely and accurately with manufacturer instructions alone, whether simple, mostly pictorial instructions called a job aid could bring performance to adequate levels, and whether brief training could improve it further. The job aid and training programme were based on formative research with 32 CHWs in Luangwa District. Researchers then recruited three groups of CHWs in Chongwe and Chibombo districts. All had treated malaria based on clinical diagnosis, but only six had used RDTs before.

Trained observers used structured observation checklists to score each participant preparing three RDTs. Each participant also interpreted 10 photographs showing different test results. The first group (32 CHWs) used only the manufacturer's instructions. The second group (21) used only the job aid. The third group (26) used the job aid after three hours of training.

After adjustment for education, age, gender and experience, the groups correctly completed an average of 57%, 80% and 92%, respectively, of the 16 RDT steps. The mean percentages of test results interpreted correctly were 54%, 80% and 93%, respectively. All differences were statistically significant (p < 0.05).

The authors concluded that manufacturer instructions like those supplied with the tests in this study were insufficient to ensure safe and accurate use by CHWs. They concluded that well-designed instructions plus training can ensure high performance. Further study was underway to see how well that performance lasts over time.