Date Published: July 01, 2012
Publisher: The American Society of Tropical Medicine and Hygiene
Author(s): Helen Counihan, Steven A. Harvey, Masela Sekeseke-Chinyama, Busiku Hamainza, Rose Banda, Thindo Malambo, Freddie Masaninga, David Bell.
Malaria rapid diagnostic tests (RDTs) could radically improve febrile illness management in remote and low-resource populations. However, reliance upon community health workers (CHWs) remains controversial because of concerns about blood safety and appropriate use of artemisinin combination therapy. This study assessed CHW ability to use RDTs safely and accurately up to 12 months post-training. We trained 65 Zambian CHWs, and then provided RDTs, job-aids, and other necessary supplies for village use. Observers assessed CHW performance at 3, 6, and 12 months post-training. Critical steps performed correctly increased from 87.5% at 3 months to 100% subsequently. However, a few CHWs incorrectly read faint positive or invalid results as negative. Although most indicators improved or remained stable over time, interpretation of faint positives fell to 76.7% correct at 12 months. We conclude that appropriately trained and supervised CHWs can use RDTs safely and accurately in community practice for up to 12 months post-training.
Recent advances in point-of-care (POC) diagnostic technology offer tremendous potential for community-based infectious disease management. POC diagnostics could significantly increase the quality of basic health services for remote populations in low-resource settings. Currently, many such services are provided by community health workers (CHWs) with limited training and supervision.1,2 Realizing the potential of POC diagnostics at the community level will depend upon demonstrating that CHWs can prepare and interpret such tests accurately and safely.
The study demonstrated consistently high performance over 12 months by CHWs using malaria RDTs after receiving a half-day competency-based training and a field-tested job-aid. The study also revealed a few instances of poor practice, with some participants repeating the same or similar errors throughout the 12-month period. In particular, difficulty reading faint positive test lines could lead to false-negative results. Previous studies have noted both this difficulty and the difficulty manipulating blood transfer devices.14,20–23
With a well-designed job-aid and half-day training, CHWs can diagnose malaria safely and accurately using RDTs. CHWs participating in the study retained these skills in community practice up to 12 months post-training. However, occasional errors occur, therefore supervisors should conduct periodic performance appraisals and make necessary corrections to ensure patient, CHW, and community safety. The results offer good evidence for the appropriateness of CHWs taking finger-prick blood samples and using POC diagnostic tests in the community, provided they receive adequate training, job-aids, supplies, and follow-up supervision.