A mixed methods study of a health worker training intervention to increase syndromic referral for gambiense human African trypanosomiasis in South Sudan

Abstract

Background: Active screening by mobile teams is considered the most effective method for detecting gambiense-type human African trypanosomiasis (HAT) but constrained funding in many post-conflict countries limits this approach. Non-specialist health care workers (HCWs) in peripheral health facilities could be trained to identify potential cases for testing based on symptoms. We tested a training intervention for HCWs in peripheral facilities in Nimule, South Sudan to increase knowledge of HAT symptomatology and the rate of syndromic referrals to a central screening and treatment centre.

Methodology/principal findings: We trained 108 HCWs from 61/74 of the public, private and military peripheral health facilities in the county during six one-day workshops and assessed behaviour change using quantitative and qualitative methods. In four months prior to training, only 2/562 people passively screened for HAT were referred from a peripheral HCW (0 cases detected) compared to 13/352 (2 cases detected) in the four months after, a 6.5-fold increase in the referral rate observed by the hospital. Modest increases in absolute referrals received, however, concealed higher levels of referral activity in the periphery. HCWs in 71.4% of facilities followed-up had made referrals, incorporating new and pre-existing ideas about HAT case detection into referral practice. HCW knowledge scores of HAT symptoms improved across all demographic sub-groups. Of 71 HAT referrals made, two-thirds were from new referrers. Only 11 patients completed the referral, largely because of difficulties patients in remote areas faced accessing transportation.

Conclusions/significance: The training increased knowledge and this led to more widespread appropriate HAT referrals from a low base. Many referrals were not completed, however. Increasing access to screening and/or diagnostic tests in the periphery will be needed for greater impact on case-detection in this context. These data suggest it may be possible for peripheral HCWs to target the use of rapid diagnostic tests for HAT.

Figure 1. Treatment-seeking and test referral pathways which lead to successful HAT detection via passive screening.

Boxes and arrows in green represent HAT test referral because the patient or a lay-person suspects symptoms may be due to HAT. Boxes and arrows in red represent HAT test referral because a HCW suspects symptoms may be due to HAT. Thick red arrows are the pathways targeted by the HCW HAT training intervention, which are influenced by HCW perceptions of the appropriateness of HAT referral at the peripheral level. Boxes and arrows in blue and purple represent treatment-seeking events that precede and follow consideration of HAT referral, respectively.

Figure 2. Source of referral for patients screened at hospital for HAT, by month of screening.

Figure 3. Distribution of correct test responses for individual symptoms, before and after HAT training.

The numbers of people providing an answer for each symptom-association varied between tests. Pre-training (Pre-) test n = 107–113, post-training (Post-) test n = 106–110, post-intervention evaluation (Eval-) test n = 54–55. “Don't know” responses were categorised as incorrect. Fever for 2 days, cough and abdominal pains are not associated with HAT. *McNemar's p-value indicates a significant (p<0.05) increase in correct associations between pre-training and post-intervention evaluation tests.

Figure 4. Screening outcome of new referrals made.