Research for Equity and Community Health Trust, Lilongwe, Malawi.
PLoS One. 2012;7(9):e39746. doi: 10.1371/journal.pone.0039746. Epub 2012 Sep 4.
Early access to tuberculosis diagnosis and treatment remains a challenge in developing countries. General use of informal providers such as storekeepers is common. The aim of this study was to determine the effectiveness and acceptability of a storekeeper-based referral system for TB suspects in urban settings of Lilongwe, Malawi.
The referral system intervention was implemented in two sub-districts. This was evaluated using a pre and post comparison as well as comparison with a third sub-district designated as the control. The intervention included training of storekeepers to detect and refer clients with chronic cough using predesigned referral letters along with monitoring and supervision. Data from a community based chronic cough survey and an audit of health centre records were used to measure its effectiveness. Focus group discussions and in-depth interviews were carried out to document acceptability of the intervention with the different stakeholders.
Following the intervention, the mean patient delay appeared lower in the intervention than comparison areas (2.14 weeks (SD 5.8) vs 8.8 weeks (SD 15.1)). However, after adjusting for confounding variables this difference was not significant (p = 0.07). After the intervention the proportion of the population diagnosed with smear positive TB in the intervention sites (1.2 per 1000) was significantly higher than in the comparison area (0.6 per 1000, p<0.01) even after adjusting for sex and age. Qualitative findings suggested that (a) the referral letters triggered health workers to ask patients to submit sputum for TB diagnosis (b) the approach may be sustainable as the referral role was linked to the livelihood of the storekeepers.
The study suggests that the referral system with storekeepers is sustainable and effective in increasing smear positive TB case notification. Studies that assess this approach for control of other diseases along with collection of specimens by storekeepers or similar providers are needed.
在发展中国家，早期诊断和治疗结核病仍然是一个挑战。通常会利用店主等非正规提供者。本研究旨在确定在马拉维利隆圭市城区，基于店主的转介系统对疑似结核病患者的有效性和可接受性。
该转介系统干预措施在两个分区实施。采用前后对照以及与第三个指定为对照的分区进行比较进行评估。干预措施包括培训店主使用预先设计的转介信识别和转介慢性咳嗽患者，并进行监测和监督。使用基于社区的慢性咳嗽调查和卫生中心记录审核的数据来衡量其效果。开展焦点小组讨论和深入访谈，记录不同利益攸关方对干预措施的接受程度。
干预后，干预区的平均患者延迟时间低于对照区（2.14 周（SD5.8）比 8.8 周（SD15.1））。然而，在调整混杂变量后，这种差异没有统计学意义（p=0.07）。干预后，干预区（每 1000 人 1.2 例）诊断为涂片阳性结核病的人口比例明显高于对照区（每 1000 人 0.6 例，p<0.01），即使在调整性别和年龄后也是如此。定性研究结果表明：（a）转介信促使卫生工作者要求患者提交痰液进行结核病诊断；（b）这种方法可能是可持续的，因为转介角色与店主的生计有关。
该研究表明，基于店主的转介系统可持续且有效地增加涂片阳性结核病病例报告。需要进行评估这种方法对其他疾病的控制效果以及店主或类似提供者采集标本的研究。
