Strachan C E, Nuwa A, Muhangi D, Okui A P, Helinski M E H, Tibenderana J K
Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2A 4LT, UK.
London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK.
BMC Health Serv Res. 2018 Jun 19;18(1):470. doi: 10.1186/s12913-018-3209-4.
Successful pre-referral treatment with rectal artesunate (RA) for suspected severe malaria requires operational linkages between community health workers (CHWs) and referral facilities, acceptance of pre-referral treatment and adherence to referral practices by CHWs and caregivers. This qualitative study investigated how community understanding of the concept of 'pre-referral treatment' is used in referral related decision-making following provision of RA in Uganda.
Narrative interviews were conducted with 30 caregivers of children under five who received RA within the previous three months and the 30 associated CHWs who provided the treatment. Nineteen focus group discussions incorporating vignettes from the interviews were held with further caregivers, and 12 with CHWs and women representatives. Twenty traditional healers were targeted for semi-structured interview. Thematic analysis followed a 'meaning-based' approach.
CHWs were aware of essential information to be given to caregivers on prescribing RA as indicated by the job aid, specifically urgency for referral, yet there was insufficient emphasis on RA not being a full treatment for severe malaria. Information shared by the CHW appeared to be influenced by the perceived urgency with which the CHW needed to act and the time of day or night the child was seen. Seven of the 32 caregivers did not complete referral post RA administration. Caregivers seemed more likely to adhere to referral advice if they perceived their child's condition to be severe. Previous caregiver experience and CHW comparisons with Artemisinin-based Combination Therapy (ACT) as a treatment for uncomplicated malaria appeared to raise misperceptions that RA is a complete treatment for severe malaria, thus reducing likelihood to complete referral. CHW implication, or caregiver interpretation, of the need to monitor the child, and some prescription of ACT post RA administration, also confused the need for referral. Both CHWs and caregivers requested further information about the role of RA.
CHW advice should emphasise RA as providing temporary relief prior to facility-based treatment, the importance of referral whether or not a change is seen in the child's condition, and the dangers of not completing referral. Social behaviour change communication, training and support supervision activities could help promote these messages.
使用直肠青蒿琥酯（RA）对疑似重症疟疾进行成功的转诊前治疗需要社区卫生工作者（CHW）与转诊机构之间建立业务联系，CHW和照顾者接受转诊前治疗并遵守转诊流程。这项定性研究调查了在乌干达提供RA后，社区对“转诊前治疗”概念的理解如何用于与转诊相关的决策。
对30名在过去三个月内接受RA治疗的五岁以下儿童的照顾者以及30名提供治疗的相关CHW进行了叙事访谈。与更多照顾者进行了19次焦点小组讨论，讨论内容包含访谈中的案例，与CHW和女性代表进行了12次焦点小组讨论。针对20名传统治疗师进行了半结构化访谈。主题分析采用“基于意义”的方法。
CHW知道工作辅助工具中规定的应向照顾者提供的关于开具RA的基本信息，特别是转诊的紧迫性，但对RA并非重症疟疾的完整治疗方法的强调不足。CHW分享的信息似乎受到CHW认为需要采取行动的紧迫性以及见到孩子的白天或夜晚时间的影响。32名照顾者中有7名在给予RA后未完成转诊。如果照顾者认为孩子的病情严重，他们似乎更有可能遵守转诊建议。照顾者以前的经验以及CHW将基于青蒿素的联合疗法（ACT）作为单纯性疟疾治疗方法的比较似乎引发了误解，即RA是重症疟疾的完整治疗方法，从而降低了完成转诊的可能性。CHW对监测孩子必要性的暗示或照顾者的解释，以及在给予RA后开具ACT的一些处方，也使转诊的必要性变得模糊。CHW和照顾者都要求提供有关RA作用的更多信息。
CHW的建议应强调RA在基于机构的治疗之前提供临时缓解，无论孩子的病情是否有变化，转诊的重要性以及不完成转诊的危险。社会行为改变沟通、培训和支持监督活动有助于传播这些信息。
