University Research Co. - United States (Harvey, Jennings, Mulholland), Malaria Consortium - Zambia (Chinyama), World Health Organization - WHO Zambia Office (Masaninga), World Health Organization - Regional Office for the Western Pacific (Bell)

This Zambia-based study, published by the Malaria Journal, was designed to determine: (i) whether community health workers (CHWs) could prepare and interpret rapid diagnostic tests (RDTs) for malaria accurately and safely using manufacturer's instructions alone; (ii) whether simple, mostly pictorial instructions (a "job aid") could raise performance to adequate levels; and (iii) whether a brief training programme would produce further improvement. The study was carried out under the auspices of the Zambia National Malaria Control Center (NMCC), with assistance from the United States Agency for international Development (USAID) through the Quality Assurance Project and the World Health Organization (WHO). The article describes the methodology used for the study and provides details about the job aid and half-day training programme.

As stated here, many countries in Africa where malaria is most widespread have been reluctant to allow CHWs to handle blood because of risks of HIV transmission and concerns about whether these minimally-trained providers could accurately use and interpret RDTs. However, this study found that CHWs were able to master the skills needed to administer and interpret RDTs correctly and safely. The study, conducted in July 2006 in Lusaka Province, Zambia, recruited three independent groups of CHWs; trained observers used structured observation checklists to score each participant's preparation of three RDTs; each CHW also read 10 photographs showing different test results. To test the effect of job aid and job aid-plus-training on CHW performance, the first group of CHWs prepared the RDT using only the manufacturer's instructions in English and Nyanja, the local language. In group 2, CHWs used only the job aid, a pictorial and scripted procedures card, also provided in English and Nyanja. In group 3, CHWs prepared the RDT, using the job aid, after receiving three hours of training.

Prior to the controlled study, formative research was done with 9 focus groups by: 1) demonstrating the RDT preparation and interpretation; and 2) collecting suggestions on how best to explain the test to other CHWs, comments on what steps CHWs might find difficult, and recommendations on how best to overcome these difficulties. Based on these findings, the study team designed a draft job aid. A second round of focus groups was conducted to get feedback on the draft, which was then modified to incorporate CHW recommendations. This modified job aid was then used to conduct the present study.

This study measured two outcomes: 1) ability to conduct test procedures safely and correctly; and 2) ability to interpret the results correctly. Regarding outcome #1: On average, CHWs using the manufacturer's instructions performed 57% of test steps correctly. Those using the job aid alone improved significantly to 80%. Job aid-plus-training CHWs scored highest, at 90% correct. Regarding outcome #2: Accuracy of the RDT test interpretation improved significantly in the job aid-only and job aid-plus-training groups. Manufacturer's instructions CHWs read a mean 54% of test results correctly compared to 82% in the job aid-only group and 93% in the job aid-plus-training group. The most common mistake was to read a faint positive or invalid result as negative. Occurrences of this error declined significantly from a mean of 2.3 in the manufacturer's instructions group to 1.7 in the job aid-only group and again to 0.3 in the job aid-plus-training group (p < 0.05). In the manufacturer's instructions group, no CHW correctly read all 10 test results compared to 7 (33%) in the job aid-only and 16 (62%) in the trained group (p < 0.05).

The study concludes that volunteer CHWs can use malaria RDTs safely and effectively. "Use of malaria rapid diagnostic tests by community health workers is potentially an effective alternative for malaria case management in areas with limited functional microscopy and limited health care personnel or facilities. Findings from this study show that a well-designed job aid and brief training can ensure high CHW performance. Addressing design issues related to time-keeping, visibility and blood sampling may further enhance RDT preparation and interpretation by CHWs and the resultant quality of case management."

The Malaria Journal is an open access publication, so its articles are available worldwide at no charge and with no subscription required. A free-of-charge registration is required to access the full text.

Emails from Tula Michaelides and Steven A. Harvey to The Communication Initiative on September 10 2008 and May 6 2009, respectively.