A Mixed Methods Study of a Health Worker Training Intervention to Increase Syndromic Referral for Gambiense Human African Trypanosomiasis in South Sudan

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. Author Summary: Human African trypanosomiasis (HAT or sleeping sickness) is a fatal but treatable disease affecting poor people in sub-Saharan Africa. Most HAT diagnostic equipment, infrastructure and expertise is located in hospitals. The expense of expanding testing services to remote areas using mobile teams severely restricts their use. Non-specialist healthcare workers (HCWs) in first-line (primary) health care facilities can contribute to control by identifying patients in need of testing based on their symptoms. We therefore trained first-line HCWs to recognise potential syndromic cases of HAT and refer them to a hospital screening service. Against a low baseline of HCW HAT referral experience, four months after the intervention, HCW knowledge of HAT symptoms increased and HCWs in 71.4% of facilities across the county had made referrals, incorporating new and pre-existing ideas about HAT case detection into referral practice. There was only a modest increase in numbers of referred patients received at the hospital for screening, however, largely because of distance. In an era where approaches to HAT case detection and control must increasingly be integrated into health referral systems, it is vital to understand the opportunities and challenges associated with syndromic case detection in first line facilities to design effective interventions.