Empowerment of Community workers in using a newly developed diagnostic algorithm for Early Detection of Dermatological Problems in a Resource - poor Tribal Setting of Agasthyamala Biosphere Reserve Forest area of Thiruvananthapuram district of Kerala
Authors: Maheswariamma Simi Surendrannair , Jose Regi , Pillai Rajamohanan K 
Published: April 2023

Background: Tribes, constituting 8.6% of India’s population (according to the 2011 census) have remained marginalized through centuries geographically, politically, and socio-economically. The health care needs of the tribals have always been considered similar to the health needs in rural India and health programmes have been devised accordingly. The uniqueness in terms of the terrain and environment in which they live, their socio-cultural differences, and their genetic make-up need to be taken into consideration when assessing their health status as well as in planning and implementing health programmes for their welfare.
Racial and ethnic minorities have been historically underrepresented in medical research. Through increased research, awareness, education, outreach, and change in public policy, dermatologic and general health disparities can be decreased resulting in improved health.
Skin diseases have a broad and burdensome impact on the health and well-being of people, and account for substantial health care costs to the individual as well as the nation but has been a low priority because of low mortality. The hot, humid climate, the proximity to forest which increases exposure to insects and the housing conditions may increase the susceptibility of tribal people to various skin diseases especially the infectious dermatoses.
But it has been seen that primary care providers who have not been specially trained might be unable to diagnose skin conditions correctly. Many skin diseases like leprosy and cutaneous leishmaniasis, if neglected and not adequately treated, can lead to complications that warrant costly and prolonged treatment. There are reports of many persons affected with cutaneous leishmaniasis being caused by Leishmania donovani (which is known to cause visceral leishmaniasis) from the Agasthyamala biosphere area. Hence early diagnosis of such diseases can be beneficial in providing appropriate intervention.
Training community health workers to detect and report skin disease is a sustainable method to reduce the burden due to skin diseases in the area and a convenient diagnostic algorithm could help them to achieve this in an effective manner.
Methods: The objectives of the study are to evaluate the diagnostic ability of a newly developed diagnostic algorithm along with flash cards, to be used by community health workers in detecting common skin diseases among tribal people, to provide structured training to the community health workers to diagnose some common skin diseases using the diagnostic algorithm and flash cards, and to find out the effectiveness of the training in changing their knowledge, attitude and practice related to common skin diseases in the study population and to find out the prevalence and domestic, socio-economic, and environmental factors associated with different types of skin diseases in the study population. It is planned as a community based cross sectional study with an educational intervention to the community health workers already catering to the study area. A diagnostic algorithm to be used by the community health workers to diagnose common skin diseases will be devised by literature review and this will be validated by experts in the field of dermatology. A pre-test questionnaire will be administered to the workers to assess their existing knowledge and ability to identify common skin conditions, prevalence of skin diseases in their area, attitude of the health worker towards skin diseases, their perception of the attitude of tribal people in their area towards skin diseases and the health care seeking behaviour of tribals in their area for skin conditions. A structured training will be given to about 20 community health workers in diagnosing common skin diseases with the help of the diagnostic algorithm and flash cards. A post test questionnaire will be administered to assess the change in the knowledge, attitude and practices of the health workers. Multi- stage sampling will be used to select 920 study participants from the designated tribal hamlets in the study area. The community health works and a panel of three dermatologists will independently look for and diagnose skin diseases in the study participants. The diagnostic accuracy of the community health worker administered algorithm based dermatological diagnosis with respect to selected individual skin diseases will be assessed in terms of its sensitivity, specificity, predictive values, and its likelihood ratios keeping dermatologist’s diagnosis as the reference standard. Change in knowledge, attitude and practice of the health workers will be assessed using paired t test /Wilcoxon signed rank test.
Discussion: Community health workers can be trained to detect common skin diseases sufficiently early so as to reduce the burden of skin diseases in the community and on the health care system.
Trial registration: Has applied for CTRI registration