Published in PLOS One on 2026-03-30, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Paul W. Warren, Scott Wirth, Jafesi Pulle, Doreen Nakaagayi, Charles Oyoo Akia, Evelyn Ayaa, Michaela Pardo, Francis Odong, Ronald Ogwanh, John Omagino, Isaac Otim, Craig Sable, Alison Spaziani, Henry Okello Otto, David Watkins, Emmy Okello, Kristen Danforth, Andrea Beaton
Source: PLOS One • DOI 10.1371/journal.pone.0344012
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Echocardiography screening for rheumatic heart disease (RHD) has gained support as a public health approach, but scale up of RHD screening services is complex. We sought to evaluate the effectiveness of a novel training program to build non-expert competency for RHD echocardiography screening within the Uganda public health system and to describe the human and material resources required to support it.
Guided by a logic model, we evaluated the Accelerating Delivery of Rheumatic Heart Disease Prevention in Northern Uganda (ADUNU) Program, a novel RHD control program, 15 months after its implementation within the Ugandan public health care system.
Sixty-one healthcare workers (HCW) across 10 public health facilities started in training under the program, of which 58 (95%) advanced past the initial stage of training and earned conditional certification to screen for RHD with ongoing remote and in-person feedback and oversight. Of these, 17 (29%) completed all stages of training and earned full certification to independently screen for RHD with no ongoing oversight. A total of 17,927 community members were screened through ADUNU during the program’s first 15 months. After receiving final certification, 14 HCWs (93%) continued to perform screening echocardiograms (≥20/month) at median follow-up of 8 months [IQR 8–10]. HCW sensitivity and specificity were 61% and 96%, respectively.
Development and deployment of a large scale RHD screening echocardiography training program within an existing public health system is feasible. Future program iterations are needed to improve HCW screening sensitivity and decrease the reliance on human resources.
Introduction
Echocardiography is a powerful tool for early rheumatic heart disease (RHD) detection [1–3]. While originally employed as epidemiological research, echocardiography screening for RHD has more recently gained support as a public health approach [4–6]. This shift resulted from a randomized controlled trial which found early diagnosis and initiation of secondary antibiotic prophylaxis significantly decreased the 2-year risk for RHD progression [7]. In 2023, the World Heart Federation (WHF) published updated guidance on echocardiographic screening for RHD in high-risk populations, and in 2024 the World Health Organization formally recommended countries implement screening, especially in high prevalence settings [1,8].
However, scale up of RHD screening services is complex, especially in resource-limited settings with low availability of subspecialty expertise and equipment [9]. Shifting the screening burden to a more readily available workforce through task-shifting presents an alternative solution. Training for task-shifting RHD screening has been proposed since at least 2015, but no standardized programs have emerged [10]. Most models have relied on training non-expert health care workers (often nurses), utilizing hand-held ultrasound machines [11–14], and performing simplified screening protocols to reduce time and complexity [15–17]. These approaches have shown acceptable sensitivity and specificity. However, most studies have involved a small number of non-expert providers, often in the context of an incentivized research study. With RHD screening now recommended as a public health approach, there is need for replicable training programs to support the scale-up of service provision [18].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider research & evidence desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Paul W. Warren, Scott Wirth, Jafesi Pulle, Doreen Nakaagayi, Charles Oyoo Akia, Evelyn Ayaa, Michaela Pardo, Francis Odong, Ronald Ogwanh, John Omagino, Isaac Otim, Craig Sable, Alison Spaziani, Henry Okello Otto, David Watkins, Emmy Okello, Kristen Danforth, Andrea Beaton. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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