Health worker factors associated with prescribing of artemisinin combination therapy for uncomplicated malaria in rural Tanzania

Simulated Malaria Online Tool: an instrument for evaluating healthcare providers' practices and contributing to the evidence base for certifying malaria elimination and preventing its re-establishment

BACKGROUND

Healthcare providers (HCPs) practice and correct management of suspected malaria (CMSM) are central components of malaria elimination and prevention of re-establishment (POR) in countries in the elimination phase. However, knowledge of malaria surveillance systems and HCPs practices often wanes in countries aiming to eliminate malaria due to the low numbers of cases. The study aimed to implement a valid Simulated Malaria Online Tool (SMOT) for assessment HCP performance in CMSM and POR in a malaria-free area.

METHODS

HCPs were evaluated using SMOT tool based on four criteria including presenting a suspected malaria case for detection of HCPs' failures in recognition (a), diagnosis (b), appropriate treatment (c), and urgent reporting (d); and compared with simulated patients (SP). Multiple logistic regression analysis was carried out to estimate adjusted odds ratios (ORs) for the risk of HCPs failures.

RESULTS

The overall failure proportion was 237 (83%), and the majority of failures were in recognition (a). There was no significant difference between the SMOT and SP based on all failure criteria (P > 0.05). The private clinic (93%) and the public specialized clinic (70%) had the highest and lowest failure proportions. After passing the recognition stage (a), the overall failure proportions decreased to 47.8% and 25.0% for total HCPs and infectious disease specialists, respectively. In the final analysis, private sector (AOR = 4.36: 1.25-15.2), not-specialist providers (AOR = 2.84: 1.29-6.25) and HCPs with ≥ 5 years' experience (AOR = 2.03: 1.01-6.25) increased the risk of failure.

CONCLUSION

Findings confirmed the implementation of SMOT tool in settings where malaria transmission is low or interrupted. The tool is able to identify sub-groups of providers needing strengthening, and contributes to the prevention of malaria re-establishment.

Malaria diagnostic and treatment practices for febrile children under 5 years at two general hospitals in Karamoja, a high transmission setting in Uganda

BACKGROUND

Malaria is one of the leading causes of morbidity and mortality among children under 5 years of age in Uganda. Although Karamoja sub-region has the highest prevalence of malaria, and one of the highest case fatality rates in children under 5 years, information on malaria case management for the sub-region is scarce. The study evaluated the malaria diagnostic and treatment practices, as well as the factors associated with inappropriate care for children under 5 years of age presenting with fever in two public hospitals within the sub-region.

METHODS

A cross-sectional study was conducted amongst 857 children under 5 years of age who presented with fever at Abim and Kaabong general hospitals between February and March 2020. A questionnaire was administered to the primary caregiver during exit/bedside interviews to collect socio-demographic information. The participant clinical notes were reviewed to capture information on laboratory tests conducted, diagnosis given, and treatment prescribed. In addition, a health facility assessment was conducted and information on healthcare workers was collected. The healthcare worker and facility data was linked to the participant's hospital visit. Main outcome measures were malaria diagnostic and treatment practices.

RESULTS

Of the 857 children enrolled, 820 (95.7%) had a malaria diagnostic test done and 623 (76.0%) tested positive for malaria. All test positive children received anti-malarial treatment, however, only 424/623 (68.1%) received the recommended anti-malarial drug and 376/424 (88.7%) received the right dose of the treatment. Inappropriate diagnosis/treatment was in 321 (37.5%) of the enrolled participants. Factors associated with inappropriate diagnosis/treatment included: lack of recommended anti-malarials on the day of the visit (Prevalence Ratio [PR] = 2.1, 95% confidence interval [CI] 1.8-2.4), hospital where care was sought (PR = 0.4, 95% CI 0.3-0.5), being managed by a recently supervised health worker (PR = 0.5, 95% CI 0.2-0.9), and health worker cadre (PR = 0.8, 95% CI 0.7-0.9).

CONCLUSION

The prevalence of inappropriate malaria diagnosis and treatment in the Karamoja sub-region was high with approximately one in every three children receiving inappropriate care. This was majorly influenced by health system factors, which if improved upon may reduce malaria-related mortalities in the sub-region a vital step in meeting the country's target of zero deaths from malaria by 2030.

Healthcare Professional Preferences for Prescribing Artemisinins and Quinine for Malaria in Burundi

Background

Malaria is a significant cause of morbidity and mortality throughout the world and particularly sub-Saharan Africa. The World Health Organization and many national bodies, including Burundi, recommend artemisinin-based therapy as first-line treatment for uncomplicated and severe malaria. Implementing this recommendation requires healthcare professionals' acceptance of this treatment as the optimal choice.

Methods

A survey was conducted among Burundian healthcare professionals from June to September 2017 to assess prescribing preferences regarding artemisinins versus quinine for treating malaria. Healthcare professionals were surveyed from 32 health facilities in 10 provinces. Respondents included both physicians and nurses who provided responses about their antimalarial treatment preferences for a variety of clinical scenarios. Comparisons among healthcare professionals, their level of training, work setting, and length of work experience were examined using a series of stratified analyses, where the Pearson Chi-square statistic and odds ratios with 95% confidence intervals were calculated.

Results

Respondents included 101 doctors and 196 nurses. Seventy-nine percent of respondents worked in hospitals, while 58% had more than 5 years of work experience. Although 94% of respondents correctly identified artemisinin-based treatment as first-line therapy according to the national protocol, 24-40% of respondents preferred the use of quinine in various hypothetical clinical scenarios. Overall, nurses were at greater odds of preferring quinine versus artemisinins compared with physicians. Availability of artemisinins was associated positively with artemisinin preference. These results did not vary by duration of work experience.

Conclusions

Though knowledge of artemisinin-based therapy was recognised by the majority of respondents as the recommended antimalarial treatment, a high proportion of Burundian healthcare professionals, especially nurses, prefer using oral and IV quinine in a number of clinical scenarios. These findings identify a significant barrier to the satisfactory implementation of a life-saving treatment in accordance with national and international recommendations.

Determinants of improvement trends in health workers' compliance with outpatient malaria case-management guidelines at health facilities with available "test and treat" commodities in Kenya

BACKGROUND

Health workers' compliance with outpatient malaria case-management guidelines has been improving in Africa. This study examined the factors associated with the improvements.

METHODS

Data from 11 national, cross-sectional health facility surveys undertaken from 2010-2016 were analysed. Association between 31 determinants and improvement trends in five outpatient compliance outcomes were examined using interactions between each determinant and time in multilevel logistic regression models and reported as an adjusted odds ratio of annual trends (T-aOR).

RESULTS

Among 9,173 febrile patients seen at 1,208 health facilities and by 1,538 health workers, a higher annual improvement trend in composite "test and treat" performance was associated with malaria endemicity-lake endemic (T-aOR = 1.67 annually; p<0.001) and highland epidemic (T-aOR = 1.35; p<0.001) zones compared to low-risk zone; with facilities stocking rapid diagnostic tests only (T-aOR = 1.49; p<0.001) compared to microscopy only services; with faith-based/non-governmental facilities compared to government-owned (T-aOR = 1.15; p = 0.036); with a daily caseload of >25 febrile patients (T-aOR = 1.46; p = 0.003); and with under-five children compared to older patients (T-aOR = 1.07; p = 0.013). Other factors associated with the improvement trends in the "test and treat" policy components and artemether-lumefantrine administration at the facility included the absence of previous RDT stock-outs, community health workers dispensing drugs, access to malaria case-management and Integrated Management of Childhood Illness (IMCI) guidelines, health workers' gender, correct health workers' knowledge about the targeted malaria treatment policy, and patients' main complaint of fever. The odds of compliance at the baseline were variable for some of the factors.

CONCLUSIONS

Targeting of low malaria risk areas, low caseload facilities, male and government health workers, continuous availability of RDTs, improving health workers' knowledge about the policy considering age and fever, and dissemination of guidelines might improve compliance with malaria guidelines. For prompt treatment and administration of the first artemether-lumefantrine dose at the facility, task-shifting duties to community health workers can be considered.

Malaria Test, Treat and Track policy implementation in Angola: a retrospective study to assess the progress achieved after 4 years of programme implementation

Background

Malaria is one of the main causes of death in Angola, particularly among children under 5 years of age. An essential means to improve the situation is with strong malaria case management; this includes diagnosing suspected patients with a confirmatory test, either with a rapid diagnostic test (RDT) or microscopy, prompt and correct treatment with artemisinin-based combination therapy (ACT), and proper case registration (track). In 2011, the United States President’s Malaria Initiative (PMI) launched a country-wide programme to improve malaria case management through the provision of regular training and supervision at different levels of health care provision. An evaluation of malaria testing, treatment and registration practices in eight provinces, and at health facilities of various capacities, across Angola was conducted to assess progress of the national programme implementation.

Methods

A retrospective assessment analysed data collected during supervision visits to health facilities conducted between 2012 and 2016 in 8 provinces in Angola. The supervision tool used data collected for malaria knowledge, testing, treatment and case registration practices among health workers as well as health facilities stock outs from different levels of health care delivery. Contingency tables with Pearson chi-squared (χ²) tests were used to identify factors associated with “knowledge”, “test”, “treat” and “track.” Multivariable logistic regression models were used to assess factors associated with the defined outcomes.

Results

A total of 7156 supervisions were conducted between September 2012 and July 2016. The overall knowledge, testing, treatment and tracking practices among health care workers (HCWs) increased significantly from 2013 to 2016. Health care workers in 2016 were 3.3 times (95% CI: 2.7–3.9) as likely to have a higher knowledge about malaria case management as in 2013 (p < 0.01), 7.4 (95% CI: 6.1–9.0) times as likely to test more suspected cases (p < 0.01), 10.9 (95% CI: 8.6–13.6) times as likely to treat more confirmed cases (p < 0.01) and 3.7 (95% CI: 3.2–4.4) times as likely to report more accurately in the same period (p < 0.01).

Discussion

Improvements demonstrated in knowledge about malaria case management, testing with RDT and treatment with artemisinin-based combinations among HCWs is likely associated with malaria case management trainings and supportive supervisions. Gaps in testing and treatment practices are associated with RDT and ACT medicines stock outs in health facilities. Tracking of malaria cases still poses a major challenge, despite training and supervision. Hospitals consistently performed better compared to other health facilities against all parameters assessed; likely due to a better profile of HCWs.

Conclusion

Significant progress in malaria case management in eight provinces Angola was achieved in the period of 2013–2016. Continued training and supportive supervision is essential to sustain gains and close existing gaps in malaria case management and reporting in Angola.

Examining which clinicians provide admission hospital care in a high mortality setting and their adherence to guidelines: an observational study in 13 hospitals

BACKGROUND

We explored who actually provides most admission care in hospitals offering supervised experiential training to graduating clinicians in a high mortality setting where practices deviate from guideline recommendations.

METHODS

We used a large observational data set from 13 Kenyan county hospitals from November 2015 through November 2018 where patients were linked to admitting clinicians. We explored guideline adherence after creating a cumulative correctness of Paediatric Admission Quality of Care (cPAQC) score on a 5-point scale (0-4) in which points represent correct, sequential progress in providing care perfectly adherent to guidelines comprising admission assessment, diagnosis and treatment. At the point where guideline adherence declined the most we dichotomised the cPAQC score and used multilevel logistic regression models to explore whether clinician and patient-level factors influence adherence.

RESULTS

There were 1489 clinicians who could be linked to 53 003 patients over a period of 3 years. Patients were rarely admitted by fully qualified clinicians and predominantly by preregistration medical officer interns (MOI, 46%) and diploma level clinical officer interns (COI, 41%) with a median of 28 MOI (range 11-68) and 52 COI (range 5-160) offering care per study hospital. The cPAQC scores suggest that perfect guideline adherence is found in ≤12% of children with malaria, pneumonia or diarrhoea with dehydration. MOIs were more adherent to guidelines than COI (adjusted OR 1.19 (95% CI 1.07 to 1.34)) but multimorbidity was significantly associated with lower guideline adherence.

CONCLUSION

Over 85% of admissions to hospitals in high mortality settings that offer experiential training in Kenya are conducted by preregistration clinicians. Clinical assessment is good but classifying severity of illness in accordance with guideline recommendations is a challenge. Adherence by MOI with 6 years' training is better than COI with 3 years' training, performance does not seem to improve during their 3 months of paediatric rotations.

Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa

BACKGROUND

There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given.

METHODS

Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007-2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones.

RESULTS

Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of < 5-year-olds not prescribed ACT ranged up to 41.8% across sites. The odds of not being prescribed an ACT were 2-32 times higher for patients in settings with lower-transmission intensity (using test positivity as a proxy) compared to areas of higher transmission. mRDT-positive children in low-transmission settings were especially likely not to be prescribed ACT, with proportions untreated up to 70%. Of the 7426 mRDT-positive patients not prescribed an ACT, 4121 (55.5%) were prescribed other, non-recommended non-ACT antimalarial medications, and the remainder (44.5%) were prescribed no antimalarial.

CONCLUSIONS

In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children < 5 years and those in low-transmission settings, were most likely to not be prescribed antimalarials, and young children in low-transmission settings were least likely to be treated for malaria. This major public health risk must be addressed in training and practice.

TRIAL REGISTRATION

Reported in individual primary studies.

Extent of inappropriate prescription of artemisinin and anti-malarial injections to febrile outpatients, a cross-sectional analytic survey in the Greater Accra region, Ghana

BACKGROUND

Febrile children seen in malaria hypo-endemic settings, such as the Greater Accra region (GAR) of Ghana are more likely to be suffering from a non-malarial febrile illness compared to those seen in hyper-endemic settings. The need for prescribers to rely on malaria test results to guide treatment practices in the GAR is even greater. This study was designed to investigate the factors associated with inappropriate artemisinin-based combination therapy (ACT) prescription.

METHODS

A survey was conducted in six health facilities in the region in 2015. Treatment practices for febrile outpatient department (OPD) patients were obtained from their records. Prescribers were interviewed and availability of malaria commodities were assessed. The primary outcome was the proportion of patients prescribed ACT inappropriately. Independent variables included patient age and access to care, prescriber factors (professional category, work experience, access to guidelines, exposure to training). Data were analysed using Stata at 95% CI (α-value of 0.05). Frequencies and means were used to describe the characteristics of patients and prescribers. To identify the predictors of inappropriate ACT prescription, regression analyses were performed accounting for clustering.

RESULTS

Overall, 2519 febrile OPD records were analysed; 45.6% (n = 1149) were younger than 5 years. Only 40.0% of patients were tested. The proportion of patients who were prescribed ACT inappropriately was 76.4% (n = 791 of 1036). Of these 791 patients, 141 (17.8%) were prescribed anti-malarial injections. Patients seen in facilities with rapid diagnostic tests (RDT) in stock were less likely to be prescribed ACT inappropriately, (AOR: 0.04, 95% CI 0.01-0.14, p < 0.001) compared to those seen in facilities with RDT stock-outs. Prescribers who had been trained on malaria case management within the past year were 4 times more likely to prescribe ACT inappropriately compared to those who had not been trained (AOR: 4.1; 95% CI (1.5-11.6); p < 0.01). Patients seen by prescribers who had been supervised were 8 times more likely to be  prescribed ACT inappropriately.

CONCLUSION

Inappropriate ACT prescription to OPD febrile cases was high. Training and supervision of health workers appears not to be yielding the desired outcomes. Further research is needed to understand this observation.

Improving quality of care for maternal and newborn health: a pre-post evaluation of the Safe Childbirth Checklist at a hospital in Bangladesh

BACKGROUND

Bangladesh has achieved major gains in maternal and newborn survival, facility childbirth and skilled birth attendance between 1991 and 2010, but excess maternal mortality persists. High-quality maternal health care is necessary to address this burden. Implementation of WHO Safe Childbirth Checklist (SCC), whose items address the major causes of maternal deaths, is hypothesized to improve adherence of providers to essential childbirth practices.

METHOD

The SCC was adapted for the local context through expert consultation meetings, creating a total of 27 checklist items. This study was a pre-post evaluation of SCC implementation. Data were collected over 8 months at Magura District Hospital. We analysed 468 direct observations of birth (main analysis using 310 complete observations and sensitivity analysis with the additional 158 incomplete observations) from admission to discharge. The primary outcome of interest was the number of essential childbirth practices performed before compared to after SCC implementation. The change was assessed using adjusted Poisson regression models accounting for clustering by nurse-midwives.

RESULT

After checklist introduction, significant improvements were observed: on average, around 70% more of these safe childbirth practices were performed in the follow-up period compared to baseline (from 11 to 19 out of 27 practices). Substantial increases were seen in communication between nurse-midwives and mothers (counselling), and in management of complications (including rational use of medicines). In multivariable models that included characteristics of the mothers and of the nurse-midwives, the rate of delivering the essential childbirth practices was 1.71 times greater in the follow-up compared to baseline (95% CI 1.61-1.81).

CONCLUSION

Implementation of SCC has the potential to improve essential childbirth practice in resource-poor settings like Bangladesh. This study emphasizes the need for health system strengthening in order to achieve the full advantages of SCC implementation.

Health Worker Compliance with a 'Test And Treat' Malaria Case Management Protocol in Papua New Guinea

The Papua New Guinea (PNG) Department of Health introduced a ‘test and treat’ malaria case management protocol in 2011. This study assesses health worker compliance with the test and treat protocol on a wide range of measures, examines self-reported barriers to health worker compliance as well as health worker attitudes towards the test and treat protocol. Data were collected by cross-sectional survey conducted in randomly selected primary health care facilities in 2012 and repeated in 2014. The combined survey data included passive observation of current or recently febrile patients (N = 771) and interviewer administered questionnaires completed with health workers (N = 265). Across the two surveys, 77.6% of patients were tested for malaria infection by rapid diagnostic test (RDT) or microscopy, 65.6% of confirmed malaria cases were prescribed the correct antimalarials and 15.3% of febrile patients who tested negative for malaria infection were incorrectly prescribed an antimalarial. Overall compliance with a strictly defined test and treat protocol was 62.8%. A reluctance to test current/recently febrile patients for malaria infection by RDT or microscopy in the absence of acute malaria symptoms, reserving recommended antimalarials for confirmed malaria cases only and choosing to clinically diagnose a malaria infection, despite a negative RDT result were the most frequently reported barriers to protocol compliance. Attitudinal support for the test and treat protocol, as assessed by a nine-item measure, improved across time. In conclusion, health worker compliance with the full test and treat malaria protocol requires improvement in PNG and additional health worker support will likely be required to achieve this. The broader evidence base would suggest any such support should be delivered over a longer period of time, be multi-dimensional and multi-modal.

Association between sociodemographic characteristics of female community health volunteers and their knowledge and performance on maternal and child health services in rural Nepal

Background

Engaging community health volunteers and community health workers to provide maternal and child health (MCH) care services in resource-poor settings is one of the global and widely used concepts. Despite a great role of female community health volunteers (FCHVs) in MCH services in Nepal, few research studies have been performed in this area. Our research aimed to assess the knowledge and performance of FCHVs on MCH services associated with their sociodemographic characteristics.

Methods

A cross-sectional survey was conducted to assess the knowledge and performance on selected MCH services of FCHVs using structured questionnaire in 16 village development committees of Dhanusha district, Southern Terai, Nepal, from the first of January to the end of February of 2014. A total of 138 FCHVs were selected by using multistage random sampling technique. Logistic regression was employed to examine the association between selected sociodemographic characteristics and knowledge and performance on MCH services of FCHVs after adjusting for significant variables associated with knowledge and performance and within-cluster effect.

Results

Our findings demonstrated that sociodemographic characteristics were associated independently with good knowledge of FCHVs on MCH services: education level secondary and above (adjusted odds ratio [aOR] 5.2; 95% confidence interval [CI] 2.2–12.2); residing in Mother and Infant Research Activities, nongovernmental organization working area (aOR 3.7; 95% CI 1.5–8.8); and middle caste (aOR 3.3; 95% CI 1.0–10.3). Similarly, satisfactory performance of FCHVs significantly associated with MCH services were education level secondary and above (aOR 8.9; 95% CI 3.2–24.3) and residing in Mother and Infant Research Activities working areas (aOR 9.0; 95% CI 3.5–22.6).

Conclusion

The study recommends considering education level while recruiting rural FCHVs and capacity enhancement through additional training and development programs in collaboration with developmental partner.

Health workers' compliance to rapid diagnostic tests (RDTs) to guide malaria treatment: a systematic review and meta-analysis

Background

The World Health Organization recommends malaria to be confirmed by either microscopy or a rapid diagnostic test (RDT) before treatment. The correct use of RDTs in resource-limited settings facilitates basing treatment onto a confirmed diagnosis; contributes to speeding up considering a correct alternative diagnosis, and prevents overprescription of anti-malarial drugs, reduces costs and avoids unnecessary exposure to adverse drug effects. This review aims to evaluate health workers’ compliance to RDT results and factors contributing to compliance.

Methods

A PROSPERO-registered systematic review was conducted to evaluate health workers’ compliance to RDTs in sub-Saharan Africa, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published up to November 2015 were searched without language restrictions in Medline/Ovid, Embase, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, Biosis Previews and the African Index Medicus. The primary outcome was health workers treating patients according to the RDT results obtained.

Results

The literature search identified 474 reports; 14 studies were eligible and included in the quantitative analysis. From the meta-analysis, health workers’ overall compliance in terms of initiating treatment or not in accordance with the respective RDT results was 83 % (95 % CI 80–86 %). Compliance to positive and negative results was 97 % (95 % CI 94–99 %) and 78 % (95 % CI 66–89 %), respectively. Community health workers had higher compliance rates to negative test results than clinicians. Patient expectations, work experience, scepticism of results, health workers’ cadres and perceived effectiveness of the test, influenced compliance.

Conclusions

With regard to published data, compliance to RDT appears to be generally fair in sub-Saharan Africa; compliance to negative results will need to improve to prevent mismanagement of patients and overprescribing of anti-malarial drugs. Improving diagnostic capacity for other febrile illnesses and developing local evidence-based guidelines may help improve compliance and management of negative RDT results.

Trial registration: CRD42015016151 (PROSPERO)

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1218-5) contains supplementary material, which is available to authorized users.

Factors affecting adherence to national malaria treatment guidelines in management of malaria among public healthcare workers in Kamuli District, Uganda

Background

Malaria remains a major public health threat accounting for 30.4 % of disease morbidity in outpatient clinic visits across all age groups in Uganda. Consequently, malaria control remains a major public health priority in endemic countries such as Uganda. Experiences from other countries in Africa that revised their malaria case management suggest that health workers adherence may be problematic.

Methods

A descriptive, cross-sectional design was used and collected information on health system, health workers and patients. Using log-binomial regression model, adjusted prevalence risk ratios (PRRs) and their associated 95 % confidence intervals were determined in line with adherence to new treatment guidelines of parasitological diagnosis and prompt treatment with artemisinin combination therapy (ACT).

Results

Nine health centres, 24 health workers and 240 patient consultations were evaluated. Overall adherence to national malaria treatment guidelines (NMTG) was 50.6 % (122/241). It was significantly high at HC III [115 (53 %)] than at HC IV (29 %) [PRR = 0.28 (95 % CI 0.148 0.52), p = 0.000]. Compared to the nursing aide, the adherence level was 1.57 times higher among enrolled nurses (p = 0.004) and 1.68 times higher among nursing officers, p = 0.238, with statistical significance among the former. No attendance of facility malaria-specific continuing medical education (CME) sessions [PRR = 1.9 (95 % CI 1.29 2.78), p = 0.001] and no display of malaria treatment job aides in consultation rooms [PRR = 0.64 (95 % CI 0.4 1.03), p = 0.07] was associated with increased adherence to guidelines with the former showing a statistical significance and the association of the latter borderline statistical significance. The adherence was higher when the laboratory was functional [PRR = 0.47 (95 % CI 0.35 0.63)] when the laboratory was functional in previous 6 months. Age of health worker, duration of employment, supervision, educational level, and age of patient were found not associated with adherence to new treatment guidelines.

Conclusion

Adherence to malaria treatment guidelines in Uganda is sub-optimal. There is an urgent need for deliberate interventions to improve adherence to these guidelines. Possible interventions to be explored should include: provision of job aides and improved access to laboratory services. There is also a need for continuous medical educational sessions for health workers, especially those at higher-level facilities and higher cadres, on adherence to guidelines in management of fever, including management of other causes of fever.

Provider compliance to artemisinin-based combination therapy at primary health care facilities in the middle belt of Ghana

BACKGROUND

In 2004, Ghana implemented the artemisinin-based combination therapy (ACT) policy. Health worker (HW) adherence to the national malaria guidelines on case-management with ACT for children below 5 years of age and older patients presenting at health facilities (HF) for primary illness consultations was evaluated 5 years post-ACT policy change.

METHODS

Cross-sectional surveys were conducted from 2010 to 2011 at HFs that provide curative care as part of outpatient activities in two districts located in the middle belt of Ghana to coincide with the periods of low and high malaria transmission seasons. A review of patient medical records, HW interviews, HF inventories and finger-pricked blood obtained for independent malaria microscopy were used to assess HW practices on malaria case-management.

RESULTS

Data from 130 HW interviews, 769 patient medical records at 20 HFs over 75 survey days were individually linked and evaluated. The majority of consultations were performed at health centres/clinics (68.3 %) by medical assistants (28.6 %) and nurse aids (23.5 %). About 68.4 % of HWs had received ACT-specific training and 51.9 %, supervisory visits in the preceding 6 months. Despite the availability of malaria diagnostic test at most HFs (94 %), only 39.8 % (241) out of 605 (78.7 %) patients who reported fever were investigated for malaria. Treatment with ACT in line with the guidelines was 66.7 %; higher in <5 children compared to patients ≥5 years old. Judged against reference microscopy, only 44.8 % (107/239) of ACT prescriptions that conformed to the guidelines were "truly malaria". Multivariate logistic regression analysis showed that HW were significantly more likely to comply with the guidelines if treatment were by low cadre of health staff, were for children below 5 years of age, and malaria test was performed.

CONCLUSION

Although the majority of patients presenting with malaria received treatment according to the national malaria guidelines, there were widespread inappropriate treatment with ACT. Compliance with the guidelines on ACT use was low, 5 years post-ACT policy change. The Ghana NMCP needs to strengthen HW capacity on malaria case-management through regular training supported by effective laboratory quality control measures.

Predictors of health worker performance after Integrated Management of Childhood Illness training in Benin: a cohort study

Background

Correct treatment of potentially life-threatening illnesses (PLTIs) in children under 5 years, such as malaria, pneumonia, and diarrhea, can substantially reduce mortality. The Integrated Management of Childhood Illness (IMCI) strategy has been shown to improve treatment of child illnesses, but multiple studies have shown that gaps in health worker performance remain after training. To better understand factors related to health worker performance, we analyzed 9,330 patient consultations in Benin from 2001–2002, after training one of the first cohorts of 32 health workers in IMCI.

Methods

With data abstracted from patient registers specially designed for IMCI-trained health workers, we examined associations between health facility-, health worker-, and patient-level factors and 10 case-management outcomes for PLTIs.

Results

Altogether, 63.6 % of children received treatment for all their PLTIs in accordance with IMCI guidelines, and 77.8 % received life-saving treatment (i.e., clinically effective treatment, even if not exactly in accordance with IMCI guidelines). Performance of individual health workers varied greatly, from 15–88 % of patients treated correctly, on average. Multivariate regression analyses identified several factors that might have influenced case-management quality, many outside a manager’s direct control. Younger health workers significantly outperformed older ones, and infants received better care than older children. Children with danger signs, those with more complex illnesses, and those with anemia received worse care. Health worker supervision was associated with improved performance for some outcomes.

Conclusions

A variety of factors, some outside the direct control of program managers, can influence health worker practices. An understanding of these influences can help inform the development of strategies to improve performance.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0910-4) contains supplementary material, which is available to authorized users.

Health & Demographic Surveillance System Profile: The Ifakara Rural and Urban Health and Demographic Surveillance System (Ifakara HDSS)

The Ifakara Rural HDSS (125,000 people) was set up in 1996 for a trial of the effectiveness of social marketing of bed nets on morbidity and mortality of children aged under 5 years, whereas the Ifakara Urban HDSS (45,000 people) since 2007 has provided demographic indicators for a typical small urban centre setting. Jointly they form the Ifakara HDSS (IHDSS), located in the Kilombero valley in south-east Tanzania. Socio-demographic data are collected twice a year. Current malaria work focuses on phase IV studies for antimalarials and on determinants of fine-scale variation of pathogen transmission risk, to inform malaria elimination strategies. The IHDSS is also used to describe the epidemiology and health system aspects of maternal, neonatal and child health and for intervention trials at individual and health systems levels. More recently, IHDSS researchers have studied epidemiology, health-seeking and national programme effectiveness for chronic health problems of adults and older people, including for HIV, tuberculosis and non-communicable diseases. A focus on understanding vulnerability and designing methods to enhance equity in access to services are cross-cutting themes in our work. Unrestricted access to core IHDSS data is in preparation, through INDEPTH iSHARE [www.indepth-ishare.org] and the IHI data portal [http://data.ihi.or.tz/index.php/catalog/central].

Patient-, health worker-, and health facility-level determinants of correct malaria case management at publicly funded health facilities in Malawi: results from a nationally representative health facility survey

Background

Prompt and effective case management is needed to reduce malaria morbidity and mortality. However, malaria diagnosis and treatment is a multistep process that remains problematic in many settings, resulting in missed opportunities for effective treatment as well as overtreatment of patients without malaria.

Methods

Prior to the widespread roll-out of malaria rapid diagnostic tests (RDTs) in late 2011, a national, cross-sectional, complex-sample, health facility survey was conducted in Malawi to assess patient-, health worker-, and health facility-level factors associated with malaria case management quality using multivariate Poisson regression models.

Results

Among the 2,019 patients surveyed, 34% had confirmed malaria defined as presence of fever and parasitaemia on a reference blood smear. Sixty-seven per cent of patients with confirmed malaria were correctly prescribed the first-line anti-malarial, with most cases of incorrect treatment due to missed diagnosis; 31% of patients without confirmed malaria were overtreated with an anti-malarial. More than one-quarter of patients were not assessed for fever or history of fever by health workers. The most important determinants of correct malaria case management were patient-level clinical symptoms, such as spontaneous complaint of fever to health workers, which increased both correct treatment and overtreatment by 72 and 210%, respectively (p < 0.0001). Complaint of cough was associated with a 27% decreased likelihood of correct malaria treatment (p = 0.001). Lower-level cadres of health workers were more likely to prescribe anti-malarials for patients, increasing the likelihood of both correct treatment and overtreatment, but no other health worker or health facility-level factors were significantly associated with case management quality.

Conclusions

Introduction of RDTs holds potential to improve malaria case management in Malawi, but health workers must systematically assess all patients for fever, and then test and treat accordingly, otherwise, malaria control programmes might miss an opportunity to dramatically improve malaria case management, despite better diagnostic tools.