Summary Background Health workers' malaria case-management practices often differ from national guidelines. We assessed whether text-message reminders sent to health workers' mobile phones could ...improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya. Methods From March 6, 2009, to May 31, 2010, we did a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. With a computer-generated sequence, health facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for 6 months, or the control group, in which health workers did not receive any text messages. Health workers were not masked to the intervention, although patients were unaware of whether they were in an intervention or control facility. The primary outcome was correct management with artemether-lumefantrine, defined as a dichotomous composite indicator of treatment, dispensing, and counselling tasks concordant with Kenyan national guidelines. The primary analysis was by intention to treat. The trial is registered with Current Controlled Trials, ISRCTN72328636. Findings 119 health workers received the intervention. Case-management practices were assessed for 2269 children who needed treatment (1157 in the intervention group and 1112 in the control group). Intention-to-treat analysis showed that correct artemether-lumefantrine management improved by 23·7 percentage-points (95% CI 7·6–40·0; p=0·004) immediately after intervention and by 24·5 percentage-points (8·1–41·0; p=0·003) 6 months later. Interpretation In resource-limited settings, malaria control programmes should consider use of text messaging to improve health workers' case-management practices. Funding The Wellcome Trust.
Change of Kenyan treatment policy for uncomplicated malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine (AL) was accompanied by revised recommendations promoting presumptive malaria ...diagnosis in young children and, wherever possible, parasitological diagnosis and adherence to test results in older children and adults. Three years after the policy implementation, health workers' adherence to malaria diagnosis and treatment recommendations was evaluated.
A national cross-sectional, cluster sample survey was undertaken at public health facilities. Data were collected using quality-of-care assessment methods. Analysis was restricted to facilities with AL in stock. Main outcomes were diagnosis and treatment practices for febrile outpatients stratified by age, availability of diagnostics, use of malaria diagnostic tests, and test result.
The analysis included 1,096 febrile patients (567 aged <5 years and 529 aged ≥5 years) at 88 facilities with malaria diagnostics, and 880 febrile patients (407 aged <5 years and 473 aged ≥5 years) at 71 facilities without malaria diagnostic capacity. At all facilities, 19.8% of young children and 28.7% of patients aged ≥5 years were tested, while at facilities with diagnostics, 33.5% and 53.7% were respectively tested in each age group. Overall, AL was prescribed for 63.6% of children aged <5 years and for 65.0% of patients aged ≥5 years, while amodiaquine or sulphadoxine-pyrimethamine monotherapies were prescribed for only 2.0% of children and 3.9% of older children and adults. In children aged <5 years, AL was prescribed for 74.7% of test positive, 40.4% of test negative and 60.7% of patients without test performed. In patients aged ≥5 years, AL was prescribed for 86.7% of test positive, 32.8% of test negative and 58.0% of patients without test performed. At least one anti-malarial treatment was prescribed for 56.6% of children and 50.4% of patients aged ≥5 years with a negative test result.
Overall, malaria testing rates were low and, despite different age-specific recommendations, only moderate differences in testing rates between the two age groups were observed at facilities with available diagnostics. In both age groups, AL use prevailed, and prior ineffective anti-malarial treatments were nearly non-existent. The large majority of test positive patients were treated with recommended AL; however, anti-malarial treatments for test negative patients were widespread, with AL being the dominant choice. Recent change of diagnostic policy to universal testing in Kenya is an opportunity to improve upon the quality of malaria case management. This will be, however, dependent upon the delivery of a comprehensive case management package including large scale deployment of diagnostics, good quality of training, post-training follow-up, structured supervisory visits, and more intense monitoring.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Dejan Zurovac and colleagues discuss six areas where text messaging could improve the delivery of health services and health outcomes in malaria in Africa.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Health workers' compliance with outpatient malaria case-management guidelines has been improving in Africa. This study examined the factors associated with the improvements.
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).
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.
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.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Nonadherence to national standards for malaria diagnosis and treatment has been reported in Sudan. In this study, qualitative research examined the clinical domains of nonadherence, factors ...influencing nonadherent practices and health workers' views on how to improve adherence.
In September 2023, five Focus Group Discussions (FGDs) were undertaken with 104 health workers from 42 health facilities in Sudan's Northern State. The participants included medical assistants, doctors, nurses, laboratory personnel, pharmacists and public health officers. The FGDs followed a semi-structured guide reflecting the national malaria case management protocol. Qualitative thematic analysis was performed.
Nonadherent practices included disregarding parasitological test results, suboptimal paediatric artemether-lumefantrine (AL) dosing, lack of counselling, use of prohibited artemether injections for uncomplicated and severe malaria, artesunate dose approximations and suboptimal preparations, lack of AL follow on treatment for severe malaria; and rare use of primaquine for radical Plasmodium vivax treatment and dihydroartemisinin-piperaquine as the second-line treatment for uncomplicated malaria. Factors influencing nonadherence included stock-outs of anti-malarials and RDTs; staff shortages; lack of training, job aids and supervision; malpractice by specialists; distrust of malaria microscopy and RDTs; and patient pressure for diagnosis and treatment. Health workers recommended strengthening the supply chain; hiring personnel; providing in-service protocol training including specialists; establishing external quality assurance for malaria diagnosis; and providing onsite supportive supervision and public health campaigns.
This study revealed a broad spectrum of behavioural and systemic challenges in malaria management among frontline health workers in Northern Sudan, including nonadherence to protocols due to resource shortages, training gaps, a lack of supportive supervision and patient pressure. These insights, including health workers' views about improvements, will inform evidence-based interventions by Sudan's National Malaria Control Programme to improve health systems readiness and the quality of malaria case management.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Background
Despite several efforts at addressing the barriers to adherence to the WHO-supported test, treat and track (T3) malaria case management guideline in Ghana, adherence remains a ...challenge. This study explored the challenges of prescribers regarding adherence to the T3 guideline.
Methods
This was an explorative study using key informant interviews amongst prescribers comprising medical doctors, physician assistants, nurses and a health extension worker from 16 health facilities in six districts in Ghana. The data was analysed using Nvivo 10 and organized into thematic areas.
Results
Prescribers lauded the guideline on testing and treatment as it ensures the quality of malaria case management, but irregular supply of malaria rapid diagnostic test kits (RDT), mistrust of laboratory tests, and the reluctance of prescribers to change from presumptive treatment were key barriers to testing. Patients with malaria test negative results if not treated, revisiting the facility with severe malaria, the experience of prescribers, lack of regular training and supervision for old and new staff and the inability of prescribers to investigate non-malaria fever hindered adherence to results-based treatment.
Conclusion
As malaria remains a significant cause of morbidity and mortality in Ghana, this study provides insights on gaps in adherence to the testing and treatment of malaria. While the diagnostic capacity for malaria case management is a challenge, the lack of training resulting in the inability of some prescribers to investigate non-malaria fever hinders adherence to the malaria case management guideline. Therefore, there is a need to train new prescribers, laboratory personnel, and other staff involved in malaria diagnosis and treatment on the malaria case management guideline before they assume duty. Equipping laboratory personnel and prescribers with the knowledge to investigate non-malaria fevers could improve adherence to the guideline for improved patient care.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The growth of Information and Communication Technology in Kenya has facilitated implementation of a large number of eHealth projects in a bid to cost-effectively address health and health system ...challenges. This systematic review aims to provide a situational analysis of eHealth initiatives being implemented in Kenya, including an assessment of the areas of focus and geographic distribution of the health projects. The search strategy involved peer and non-peer reviewed sources of relevant information relating to projects under implementation in Kenya. The projects were examined based on strategic area of implementation, health purpose and focus, geographic location, evaluation status and thematic area.
A total of 114 citations comprising 69 eHealth projects fulfilled the inclusion criteria. The eHealth projects included 47 mHealth projects, 9 health information system projects, 8 eLearning projects and 5 telemedicine projects. In terms of projects geographical distribution, 24 were executed in Nairobi whilst 15 were designed to have a national coverage but only 3 were scaled up. In terms of health focus, 19 projects were mainly on primary care, 17 on HIV/AIDS and 11 on maternal and child health (MNCH). Only 8 projects were rigorously evaluated under randomized control trials.
This review discovered that there is a myriad of eHealth projects being implemented in Kenya, mainly in the mHealth strategic area and focusing mostly on primary care and HIV/AIDs. Based on our analysis, most of the projects were rarely evaluated. In addition, few projects are implemented in marginalised areas and least urbanized counties with more health care needs, notwithstanding the fact that adoption of information and communication technology should aim to improve health equity (i.e. improve access to health care particularly in remote parts of the country in order to reduce geographical inequities) and contribute to overall health systems strengthening.
Health workers' compliance with outpatient malaria case-management guidelines has been improving, specifically regarding the universal testing of suspected cases and the use of artemisinin-based ...combination therapy (ACT) only for positive results (i.e., 'test and treat'). Whether the improvements in compliance with 'test and treat' guidelines are consistent across different malaria endemicity areas has not been examined.
Data from 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 were analysed. Four primary indicators (i.e., 'test and treat') and eight secondary indicators of artemether-lumefantrine (AL) dosing, dispensing, and counselling were measured. Mixed logistic regression models were used to analyse the annual trends in compliance with the indicators across the different malaria endemicity areas (i.e., from highest to lowest risk being lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission, and low risk).
Compliance with all four 'test and treat' indicators significantly increased in the area with the highest malaria risk (i.e., lake endemic) as follows: testing of febrile patients (OR = 1.71 annually; 95% CI = 1.51-1.93), AL treatment for test-positive patients (OR = 1.56; 95% CI = 1.26-1.92), no anti-malarial for test-negative patients (OR = 2.04; 95% CI = 1.65-2.54), and composite 'test and treat' compliance (OR = 1.80; 95% CI = 1.61-2.01). In the low risk areas, only compliance with test-negative results significantly increased (OR = 2.27; 95% CI = 1.61-3.19) while testing of febrile patients showed declining trends (OR = 0.89; 95% CI = 0.79-1.01). Administration of the first AL dose at the facility significantly increased in the areas of lake endemic (OR = 2.33; 95% CI = 1.76-3.10), coast endemic (OR = 5.02; 95% CI = 2.77-9.09) and semi-arid seasonal transmission (OR = 1.44; 95% CI = 1.02-2.04). In areas of the lowest risk of transmission and highland epidemic zone, none of the AL dosing, dispensing, and counselling tasks significantly changed over time.
There is variability in health workers' compliance with outpatient malaria case-management guidelines across different malaria-risk areas in Kenya. Major improvements in areas of the highest risk have not been seen in low-risk areas. Interventions to improve practices should be targeted geographically.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Health workers' compliance with outpatient malaria 'test and treat' guidelines has improved since 2010 but plateaued from 2014 at suboptimal levels in Kenya. This study examined the factors ...associated with high but suboptimal compliance levels at facilities with available malaria tests and drugs.
Data from four national, cross-sectional health facility surveys undertaken between 2014 and 2016 in Kenya were analysed. Association between 31 factors and compliance with malaria testing (survey range (SR): 65-69%) and no anti-malarial treatment for test negative patients (SR: 90-92%) were examined using multilevel logistic regression models.
A total of 2,752 febrile patients seen by 594 health workers at 486 health facilities were analysed. Higher odds of malaria testing were associated with lake endemic (aOR = 12.12; 95% CI: 5.3-27.6), highland epidemic (aOR = 5.06; 95% CI: 2.7-9.5) and semi-arid seasonal (aOR = 2.07; 95% CI: 1.2-3.6) compared to low risk areas; faith-based (FBO)/ non-governmental organization (NGO)-owned compared to government-owned facilities (aOR = 5.80; 95% CI: 3.2-10.6); health workers' perception of malaria endemicity as high-risk (aOR = 3.05; 95% CI: 1.8-5.2); supervision with feedback (aOR = 1.84; 95% CI: 1.2-2.9); access to guidelines (aOR = 1.96; 95% CI: 1.1-3.4); older patients compared to infants, higher temperature measurements and main complaints of fever, diarrhoea, headache, vomiting and chills. Lower odds of testing were associated with febrile patients having main complaints of a cough (aOR = 0.65; 95% CI: 0.5-0.9), a rash (aOR = 0.32; 95% CI: 0.2-0.7) or a running nose (aOR = 0.59; 95% CI: 0.4-0.9). Other factors associated with compliance with test negative results included the type of diagnostic test available at the facility, in-service training, health workers' age, and correct knowledge of the targeted treatment policy.
To optimize outpatient malaria case-management, reduce testing compliance gaps and eliminate overtreatment of test negative patients, there is a need to focus on compliance within low malaria risk areas in addition to ensuring the universal and continuous availability of 'test and treat' commodities. Targeting of older and government health workers; dissemination of updated guidelines; and continuing with in-service training and supportive supervision with feedback is essential. Lastly, there is a need to improve health workers' knowledge about malaria testing criteria considering their perceptions of endemicity.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Simple interventions for improving health workers' adherence to malaria case-management guidelines are urgently required across Africa. A recent trial in Kenya showed that text-message reminders sent ...to health workers' mobile phones improved management of pediatric outpatients by 25 percentage points. In this paper we examine costs and cost-effectiveness of this intervention.
We evaluate costs and cost-effectiveness in 2010 USD under three implementation scenarios: (1) as implemented under study conditions in study areas; (2) if the intervention was routinely implemented by the Ministry of Health (MoH) in the same areas; and (3) if the intervention was scaled up nationally. Under study conditions, intervention costs were 19,342 USD, of which 45% were for developing and pretesting text-messages, 12% for developing text-message distribution system, 29% for collecting health workers' phone numbers, and 13% were costs of sending text-messages and monitoring of the system. If the intervention was implemented in the same areas by the MoH, the costs would be 28% lower (13,920 USD) due to lower costs of collecting health workers' numbers. The cost of national scale-up would be 97,350 USD, and the majority of these costs (66%) would be for sending text-messages. The cost per additional child correctly managed was 0.50 USD under study conditions, 0.36 USD if implemented by the MoH in the same area, and estimated at only 0.03 USD if implemented nationally. Even if the effect size was only 5% or the cost on the national scale was 400% higher than estimated, the cost per additional child correctly managed would be only 0.16 USD.
A simple text-messaging intervention improving health worker adherence to malaria guidelines is effective and inexpensive. Further research is justified to optimize delivery of the intervention and expand targets beyond children and malaria disease.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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