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Nsengimana A, Biracyaza E, Isimbi J, Uwambajimana C, Hategekimana JC, Kagisha V, Asingizwe D, Nyandwi JB. Request for Antimalarial Medicines and Their Dispensing Without a Prescription in Community Pharmacies in Rwanda. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2023; 12:195-212. [PMID: 37928945 PMCID: PMC10625414 DOI: 10.2147/iprp.s428105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023] Open
Abstract
Purpose This study aimed to explore the request and dispensing of antimalarial medicines without a prescription in community pharmacies in Rwanda, as well as factors associated. Methods We employed an embedded mixed-methods design that involved a convenience sample of 235 licensed community pharmacists between February and April 2022. To simultaneously collect qualitative and quantitative data, we used a self-administered questionnaire containing a combination of close and open-ended questions. Bivariate and multivariate regression analyses were performed to examine the relationship between dispensing antimalarial medicines without a prescription and the selected independent variables. Statistical significance was set at p<0.05, and a 95% confidence interval was applied. The factors influencing the dispensing of antimalarial medicines without a prescription were analyzed using thematic content analysis as a qualitative analysis approach. Results Most respondents (88.5%) were asked to dispense antimalarial medicines by clients without a prescription. More than half of them (54%) agreed, but 34.5% refused; instead, they referred clients to malaria diagnostic testing facilities. Those who had rapid diagnostic tests for malaria in stock (OR=2.08, 95% CI:1.1-3.94), and thought that antimalarials were over-the-counter medicines (OR=7.03, 95% CI:2.01-24.5) were more likely to dispense antimalarial medicines without prescriptions. The primary reasons reported by community pharmacists for dispensing antimalarial medicines without prescriptions included their prior knowledge of malaria diagnosis, client pressure, and fear of losing clients. However, non-adherence to negative results obtained from formal health facilities and long queues at these institutions have also been cited as additional factors driving clients to seek antimalarial medicines without prescriptions. Conclusion Dispensing antimalarial medicines without prescriptions is a common practice in community pharmacies in Rwanda. The main factors contributing to this practice include lack of awareness regarding the classification of antimalarials as prescription medicines, the availability of malaria diagnostic tests, client pressure, and fear of losing clients.
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Affiliation(s)
- Amon Nsengimana
- US Agency for International Development Global Health Supply Chain Program, Procurement and Supply Chain Management, Kigali, Rwanda
| | - Emmanuel Biracyaza
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, Canada
| | - Joyce Isimbi
- Department of Pharmacy, University of Rwanda, Kigali, Rwanda
| | | | | | - Vedaste Kagisha
- Department of Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Domina Asingizwe
- Department of Physiotherapy; University of Rwanda, Kigali, Rwanda
- East African Community Regional Centre of Excellence for Vaccines, Immunization and Health Supply Chain Management, University of Rwanda, Kigali, Rwanda
| | - Jean Baptiste Nyandwi
- Department of Pharmacy, University of Rwanda, Kigali, Rwanda
- East African Community Regional Centre of Excellence for Vaccines, Immunization and Health Supply Chain Management, University of Rwanda, Kigali, Rwanda
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Nsengimana A, Isimbi J, Uwizeyimana T, Biracyaza E, Hategekimana JC, Uwambajimana C, Gwira O, Kagisha V, Asingizwe D, Adedeji A, Nyandwi JB. Malaria rapid diagnostic tests in community pharmacies in Rwanda: availability, knowledge of community pharmacists, advantages, and disadvantages of licensing their use. Glob Health Res Policy 2023; 8:40. [PMID: 37700374 PMCID: PMC10496312 DOI: 10.1186/s41256-023-00324-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 08/22/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Presumptive treatment of malaria is often practiced in community pharmacies across sub-Saharan Africa (SSA).To address this issue, the World Health Organization (WHO) recommends that malaria Rapid Diagnostic Tests (m-RDTs) be used in these settings, as they are used in the public sector. However, their use remains unlicensed in the community pharmacies in Rwanda. This can lessen their availability and foster presumptive treatment. Therefore, this study investigated the availability of m-RDTs, knowledge of community pharmacists on the use of m-RDTs, and explored Pharmacists' perceptions of the advantages and disadvantages of licensing the use of m-RDTs in community pharmacies. METHODS This was a cross-sectional study among 200 licensed community pharmacists who were purposefully sampled nationwide from 11th February to 12th April 2022. Data was collected using an online data collection instrument composed of open-ended and closed-ended questions. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 25.0. The chi-square test was used to evaluate the association between the availability of m-RDTs and independent variables of interest. Content analysis was used for qualitative data. RESULTS Although 59% were consulted by clients requesting to purchase m-RDTs, only 27% of the participants had m-RDTs in stock, 66.5% had no training on the use of m-RDTs, and 18.5% were not at all familiar with using the m-RDTs. Most of the participants (91.5%) agreed that licensing the use of m-RDTs in community pharmacies could promote the rational use of antimalarials. The chi-square test indicated that being requested to sell m-RDTs (x2 = 6.95, p = 0.008), being requested to perform m-RDTs (x2 = 5.39, p = 0.02),familiarity using m-RDTs (x2 = 17.24, p = 0.002), availability of a nurse in the Pharmacy (x2 = 11.68, p < 0.001), and location of the pharmacy (x2 = 9.13, p = 0.048) were all significantly associated with the availability of m-RDTs in the pharmacy. CONCLUSIONS The availability of m-RDTs remains low in community pharmacies in Rwanda, and less training is provided to community pharmacists regarding the use of m-RDTs. Nevertheless, community pharmacists had positive perceptions of the advantages of licensing the use of m-RDTs. Thus, licensing the use of m-RDTs is believed to be the first step toward promoting the rational use of antimalarial medicines in Rwanda.
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Affiliation(s)
- Amon Nsengimana
- USAID Global Health Supply Chain Program-Procurement and Supply Management, Kigali, Rwanda.
| | - Joyce Isimbi
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | | | - Emmanuel Biracyaza
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montréal, QC, Canada
| | | | - Charles Uwambajimana
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Olivia Gwira
- USAID Global Health Supply Chain Program-Procurement and Supply Management, Kigali, Rwanda
| | - Vedaste Kagisha
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Domina Asingizwe
- Department of Physiotherapy, School of Health Sciences, University of Rwanda, Kigali, Rwanda
- East African Community Regional Center of Excellence for Vaccines, Immunization and Health Supply Chain Management, Kigali, Rwanda
| | - Ahmed Adedeji
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Jean Baptiste Nyandwi
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
- East African Community Regional Center of Excellence for Vaccines, Immunization and Health Supply Chain Management, Kigali, Rwanda
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Kirui J, Malinga J, Sang E, Ambani G, Abel L, Nalianya E, Namae J, Boyce M, Laktabai J, Menya D, O'Meara W. Supply-side and demand-side factors influencing uptake of malaria testing services in the community: lessons for scale-up from a post-hoc analysis of a cluster randomised, community-based trial in western Kenya. BMJ Open 2023; 13:e070482. [PMID: 37369403 PMCID: PMC10410802 DOI: 10.1136/bmjopen-2022-070482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVES Maximising the impact of community-based programmes requires understanding how supply of, and demand for, the intervention interact at the point of delivery. DESIGN Post-hoc analysis from a large-scale community health worker (CHW) study designed to increase the uptake of malaria diagnostic testing. SETTING Respondents were identified during a household survey in western Kenya between July 2016 and April 2017. PARTICIPANTS Household members with fever in the last 4 weeks were interviewed at 12 and 18 months post-implementation. We collected monthly testing data from 244 participating CHWs and conducted semistructured interviews with a random sample of 70 CHWs. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was diagnostic testing before treatment for a recent fever. The secondary outcomes were receiving a test from a CHW and tests done per month by each CHW. RESULTS 55% (n=948 of 1738) reported having a malaria diagnostic test for their recent illness, of which 38.4% were tested by a CHW. Being aware of a local CHW (adjusted OR=1.50, 95% CI: 1.10 to 2.04) and belonging to the wealthiest households (vs least wealthy) were associated with higher testing (adjusted OR=1.53, 95% CI: 1.14 to 2.06). Wealthier households were less likely to receive their test from a CHW compared with poorer households (adjusted OR=0.32, 95% CI: 0.17 to 0.62). Confidence in artemether-lumefantrine to cure malaria (adjusted OR=2.75, 95% CI: 1.54 to 4.92) and perceived accuracy of a malaria rapid diagnostic test (adjusted OR=2.43, 95% CI: 1.12 to 5.27) were positively associated with testing by a CHW. Specific CHW attributes were associated with performing a higher monthly number of tests including formal employment, serving more than 50 households (vs <50) and serving areas with a higher test positivity. On demand side, confidence of the respondent in a test performed by a CHW was strongly associated with seeking a test from a CHW. CONCLUSION Scale-up of community-based malaria testing is feasible and effective in increasing uptake among the poorest households. To maximise impact, it is important to recognise factors that may restrict delivery and demand for such services. TRIAL REGISTRATION NUMBER NCT02461628; Post-results.
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Affiliation(s)
- Joseph Kirui
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Josephine Malinga
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Edna Sang
- Duke Global Health Institute, Duke Glopbal Inc, Nairobi, Kenya
| | - George Ambani
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Lucy Abel
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Erick Nalianya
- Duke Global Health Institute, Duke Glopbal Inc, Nairobi, Kenya
| | - Jane Namae
- School of Medicine, Department of Family Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Matthew Boyce
- Center for Global Health Science & Security, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Jeremiah Laktabai
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- School of Medicine, Department of Family Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Diana Menya
- School of Public Health, Departmental of Epidemiology and Medical Statistics, Moi University College of Health Sciences, Eldoret, Kenya
| | - Wendy O'Meara
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- School of Public Health, Departmental of Epidemiology and Medical Statistics, Moi University College of Health Sciences, Eldoret, Kenya
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Mpimbaza A, Babikako H, Rutazanna D, Karamagi C, Ndeezi G, Katahoire A, Opigo J, Snow RW, Kalyango JN. Adherence to malaria management guidelines by health care workers in the Busoga sub-region, eastern Uganda. Malar J 2022; 21:25. [PMID: 35078479 PMCID: PMC8788114 DOI: 10.1186/s12936-022-04048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/12/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Appropriate malaria management is a key malaria control strategy. The objective of this study was to determine health care worker adherence levels to malaria case management guidelines in the Busoga sub-region, Uganda. METHODS Health facility assessments, health care worker (HCW), and patient exit interview (PEI) surveys were conducted at government and private health facilities in the sub-region. All health centres (HC) IVs, IIIs, and a sample of HC IIs, representative of the tiered structure of outpatient service delivery at the district level were targeted. HCWs at these facilities were eligible for participation in the study. For PEIs, 210 patients of all ages presenting with a history of fever for outpatient care at selected facilities in each district were targeted. Patient outcome measures included testing rates, adherence to treatment, dispensing and counselling services as per national guidelines. The primary outcome was appropriate malaria case management, defined as the proportion of patients tested and only prescribed artemether-lumefantrine (AL) if positive. HCW readiness (e.g., training, supervision) and health facility capacity (e.g. availability of diagnostics and anti-malarials) to provide malaria case management were also assessed. Data were weighted to cater for the disproportionate representation of HC IIs in the study sample. RESULTS A total of 3936 patients and 1718 HCW from 392 facilities were considered in the analysis. The median age of patients was 14 years; majority (63.4%) females. Most (70.1%) facilities were HCIIs and 72.7% were owned by the government. Malaria testing services were available at > 85% of facilities. AL was in stock at 300 (76.5%) facilities. Of those with a positive result, nearly all were prescribed an anti-malarial, with AL (95.1%) accounting for most prescriptions. Among those prescribed AL, 81.0% were given AL at the facility, lowest at HC IV (60.0%) and government owned (80.1%) facilities, corresponding to AL stock levels. Overall, 86.9% (95%CI 79.7, 90.7) of all enrolled patients received appropriate malaria case management. However, only 50.7% (21.2, 79.7) of patients seen at PFPs received appropriate malaria management. CONCLUSION Adherence levels to malaria case management guidelines were good, but with gaps noted mainly in the private sector. The supply chain for AL needs to be strengthened. Interventions to improve practise at PFP facilities should be intensified.
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Affiliation(s)
- Arthur Mpimbaza
- Child Health and Development Centre, Makerere University, College of Health Sciences, Kampala, Uganda.
| | - Harriet Babikako
- Child Health and Development Centre, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Damian Rutazanna
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | - Charles Karamagi
- Department of Paediatrics and Child Health, Makerere University, College of Health Sciences, Kampala, Uganda
- Clinical Epidemiology Unit, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Grace Ndeezi
- Department of Paediatrics and Child Health, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Anne Katahoire
- Child Health and Development Centre, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Jimmy Opigo
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | - Robert W Snow
- Population Health Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Joan N Kalyango
- Clinical Epidemiology Unit, Makerere University, College of Health Sciences, Kampala, Uganda
- Department of Pharmacy, Makerere University, College of Health Sciences, Kampala, Uganda
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Shelus V, Mumbere N, Masereka A, Masika B, Kiitha J, Nyangoma G, Mulogo EM, Barrington C, Baguma E, Muhindo R, Herrington JE, Emch M, Maman S, Boyce RM. "Testing for malaria does not cure any pain" A qualitative study exploring low use of malaria rapid diagnostic tests at drug shops in rural Uganda. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001235. [PMID: 36962844 PMCID: PMC10021593 DOI: 10.1371/journal.pgph.0001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/28/2022] [Indexed: 12/15/2022]
Abstract
The World Health Organization recommends all suspected malaria cases be confirmed with a parasitological test, typically a rapid diagnostic test (RDT), prior to treatment. Despite recommendations, many fevers presenting at private drug shops are treated presumptively as malaria without diagnostic testing. The purpose of this qualitative study was to describe community perceptions of RDTs and explore ways to improve malaria case management at drug shops in Bugoye, western Uganda. A total of 63 in-depth interviews were conducted between September and December 2021 with 24 drug shop clients, 19 drug shop vendors, 12 community health workers, and 8 health and community officials. Data was analyzed using thematic content analysis and narrative techniques. While drug shop clients valued RDTs, the cost of the test limited their use. Further, mistrust in negative results and fear about treatment options for conditions other than malaria led to nonadherence to negative RDTs. Improvement with antimalarials after a negative RDT, or no RDT at all, was seen as proof an individual had malaria, reinforcing the acceptability of liberal antimalarial use. Drug shop vendors were knowledgeable about malaria case management but financially conflicted between recommending best practices and losing business. While clients viewed drug shop vendors as trusted health professionals, health officials distrusted them as business owners focused on maximizing profits. Study results suggest public-private partnerships that recognize the essential role of drug shops, better incorporate them into the healthcare system, and leverage the high levels of community trust in vendors, could provide greater opportunities for oversight and training to improve private-sector malaria case management. Interventions that address financial barriers to RDT use, emphasize the financial benefits of malaria testing, increase vendor knowledge about illnesses confused with malaria, and improve the quality of vendor-client counseling could increase RDT uptake and improve adherence to RDT results.
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Affiliation(s)
- Victoria Shelus
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, Chapel Hill, North Carolina, United States of America
| | - Nobert Mumbere
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Amos Masereka
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Bonita Masika
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joackim Kiitha
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Grace Nyangoma
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edgar M Mulogo
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, Chapel Hill, North Carolina, United States of America
| | - Emmanuel Baguma
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rabbison Muhindo
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - James E Herrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael Emch
- Carolina Population Center, Chapel Hill, North Carolina, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Suzanne Maman
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Ross M Boyce
- Carolina Population Center, Chapel Hill, North Carolina, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Danwang C, Noubiap JJ, Souopgui J, Gaudart J, Yombi JC, Robert A. Accuracy of malaria diagnostic tests performed on non-invasively collected samples: a systematic review and meta-analysis. BMJ Glob Health 2021; 6:bmjgh-2021-005634. [PMID: 34078631 PMCID: PMC8173286 DOI: 10.1136/bmjgh-2021-005634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/06/2021] [Accepted: 04/30/2021] [Indexed: 12/22/2022] Open
Abstract
Background During the last decade, many studies have assessed the performance of malaria tests on non-invasively collected specimens, but no systematic review has hitherto estimated the overall performance of these tests. We report here the first meta-analysis estimating the diagnostic performance of malaria diagnostic tests performed on saliva, urine, faeces, skin odour (‘sniff and tell’) and hair, using either microscopy or PCR on blood sample as reference test. Methods We searched on PubMed, EMBASE, African Journals Online and Cochrane Infectious Diseases from inception until 19 January 2021 for relevant primary studies. A random effects model was used to estimate the overall performance of various diagnostic methods on different types of specimen. Results Eighteen studies providing 30 data sets were included in the meta-analysis. The overall sensitivity, specificity and diagnostic OR (DOR) of PCR were 84.5% (95% CI 79.3% to 88.6%), 97.3% (95% CI 95.3% to 98.5%) and 184.9 (95% CI 95.8 to 356.9) in saliva, respectively; 57.4% (95% CI 41.4% to 72.1%), 98.6% (95% CI 97.3% to 99.3%) and 47.2 (95% CI 22.1 to 101.1) in urine, respectively. The overall sensitivity, specificity and DOR of rapid diagnostic test for malaria in urine was 59.8% (95% CI 40.0% to 76.9%), 96.9% (95% CI 91.0% to 99.0%) and 30.8 (95% CI:23.5 to 40.4). Conclusion In settings where PCR is available, saliva and urine samples should be considered for PCR-based malaria diagnosis only if blood samples cannot be collected. The performance of rapid diagnostic testing in the urine is limited, especially its sensitivity. Malaria testing on non-invasively collected specimen still needs substantial improvement.
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Affiliation(s)
- Celestin Danwang
- Epidemiology and Biostatistics Unit, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Jean Jacques Noubiap
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia's, Australia
| | - Jacob Souopgui
- Department of Molecular Biology, Universite Libre de Bruxelles, Gosselies, Belgium
| | - Jean Gaudart
- Aix Marseille Univ, IRD, INSERM, SESSTIM, ISSPAM, Marseille, France.,APHM, Hop Timone, BioSTIC, Biostatistics & ICT, Marseille, France
| | - Jean Cyr Yombi
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Annie Robert
- Epidemiology and Biostatistics Unit, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
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Kigozi SP, Kigozi RN, Sebuguzi CM, Cano J, Rutazaana D, Opigo J, Bousema T, Yeka A, Gasasira A, Sartorius B, Pullan RL. Spatial-temporal patterns of malaria incidence in Uganda using HMIS data from 2015 to 2019. BMC Public Health 2020; 20:1913. [PMID: 33317487 PMCID: PMC7737387 DOI: 10.1186/s12889-020-10007-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/04/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND As global progress to reduce malaria transmission continues, it is increasingly important to track changes in malaria incidence rather than prevalence. Risk estimates for Africa have largely underutilized available health management information systems (HMIS) data to monitor trends. This study uses national HMIS data, together with environmental and geographical data, to assess spatial-temporal patterns of malaria incidence at facility catchment level in Uganda, over a recent 5-year period. METHODS Data reported by 3446 health facilities in Uganda, between July 2015 and September 2019, was analysed. To assess the geographic accessibility of the health facilities network, AccessMod was employed to determine a three-hour cost-distance catchment around each facility. Using confirmed malaria cases and total catchment population by facility, an ecological Bayesian conditional autoregressive spatial-temporal Poisson model was fitted to generate monthly posterior incidence rate estimates, adjusted for caregiver education, rainfall, land surface temperature, night-time light (an indicator of urbanicity), and vegetation index. RESULTS An estimated 38.8 million (95% Credible Interval [CI]: 37.9-40.9) confirmed cases of malaria occurred over the period, with a national mean monthly incidence rate of 20.4 (95% CI: 19.9-21.5) cases per 1000, ranging from 8.9 (95% CI: 8.7-9.4) to 36.6 (95% CI: 35.7-38.5) across the study period. Strong seasonality was observed, with June-July experiencing highest peaks and February-March the lowest peaks. There was also considerable geographic heterogeneity in incidence, with health facility catchment relative risk during peak transmission months ranging from 0 to 50.5 (95% CI: 49.0-50.8) times higher than national average. Both districts and health facility catchments showed significant positive spatial autocorrelation; health facility catchments had global Moran's I = 0.3 (p < 0.001) and districts Moran's I = 0.4 (p < 0.001). Notably, significant clusters of high-risk health facility catchments were concentrated in Acholi, West Nile, Karamoja, and East Central - Busoga regions. CONCLUSION Findings showed clear countrywide spatial-temporal patterns with clustering of malaria risk across districts and health facility catchments within high risk regions, which can facilitate targeting of interventions to those areas at highest risk. Moreover, despite high and perennial transmission, seasonality for malaria incidence highlights the potential for optimal and timely implementation of targeted interventions.
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Affiliation(s)
- Simon P Kigozi
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Infectious Diseases Research Collaboration, PO Box 7475, Kampala, Uganda.
| | - Ruth N Kigozi
- USAID's Malaria Action Program for Districts, PO Box 8045, Kampala, Uganda
| | - Catherine M Sebuguzi
- Infectious Diseases Research Collaboration, PO Box 7475, Kampala, Uganda.,National Malaria Control Division, Uganda Ministry of Health, Kampala, Uganda
| | - Jorge Cano
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Damian Rutazaana
- National Malaria Control Division, Uganda Ministry of Health, Kampala, Uganda
| | - Jimmy Opigo
- National Malaria Control Division, Uganda Ministry of Health, Kampala, Uganda
| | - Teun Bousema
- Department of Medical Microbiology, Radboud University, Nijmegen, Netherlands
| | - Adoke Yeka
- Department of Disease Control and Environmental Health, College of Health Sciences, School of Public Health, Makerere University, PO Box 7072, Kampala, Uganda
| | - Anne Gasasira
- African Leaders Malaria Alliance (ALMA), Kampala, Uganda
| | - Benn Sartorius
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Rachel L Pullan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Argaw MD, Mavundla TR, Gidebo KD. Management of uncomplicated malaria in private health facilities in North-West Ethiopia: a clinical audit of current practices. BMC Health Serv Res 2019; 19:932. [PMID: 31801533 PMCID: PMC6894146 DOI: 10.1186/s12913-019-4722-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 11/07/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Malaria is one of the leading public health problems in sub-Saharan Africa that contributes to significant patient morbidity and mortality. The aim of the study was to investigate adherence to malaria diagnosis and treatment guidelines by private health sector providers and compare their performance against the public private partnership (PPP) status. METHODS A facility-based retrospective clinical audit was conducted between October 2016 and January 2017 in 11 medium clinics in the West Gojjam zone of the Amhara Region, North-west Ethiopia. Data was extracted from patient medical records using pretested data abstraction forms. Descriptive statistics were employed to present the findings and adherence of health workers against the national and international standards were classified as ideal, acceptable, minor error and major error for both malaria diagnosis and treatment. A chi-square (X2) test was used to test for a statistically significant relationship after the data had been categorized using public private partnership status at P < 0.05. RESULTS One thousand six hundred fifty clinical files were audited. All malaria suspected patients were investigated either with microscopy or rapid diagnostics test (RDT) for parasitological confirmation. The proportion of malaria treated cases was 23.7% (391/1650). Of which 16.6% (274/1650) were uncomplicated, 3.69% (61 /1650) were severe and complicated and the rest 3.39% (56/1650) were clinical diagnosed malaria cases. And the malaria parasite positivity rate was 20.30% (335/1650). All malaria suspected patients were not investigated with ideal malaria diagnosis recommendations; only 19.4% (320/1650) were investigated with acceptable malaria diagnosis (public private partnership (PPP) 19.4%; 176/907; and non-public private partnership (NPPP) 19.38%; 144/743, X2 (1) = 0.0With regards to treatments of malaria cases, the majority 82.9% of Plasmodium vivax cases were managed with ideal recommended treatment (X2 (1) = 0.35, P = 0.55); among Plasmodium falciparum, mixed (Plasmodium falciparum and Plasmodium vivax). CONCLUSION The clinical audit revealed that the majority of malaria patients had received minor error malaria diagnostic services. In addition, only one fifth of malaria patients had received ideal malaria treatment services. To understand the reasons for the low levels of malaria diagnosis and treatment adherence with national guidelines, a qualitative exploratory descriptive study is recommended.
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Affiliation(s)
- Mesele Damte Argaw
- USAID Transform: Primary Health Care, JSI Research & Training Institute, Inc., P.O. Box 1392, code 1110, Addis Ababa, Ethiopia.
- Department of Health Studies, University of South Africa, Pretoria, South Africa.
| | | | - Kassa Daka Gidebo
- School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
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Merritt MW, Sutherland CS, Tediosi F. Ethical Considerations for Global Health Decision-Making: Justice-Enhanced Cost-Effectiveness Analysis of New Technologies for Trypanosoma brucei gambiense. Public Health Ethics 2018; 11:275-292. [PMID: 30429873 PMCID: PMC6225893 DOI: 10.1093/phe/phy013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
We sought to assess formally the extent to which different control and elimination strategies for human African trypanosomiasis Trypanosoma brucei gambiense (Gambiense HAT) would exacerbate or alleviate experiences of societal disadvantage that traditional economic evaluation does not take into account. Justice-enhanced cost-effectiveness analysis (JE-CEA) is a normative approach under development to address social justice considerations in public health decision-making alongside other types of analyses. It aims to assess how public health interventions under analysis in comparative evaluation would be expected to influence the clustering of disadvantage across three core dimensions of well-being: agency, association and respect. As a case study to test the approach, we applied it to five strategies for Gambiense HAT control and elimination, in combination with two different other evaluations: a cost-effectiveness analysis and a probability of elimination analysis. We have demonstrated how JE-CEA highlights the ethical importance of adverse social justice impacts of otherwise attractive options and how it indicates specific modifications to policy options to mitigate such impacts. JE-CEA holds promise as an approach to help decision makers and other stakeholders consider social justice more fully, explicitly and systematically in evaluating public health programs.
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Affiliation(s)
- Maria W Merritt
- Johns Hopkins Berman Institute of Bioethics and Department of International Health, Johns Hopkins Bloomberg School of Public Health
| | | | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute and Universität Basel
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10
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Kitutu FE, Kalyango JN, Mayora C, Selling KE, Peterson S, Wamani H. Integrated community case management by drug sellers influences appropriate treatment of paediatric febrile illness in South Western Uganda: a quasi-experimental study. Malar J 2017; 16:425. [PMID: 29061148 PMCID: PMC5654057 DOI: 10.1186/s12936-017-2072-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/17/2017] [Indexed: 11/17/2022] Open
Abstract
Background Fever case management is a major challenge for improved child health globally, despite existence of cheap and effective child survival health technologies. The integrated Community Case Management (iCCM) intervention of paediatric febrile illnesses though adopted by Uganda’s Ministry of Health to be implemented by community health workers, has not addressed the inaccess to life-saving medicines and diagnostics. Therefore, the iCCM intervention was implemented in private drug shops and evaluated for its effect on appropriate treatment of paediatric fever in a low malaria transmission setting in South Western Uganda. Methods From June 2013 to September 2015, the effect of the iCCM intervention on drug seller paediatric fever management and adherence to iCCM guidelines was assessed in a quasi-experimental study in South Western Uganda. A total of 212 care-seeker exit interviews were done before and 285 after in the intervention arm as compared to 216 before and 268 care-seeker interviews at the end of the study period in the comparison arm. The intervention effect was assessed by difference-in-difference analysis of drug seller treatment practices against national treatment recommendations between the intervention and comparison arms. Observed proportions among care-seeker interviews were compared with corresponding proportions from 5795 child visits recorded in patient registries and 49 direct observations of drug seller–care-seeker encounters in intervention drug shops. Results The iCCM intervention increased the appropriate treatment of uncomplicated malaria, pneumonia symptoms and non-bloody diarrhoea by 80.2% (95% CI 53.2–107.2), 65.5% (95% CI 51.6–79.4) and 31.4% (95% CI 1.6–61.2), respectively. Within the intervention arm, drug seller scores on appropriate treatment for pneumonia symptoms and diagnostic test use were the same among care-seeker exit interviews and direct observation. A linear trend (negative slope, − 0.009 p value < 0.001) was observed for proportions of child cases prescribed any antimicrobial medicine in the intervention arm drug shops. Conclusions The iCCM intervention improved appropriate treatment for uncomplicated malaria, pneumonia symptoms and diarrhoea. Drug seller adherence to iCCM guidelines was high, without causing excessive prescription of antimicrobial medicines in this study. Further research should assess whether this effect is sustained over time and under routine supervision models. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-2072-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Freddy Eric Kitutu
- Pharmacy Department, Makerere University College of Health Sciences, Kampala, Uganda. .,School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda. .,International Maternal and Child Health Unit, Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden.
| | - Joan Nakayaga Kalyango
- Pharmacy Department, Makerere University College of Health Sciences, Kampala, Uganda.,Clinical Epidemiology and Biostatistics Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Chrispus Mayora
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,School of Public Health, University of Witwatersrand, 27 St. Andrews Road, Parktown, Johannesburg, 2193, South Africa
| | - Katarina Ekholm Selling
- International Maternal and Child Health Unit, Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden
| | - Stefan Peterson
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,International Maternal and Child Health Unit, Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden.,Health Section, UNICEF, 3 UN Plaza, New York, NY, 10017, USA
| | - Henry Wamani
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
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11
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Saran I, Maffioli EM, Menya D, O'Meara WP. Household beliefs about malaria testing and treatment in Western Kenya: the role of health worker adherence to malaria test results. Malar J 2017; 16:349. [PMID: 28830439 PMCID: PMC5568326 DOI: 10.1186/s12936-017-1993-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/10/2017] [Indexed: 12/02/2022] Open
Abstract
Background Although use of malaria diagnostic tests has increased in recent years, health workers often prescribe anti-malarial drugs to individuals who test negative for malaria. This study investigates how health worker adherence to malaria case management guidelines influences individuals’ beliefs about whether their illness was malaria, and their confidence in the effectiveness of artemisinin-based combination therapy (ACT). Methods A survey was conducted with 2065 households in Western Kenya about a household member’s treatment actions for a recent febrile illness. The survey also elicited the individual’s (or their caregiver’s) beliefs about the illness and about malaria testing and treatment. Logistic regressions were used to test the association between these beliefs and whether the health worker adhered to malaria testing and treatment guidelines. Results Of the 1070 individuals who visited a formal health facility during their illness, 82% were tested for malaria. ACT rates for malaria-positive and negative individuals were 89 and 49%, respectively. Overall, 65% of individuals/caregivers believed that the illness was “very likely” malaria. Individuals/caregivers had higher odds of saying that the illness was “very likely” malaria when the individual was treated with ACT, and this was the case both among individuals not tested for malaria [adjusted odds ratio (AOR) 3.42, 95% confidence interval (CI) [1.65 7.10], P = 0.001] and among individuals tested for malaria, regardless of their test result. In addition, 72% of ACT-takers said the drug was “very likely” effective in treating malaria. However, malaria-negative individuals who were treated with ACT had lower odds of saying that the drugs were “very likely” effective than ACT-takers who were not tested or who tested positive for malaria (AOR 0.29, 95% CI [0.13 0.63], P = 0.002). Conclusion Individuals/caregivers were more likely to believe that the illness was malaria when the patient was treated with ACT, regardless of their test result. Moreover, malaria-negative individuals treated with ACT had lower confidence in the drug than other individuals who took ACT. These results suggest that ensuring health worker adherence to malaria case management guidelines will not only improve ACT targeting, but may also increase patient/caregivers’ confidence in malaria testing and treatment. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1993-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Indrani Saran
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27701, USA.
| | | | - Diana Menya
- School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Wendy Prudhomme O'Meara
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27701, USA.,School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya.,Duke University Medical Center, Duke University, Durham, USA
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12
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Hansen KS, Lesner TH, Østerdal LP. Optimal price subsidies for appropriate malaria testing and treatment behaviour. Malar J 2016; 15:534. [PMID: 27814767 PMCID: PMC5097430 DOI: 10.1186/s12936-016-1582-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 10/28/2016] [Indexed: 11/25/2022] Open
Abstract
Background Malaria continues to be a serious public health problem particularly in Africa. Many people infected with malaria do not access effective treatment due to high price. At the same time many individuals receiving malaria drugs do not suffer from malaria because of the common practice of presumptive diagnosis. A global subsidy on artemisinin-based combination therapy (ACT) has recently been suggested to increase access to the most effective malaria treatment. Methods Following the recommendation by World Health Organization that parasitological testing should be performed before treatment and ACT prescribed to confirmed cases only, it is investigated in this paper if a subsidy on malaria rapid diagnostic tests (RDTs) should be incorporated. A model is developed consisting of a representative individual with fever suspected to be malaria, seeking care at a specialized drug shop where RDTs, ACT medicines, and cheap, less effective anti-malarials are sold. Assuming that the individual has certain beliefs of the accuracy of the RDT and the probability that the fever is malaria, the model predicts the diagnosis-treatment behaviour of the individual. Subsidies on RDTs and ACT are introduced to incentivize appropriate behaviour: choose an RDT before treatment and purchase ACT only if the test is positive. Results Solving the model numerically suggests that a combined subsidy on both RDT and ACT is cost minimizing and improves diagnosis-treatment behaviour of individuals. For certain beliefs, such as low trust in RDT accuracy and strong belief that a fever is malaria, subsidization is not sufficient to incentivize appropriate behaviour. Conclusions A combined subsidy on both RDT and ACT rather than a single subsidy is likely required to improve diagnosis-treatment behaviour among individuals seeking care for malaria in the private sector. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1582-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kristian Schultz Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. .,Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen, Denmark.
| | - Tine Hjernø Lesner
- Department of Business and Economics, and Centre of Health Economics Research (COHERE), University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
| | - Lars Peter Østerdal
- Department of Economics, Copenhagen Business School, Porcelænshaven 16A, 2000, Frederiksberg, Denmark
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13
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Argaw MD, Woldegiorgis AGY, Abate DT, Abebe ME. Improved malaria case management in formal private sector through public private partnership in Ethiopia: retrospective descriptive study. Malar J 2016; 15:352. [PMID: 27401095 PMCID: PMC4940756 DOI: 10.1186/s12936-016-1402-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 06/17/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria is a major public health problem and still reported among the 10 top causes of morbidity and mortality in Ethiopia. More than one-third of the people sought treatment from the private health sector. Evaluating adherences of health care providers to standards are paramount importance to determine the quality and the effectiveness of service delivery. Therefore, the aim of this study was to evaluate the contribution of public private mix (PPM) approach in improving quality of malaria case management among formal private providers. METHODS A retrospective data analysis was conducted using 2959 facility-months data collected from 110 PPM for malaria care facilities located in Amhara, Dire Dawa, Hareri, Oromia, Southern Nation Nationalities and Peoples and Tigray regions. Data abstraction formats were used to collect and collate the data on quarterly bases. The data were manually cleaned and analysed using Microsoft Office Excel 2010. To claim statistical significance non-parametric McNemar test was done and decision accepted at P < 0.05. RESULTS From April 2012-September 2015, a total of 873,707 malaria suspected patients were identified, of which one-fourth (25.6 %) were treated as malaria cases. Among malaria suspected cases the proportion of malaria investigation improved from recorded in first quarter 87.7-100.0 % in last quarter (X(2) = 66.84, P < 0.001). The majority (96.0 %) were parasitologically-confirmed cases either by using microscopy or rapid diagnostic tests. The overall slid positivity rate was 25.1 % of which half (50.7 %) were positive for Plasmodium falciparum and slightly lower than half (45.2 %) for Plasmodium vivax; the remaining 8790 (4.1 %) showed mixed infections of P. falciparum and P. vivax. Adherence to appropriate treatment using artemether-lumefantrine (AL) was improved from 47.8 % in the first quarter to 95.7 % in the last quarter (X(2) = 12.89, P < 0.001). Similarly, proper patient management using chloroquine (CQ) was improved from 44.1 % in the first quarter to 98.12 % in the last quarter (X(2) = 11.62, P < 0.001). CONCLUSIONS This study documented the chronological changes of adherence of health care providers with the national recommended standards to treat malaria. The PPM for malaria care services significantly improved the malaria case management practice of health care providers at the formal private health facilities. Therefore, regional health bureaus and partners shall closely work to scale up the initiated PPM for malaria care service.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Child
- Child, Preschool
- Coinfection/diagnosis
- Coinfection/drug therapy
- Coinfection/epidemiology
- Coinfection/parasitology
- Disease Management
- Ethiopia
- Female
- Health Services Research
- Humans
- Infant
- Infant, Newborn
- Malaria, Falciparum/diagnosis
- Malaria, Falciparum/drug therapy
- Malaria, Falciparum/epidemiology
- Malaria, Falciparum/parasitology
- Malaria, Vivax/diagnosis
- Malaria, Vivax/drug therapy
- Malaria, Vivax/epidemiology
- Malaria, Vivax/parasitology
- Male
- Middle Aged
- Plasmodium falciparum/isolation & purification
- Plasmodium vivax/isolation & purification
- Public-Private Sector Partnerships
- Retrospective Studies
- Young Adult
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Affiliation(s)
- Mesele D. Argaw
- Private Health Sector Project, Abt Associates Inc. In Ethiopia, P. O. Box 2372, 1250 Addis Ababa, Ethiopia
| | - Asfawesen GY. Woldegiorgis
- Private Health Sector Project, Abt Associates Inc. In Ethiopia, P. O. Box 2372, 1250 Addis Ababa, Ethiopia
| | - Derebe T. Abate
- Private Health Sector Project, Abt Associates Inc. In Ethiopia, P. O. Box 2372, 1250 Addis Ababa, Ethiopia
| | - Mesfin E. Abebe
- Private Health Sector Project, Abt Associates Inc. In Ethiopia, P. O. Box 2372, 1250 Addis Ababa, Ethiopia
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Saran I, Yavuz E, Kasozi H, Cohen J. Can Rapid Diagnostic Testing for Malaria Increase Adherence to Artemether-Lumefantrine?: A Randomized Controlled Trial in Uganda. Am J Trop Med Hyg 2016; 94:857-67. [PMID: 26928828 DOI: 10.4269/ajtmh.15-0420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 11/06/2015] [Indexed: 11/07/2022] Open
Abstract
Most patients with suspected malaria do not receive diagnostic confirmation before beginning antimalarial treatment. We investigated the extent to which uncertainty about malaria diagnosis contributes to patient nonadherence to artemether-lumefantrine (AL) treatment through a randomized controlled trial in central Uganda. Among 1,525 patients purchasing a course of AL at private drug shops, we randomly offered 37.6% a free malaria rapid diagnostic test (RDT) and then assessed adherence through home visits 3 days later. Of these subjects, 68.4% tested positive for malaria and 65.8% adhered overall. Patients who tested positive did not have significantly higher odds of adherence than those who were not offered the test (adjusted odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.734-1.57,P= 0.719). Patients who received a positive malaria test had 0.488 fewer pills remaining than those not offered the test (95% CI: -1.02 to 0.043,P= 0.072). We found that patients who felt relatively healthy by the second day of treatment had lower odds of completing treatment (adjusted OR: 0.532, 95% CI: 0.394-0.719,P< 0.001). Our results suggest that diagnostic testing may not improve artemisinin-based combination therapy adherence unless efforts are made to persuade patients to continue taking the full course of drugs even if symptoms have resolved.
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Affiliation(s)
- Indrani Saran
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Innovations for Poverty Action, Kampala, Uganda
| | - Elif Yavuz
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Innovations for Poverty Action, Kampala, Uganda
| | - Howard Kasozi
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Innovations for Poverty Action, Kampala, Uganda
| | - Jessica Cohen
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Innovations for Poverty Action, Kampala, Uganda
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Narrative review of current context of malaria and management strategies in Uganda (Part I). Acta Trop 2015; 152:252-268. [PMID: 26257070 DOI: 10.1016/j.actatropica.2015.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 07/28/2015] [Accepted: 07/31/2015] [Indexed: 01/26/2023]
Abstract
In accordance with international targets, the Uganda National Malaria Control Strategic Plan established specific targets to be achieved by 2010. For children under five, this included increasing the number of children sleeping under mosquito nets and those receiving a first-line antimalarial to 85%, and decreasing case fatality to 2%. This narrative review offers contextual information relevant to malaria management in Uganda since the advent of artemisinin combination therapy (ACT) as first-line antimalarial treatment in 2004. A comprehensive search using key words and phrases was conducted using the web search engines Google and Google Scholar, as well as the databases of PubMed, ERIC, EMBASE, CINAHL, OvidSP (MEDLINE), PSYC Info, Springer Link, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched. A total of 147 relevant international and Ugandan literature sources meeting the inclusion criteria were included. This review provides an insightful understanding on six topic areas: global and local priorities, malarial pathology, disease burden, malaria control, treatment guidelines for uncomplicated malaria, and role of the health system in accessing antimalarial medicines. Plasmodium falciparum remains the most common cause of malaria in Uganda, with children under five being most vulnerable due to their underdeveloped immunity. While international efforts to scale up malaria control measures have resulted in considerable decline in malaria incidence and mortality in several regions of sub-Saharan Africa, this benefit has yet to be substantiated for Uganda. At the local level, key initiatives have included implementation of a new antimalarial drug policy in 2004 and strengthening of government health systems and programs. Examples of such programs include removal of user fees, training of frontline health workers, providing free ACT from government systems and subsidized ACT from licensed private outlets, and introduction of the integrated community case management program to bring diagnostics and treatment for malaria, pneumonia and diarrhea closer to the community. However despite notable efforts, Uganda is far from achieving its 2010 targets. Several challenges in the delivery of care and treatment remain, with those most vulnerable and living in rural settings remaining at greatest risk from malaria morbidity and mortality.
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