1
|
Khalid Mohamed S, Khalid Mohamed D, Ahmed K, Saad F, Zurovac D. Health workers' adherence to malaria case management protocols in Northern Sudan: a qualitative study. Malar J 2024; 23:170. [PMID: 38816778 PMCID: PMC11137897 DOI: 10.1186/s12936-024-04998-9] [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: 03/17/2024] [Accepted: 05/23/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- Sahar Khalid Mohamed
- National Malaria Control Programme, Federal Ministry of Health, Khartoum, Sudan.
- Department of Community Medicine, Faculty of Medicine, Al-Neelain University, Khartoum, Sudan.
| | - Duha Khalid Mohamed
- National Malaria Control Programme, Federal Ministry of Health, Khartoum, Sudan
| | - Khansaa Ahmed
- National Malaria Control Programme, Federal Ministry of Health, Khartoum, Sudan
| | - Fadwa Saad
- National Malaria Control Programme, Federal Ministry of Health, Khartoum, Sudan
| | | |
Collapse
|
2
|
Guissou RM, Amaratunga C, de Haan F, Tou F, Cheah PY, Yerbanga RS, Moors EHM, Dhorda M, Tindana P, Boon WPC, Dondorp AM, Ouédraogo JB. The impact of anti-malarial markets on artemisinin resistance: perspectives from Burkina Faso. Malar J 2023; 22:269. [PMID: 37705004 PMCID: PMC10498571 DOI: 10.1186/s12936-023-04705-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Widespread artemisinin resistance in Africa could be catastrophic when drawing parallels with the failure of chloroquine in the 1970s and 1980s. This article explores the role of anti-malarial market characteristics in the emergence and spread of arteminisin resistance in African countries, drawing on perspectives from Burkina Faso. METHODS Data were collected through in-depth interviews and focus group discussions. A representative sample of national policy makers, regulators, public and private sector wholesalers, retailers, clinicians, nurses, and community members were purposively sampled. Additional information was also sought via review of policy publications and grey literature on anti-malarial policies and deployment practices in Burkina Faso. RESULTS Thirty seven in-depth interviews and 6 focus group discussions were conducted. The study reveals that the current operational mode of anti-malarial drug markets in Burkina Faso promotes arteminisin resistance emergence and spread. The factors are mainly related to the artemisinin-based combination therapy (ACT) supply chain, to ACT quality, ACT prescription monitoring and to ACT access and misuse by patients. CONCLUSION Study findings highlight the urgent requirement to reform current characteristics of the anti-malarial drug market in order to delay the emergence and spread of artemisinin resistance in Burkina Faso. Four recommendations for public policy emerged during data analysis: (1) Address the suboptimal prescription of anti-malarial drugs, (2) Apply laws that prohibit the sale of anti-malarials without prescription, (3) Restrict the availability of street drugs, (4) Sensitize the population on the value of compliance regarding correct acquisition and intake of anti-malarials. Funding systems for anti-malarial drugs in terms of availability and accessibility must also be stabilized.
Collapse
Affiliation(s)
- Rosemonde M Guissou
- Institut de Recherche en Sciences de la Sante, Centre National de la Recherche Scientifique et Technologique, Ouagadougou, Burkina Faso.
| | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Fatoumata Tou
- Institut des Sciences et Techniques, Bobo-Dioulasso, Burkina Faso
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - R Serge Yerbanga
- Institut de Recherche en Sciences de la Sante, Centre National de la Recherche Scientifique et Technologique, Ouagadougou, Burkina Faso
- Institut des Sciences et Techniques, Bobo-Dioulasso, Burkina Faso
| | - Ellen H M Moors
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Mehul Dhorda
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Paulina Tindana
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Wouter P C Boon
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | |
Collapse
|
3
|
Elnour Z, Grethe H, Siddig K, Munga S. Malaria control and elimination in Kenya: economy-wide benefits and regional disparities. Malar J 2023; 22:117. [PMID: 37029370 PMCID: PMC10080938 DOI: 10.1186/s12936-023-04505-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 02/18/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND Malaria remains a public health problem in Kenya despite several concerted control efforts. Empirical evidence regarding malaria effects in Kenya suggests that the disease imposes substantial economic costs, jeopardizing the achievement of sustainable development goals. The Kenya Malaria Strategy (2019-2023), which is currently being implemented, is one of several sequential malaria control and elimination strategies. The strategy targets reducing malaria incidences and deaths by 75% of the 2016 levels by 2023 through spending around Kenyan Shillings 61.9 billion over 5 years. This paper assesses the economy-wide implications of implementing this strategy. METHODS An economy-wide simulation model is calibrated to a comprehensive 2019 database for Kenya, considering different epidemiological zones. Two scenarios are simulated with the model. The first scenario (GOVT) simulates the annual costs of implementing the Kenya Malaria Strategy by increasing government expenditure on malaria control and elimination programmes. The second scenario (LABOR) reduces malaria incidences by 75% in all epidemiological malaria zones without accounting for the changes in government expenditure, which translates into rising the household labour endowment (benefits of the strategy). RESULTS Implementing the Kenya Malaria Strategy (2019-2023) enhances gross domestic product at the end of the strategy implementation period due to more available labour. In the short term, government health expenditure (direct malaria costs) increases significantly, which is critical in controlling and eliminating malaria. Expanding the health sector raises the demand for production factors, such as labour and capital. The prices for these factors rise, boosting producer and consumer prices of non-health-related products. Consequently, household welfare decreases during the strategy implementation period. In the long run, household labour endowment increases due to reduced malaria incidences and deaths (indirect malaria costs). However, the size of the effects varies across malaria epidemiological and agroecological zones depending on malaria prevalence and factor ownership. CONCLUSIONS This paper provides policymakers with an ex-ante assessment of the implications of malaria control and elimination on household welfare across various malaria epidemiological zones. These insights assist in developing and implementing related policy measures that reduce the undesirable effects in the short run. Besides, the paper supports an economically beneficial long-term malaria control and elimination effect.
Collapse
Affiliation(s)
- Zuhal Elnour
- Humboldt-Universität zu Berlin, Berlin, Germany.
- Agricultural Research Corporation, Wad Madani, Sudan.
| | | | - Khalid Siddig
- Humboldt-Universität zu Berlin, Berlin, Germany
- International Food Policy Research Institute, Khartoum, Sudan
- University of Khartoum, Khartoum, Sudan
| | | |
Collapse
|
4
|
The use of routine health facility data for micro-stratification of malaria risk in mainland Tanzania. Malar J 2022; 21:345. [DOI: 10.1186/s12936-022-04364-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/05/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background
Current efforts to estimate the spatially diverse malaria burden in malaria-endemic countries largely involve the use of epidemiological modelling methods for describing temporal and spatial heterogeneity using sparse interpolated prevalence data from periodic cross-sectional surveys. However, more malaria-endemic countries are beginning to consider local routine data for this purpose. Nevertheless, routine information from health facilities (HFs) remains widely under-utilized despite improved data quality, including increased access to diagnostic testing and the adoption of the electronic District Health Information System (DHIS2). This paper describes the process undertaken in mainland Tanzania using routine data to develop a high-resolution, micro-stratification risk map to guide future malaria control efforts.
Methods
Combinations of various routine malariometric indicators collected from 7098 HFs were assembled across 3065 wards of mainland Tanzania for the period 2017–2019. The reported council-level prevalence classification in school children aged 5–16 years (PfPR5–16) was used as a benchmark to define four malaria risk groups. These groups were subsequently used to derive cut-offs for the routine indicators by minimizing misclassifications and maximizing overall agreement. The derived-cutoffs were converted into numbered scores and summed across the three indicators to allocate wards into their overall risk stratum.
Results
Of 3065 wards, 353 were assigned to the very low strata (10.5% of the total ward population), 717 to the low strata (28.6% of the population), 525 to the moderate strata (16.2% of the population), and 1470 to the high strata (39.8% of the population). The resulting micro-stratification revealed malaria risk heterogeneity within 80 councils and identified wards that would benefit from community-level focal interventions, such as community-case management, indoor residual spraying and larviciding.
Conclusion
The micro-stratification approach employed is simple and pragmatic, with potential to be easily adopted by the malaria programme in Tanzania. It makes use of available routine data that are rich in spatial resolution and that can be readily accessed allowing for a stratification of malaria risk below the council level. Such a framework is optimal for supporting evidence-based, decentralized malaria control planning, thereby improving the effectiveness and allocation efficiency of malaria control interventions.
Collapse
|
5
|
Amboko B, Stepniewska K, Machini B, Bejon P, Snow RW, Zurovac D. Factors influencing health workers' compliance with outpatient malaria 'test and treat' guidelines during the plateauing performance phase in Kenya, 2014-2016. Malar J 2022; 21:68. [PMID: 35241074 PMCID: PMC8895910 DOI: 10.1186/s12936-022-04093-x] [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: 10/15/2021] [Accepted: 02/17/2022] [Indexed: 11/12/2022] Open
Abstract
Background 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. Methods 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. Results 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. Conclusions 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. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04093-x.
Collapse
Affiliation(s)
- Beatrice Amboko
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Beatrice Machini
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert W Snow
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| |
Collapse
|
6
|
Amboko B, Machini B, Githuka G, Bejon P, Zurovac D, Snow RW. Readiness of the Kenyan public health sector to provide pre‐referral care for severe paediatric malaria. Trop Med Int Health 2022; 27:330-336. [PMID: 35094454 PMCID: PMC7613004 DOI: 10.1111/tmi.13728] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To assess readiness among primary public health facilities in Kenya to provide pre‐referral antimalarials for severe malaria. Methods Nine national surveys of randomly selected primary public health facilities undertaken bi‐annually between 2017 and 2021 were analysed. The outcomes included the availability of pre‐referral antimalarial drugs at the health facilities and health worker knowledge of recommended pre‐referral treatment for severe malaria. Results A total of 1540 health workers from 1355 health facilities were interviewed. Injectable artesunate was available at 46%, injectable quinine at 7%, and artemether at 3% of the health facilities. None of the facilities had rectal artesunate suppositories in stock. A total of 960 (62%) health workers were trained on the use of injectable artesunate. 73% of the health workers who had ever referred a child with severe malaria were aware that artesunate was the recommended treatment, 49% said that intramuscular injection was the preferred route of administration, and 60% stated the correct dose. The overall knowledge level of the treatment policy was low at 21% and only slightly higher among trained than untrained health workers (24% vs 14%; p < 0.001) and those with access to guidelines versus those without access (29% vs 17%; p < 0.001). Conclusions The readiness of primary health facilities and health workers to deliver appropriate pre‐referral care to children with complicated malaria in Kenya is inadequate. Further investments are required to ensure (a) availability of nationally recommended pre‐referral antimalarials; (b) appropriate training and supervision in their administration, and (c) monitoring of the entire referral process.
Collapse
Affiliation(s)
| | - Beatrice Machini
- Division of National Malaria Programme Ministry of Health Nairobi Kenya
| | - George Githuka
- Division of National Malaria Programme Ministry of Health Nairobi Kenya
| | - Philip Bejon
- KEMRI‐Wellcome Trust Research Programme Nairobi Kenya
- Centre for Tropical Medicine and Global Health University of Oxford UK
| | - Dejan Zurovac
- KEMRI‐Wellcome Trust Research Programme Nairobi Kenya
- Centre for Tropical Medicine and Global Health University of Oxford UK
| | - Robert W Snow
- KEMRI‐Wellcome Trust Research Programme Nairobi Kenya
- Centre for Tropical Medicine and Global Health University of Oxford UK
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Machini B, Achia TN, Chesang J, Amboko B, Mwaniki P, Kipruto H. Cross-sectional study to predict subnational levels of health workers' knowledge about severe malaria treatment in Kenya. BMJ Open 2022; 12:e058511. [PMID: 34987048 PMCID: PMC8734019 DOI: 10.1136/bmjopen-2021-058511] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES This study applied a Bayesian hierarchical ecological spatial model beyond predictor analysis to test for the best fitting spatial effects model to predict subnational levels of health workers' knowledge of severe malaria treatment policy, artesunate dosing, and preparation. SETTING County referral government and major faith-based hospitals across 47 counties in Kenya in 2019. DESIGN AND PARTICIPANTS A secondary analysis of cross-sectional survey data from 345 health workers across 89 hospitals with inpatient departments who were randomly selected and interviewed. OUTCOME MEASURES Three ordinal outcome variables for severe malaria treatment policy, artesunate dose and preparation were considered, while 12 individual and contextual predictors were included in the spatial models. RESULTS A third of the health workers had high knowledge levels on artesunate treatment policy; almost three-quarters had high knowledge levels on artesunate dosing and preparation. The likelihood of having high knowledge on severe malaria treatment policy was lower among nurses relative to clinicians (adjusted OR (aOR)=0.48, 95% CI 0.25 to 0.87), health workers older than 30 years were 61% less likely to have high knowledge about dosing compared with younger health workers (aOR=0.39, 95% CI 0.22 to 0.67), while health workers exposed to artesunate posters had 2.4-fold higher odds of higher knowledge about dosing compared with non-exposed health workers (aOR=2.38, 95% CI 1.22 to 4.74). The best model fitted with spatially structured random effects and spatial variations of the knowledge level across the 47 counties exhibited neighbourhood influence. CONCLUSIONS Knowledge of severe malaria treatment policies is not adequately and optimally available among health workers across Kenya. The factors associated with the health workers' level of knowledge were cadre, age and exposure to artesunate posters. The spatial maps provided subnational estimates of knowledge levels for focused interventions.
Collapse
Affiliation(s)
- Beatrice Machini
- Department of Public and Global Health, University of Nairobi, Nairobi, Kenya
- Ministry of Health, Division of National Malaria Programme, Nairobi, Kenya
| | - Thomas No Achia
- Department of Public and Global Health, University of Nairobi, Nairobi, Kenya
- School of Mathematics and Computer Science, University of Kwa Zulu Natal, Kwa Zulu Natal, South Africa
| | - Jacqueline Chesang
- Department of Public and Global Health, University of Nairobi, Nairobi, Kenya
| | - Beatrice Amboko
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Paul Mwaniki
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Hillary Kipruto
- World Health Organization, Regional Office for Africa, Eastern and Southern Africa, Harare, Zimbabwe
| |
Collapse
|
9
|
Alegana VA, Macharia PM, Muchiri S, Mumo E, Oyugi E, Kamau A, Chacky F, Thawer S, Molteni F, Rutazanna D, Maiteki-Sebuguzi C, Gonahasa S, Noor AM, Snow RW. Plasmodium falciparum parasite prevalence in East Africa: Updating data for malaria stratification. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000014. [PMID: 35211700 PMCID: PMC7612417 DOI: 10.1371/journal.pgph.0000014] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
The High Burden High Impact (HBHI) strategy for malaria encourages countries to use multiple sources of available data to define the sub-national vulnerabilities to malaria risk, including parasite prevalence. Here, a modelled estimate of Plasmodium falciparum from an updated assembly of community parasite survey data in Kenya, mainland Tanzania, and Uganda is presented and used to provide a more contemporary understanding of the sub-national malaria prevalence stratification across the sub-region for 2019. Malaria prevalence data from surveys undertaken between January 2010 and June 2020 were assembled form each of the three countries. Bayesian spatiotemporal model-based approaches were used to interpolate space-time data at fine spatial resolution adjusting for population, environmental and ecological covariates across the three countries. A total of 18,940 time-space age-standardised and microscopy-converted surveys were assembled of which 14,170 (74.8%) were identified after 2017. The estimated national population-adjusted posterior mean parasite prevalence was 4.7% (95% Bayesian Credible Interval 2.6-36.9) in Kenya, 10.6% (3.4-39.2) in mainland Tanzania, and 9.5% (4.0-48.3) in Uganda. In 2019, more than 12.7 million people resided in communities where parasite prevalence was predicted ≥ 30%, including 6.4%, 12.1% and 6.3% of Kenya, mainland Tanzania and Uganda populations, respectively. Conversely, areas that supported very low parasite prevalence (<1%) were inhabited by approximately 46.2 million people across the sub-region, or 52.2%, 26.7% and 10.4% of Kenya, mainland Tanzania and Uganda populations, respectively. In conclusion, parasite prevalence represents one of several data metrics for disease stratification at national and sub-national levels. To increase the use of this metric for decision making, there is a need to integrate other data layers on mortality related to malaria, malaria vector composition, insecticide resistance and bionomic, malaria care-seeking behaviour and current levels of unmet need of malaria interventions.
Collapse
Affiliation(s)
- Victor A. Alegana
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Peter M. Macharia
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | - Samuel Muchiri
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Eda Mumo
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Elvis Oyugi
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
| | - Alice Kamau
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Frank Chacky
- National Malaria Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Sumaiyya Thawer
- National Malaria Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabrizio Molteni
- National Malaria Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Damian Rutazanna
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | - Catherine Maiteki-Sebuguzi
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Abdisalan M. Noor
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - 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, United Kingdom
| |
Collapse
|
10
|
Amboko B, Stepniewska K, Malla L, Machini B, Bejon P, Snow RW, Zurovac D. 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. PLoS One 2021; 16:e0259020. [PMID: 34739519 PMCID: PMC8570506 DOI: 10.1371/journal.pone.0259020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 10/11/2021] [Indexed: 11/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Lucas Malla
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Beatrice Machini
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Robert W. Snow
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
11
|
Alegana VA, Suiyanka L, Macharia PM, Ikahu-Muchangi G, Snow RW. Malaria micro-stratification using routine surveillance data in Western Kenya. Malar J 2021; 20:22. [PMID: 33413385 PMCID: PMC7788718 DOI: 10.1186/s12936-020-03529-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is an increasing need for finer spatial resolution data on malaria risk to provide micro-stratification to guide sub-national strategic plans. Here, spatial-statistical techniques are used to exploit routine data to depict sub-national heterogeneities in test positivity rate (TPR) for malaria among patients attending health facilities in Kenya. METHODS Routine data from health facilities (n = 1804) representing all ages over 24 months (2018-2019) were assembled across 8 counties (62 sub-counties) in Western Kenya. Statistical model-based approaches were used to quantify heterogeneities in TPR and uncertainty at fine spatial resolution adjusting for missingness, population distribution, spatial data structure, month, and type of health facility. RESULTS The overall monthly reporting rate was 78.7% (IQR 75.0-100.0) and public-based health facilities were more likely than private facilities to report ≥ 12 months (OR 5.7, 95% CI 4.3-7.5). There was marked heterogeneity in population-weighted TPR with sub-counties in the north of the lake-endemic region exhibiting the highest rates (exceedance probability > 70% with 90% certainty) where approximately 2.7 million (28.5%) people reside. At micro-level the lowest rates were in 14 sub-counties (exceedance probability < 30% with 90% certainty) where approximately 2.2 million (23.1%) people lived and indoor residual spraying had been conducted since 2017. CONCLUSION The value of routine health data on TPR can be enhanced when adjusting for underlying population and spatial structures of the data, highlighting small-scale heterogeneities in malaria risk often masked in broad national stratifications. Future research should aim at relating these heterogeneities in TPR with traditional community-level prevalence to improve tailoring malaria control activities at sub-national levels.
Collapse
Affiliation(s)
- Victor A Alegana
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya. .,Geography and Environmental Science, University of Southampton, Southampton, SO17 1BJ, UK. .,Faculty of Science and Technology, Lancaster University, Lancaster, LAI 4YW, UK.
| | - Laurissa Suiyanka
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Peter M Macharia
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Grace Ikahu-Muchangi
- National Malaria Control Programme, Ministry of Health, P.O Box 30016-00100, Nairobi, Kenya
| | - Robert W Snow
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ, UK
| |
Collapse
|