Challenges with adherence to the ‘test, treat, and track’ malaria case management guideline among prescribers in Ghana

Factors influencing health workers' adherence to malaria treatment guidelines in under-five children in Nigeria: A scoping review

Background

Malaria is a leading cause of mortality in children aged 5 years and below in Nigeria. Treatment guidelines stipulate among other recommendations, testing by microscopy or a rapid diagnostic test (RDT) before treatment. Non-adherence to these guidelines portends a challenge, especially among vulnerable under-five children. This study explored the factors influencing Nigerian public health workers' (HWs) adherence to these guidelines in under-five children.

Methods

A review of literature published between 2011- 2023 was conducted on Web of Science, Ovid Embase, Medline, Global Health, CAB Abstracts, Scopus, and Global Index Medicus. Data was extracted and analyzed under 4 themes: diagnosis, compliance with test results, use of recommended treatment, post-treatment counselling and severe malaria management.

Results

Nineteen (19) studies were included for review. Training and supervision, RDT and antimalarial availability, good knowledge of, and positive perception of RDTs promoted adherence to mRDT use. A lack of confidence in RDTs and age (≥ 40 years) fuelled presumptive treatment, especially among clinicians. mRDT and artemisinin-based combination therapy (ACT) stockouts dissuaded HWs from adhering to case management guidelines. Caregiver pressure for treatment was identified as a barrier to compliance with test results.

Conclusions

It is important to design context-specific strategies to improve adherence to guidelines for malaria case management, especially in under-five children. Training on the guidelines should be tailored, needs-based, and continuous, and HWs should be supportively supervised in implementing case management. Maintaining an adequate supply of quality-assured mRDTs and antimalarials can facilitate adherence to the guidelines.

Comparative evaluation of the diagnostic accuracies of four different malaria rapid diagnostic test kits available in Ghana

Malaria rapid diagnostic test (mRDT) kit is one of the techniques for diagnosing malaria. Due to its inherent advantages over the microscopy technique, several brands of the kit have flooded malaria endemic countries, without prior in-country evaluation. Two of such mRDT kits are Oscar (India) and Standard Q (Korea Republic). In this study, the performance of Oscar and Standard Q mRDT kits were compared to First Response (India) and CareStart (USA) mRDTs, which have been evaluated and deployed for use approved by the Ministry of Health (MOH). In this comparative study, whole blood samples were collected from patients suspected of malaria. Plasmodium falciparum was detected in each sample using nested polymerase chain reaction (nPCR), microscopy and the four mRDTs. The sensitivities, specificities, accuracies, positive and negative predictive values and accuracies of the mRDTs were determined using nPCR as a reference technique. Kappa statistic was used to determine the level of agreement among the techniques. Two hundred (200) blood samples were analyzed in this study. The overall detection rates of P. falciparum by microscopy, First Response, CareStart, Oscar-PfHRP2, Standard Q mRDT kits and nPCR were 31.5%, 34.5%, 33.5%, 32%, 31% and 43% (x2 = 6.1, p = 0.046), respectively. The accuracies of CareStart and First Response were comparable (90.5% vs. 89.5%). Further, comparing their sensitivities, Oscar-PfHRP2 was 74.4% (95% confidence interval (CI): 63.9-83.2) while that of Standard Q was 72.1% (95% CI: 61.4-81.2), with comparable accuracies (Oscar-PfHRP2-89% and Standard Q -88%). Apart from First Response that was 98.3% specific, the others were 100% specific. Kappa test revealed perfect diagnostic agreement (κ = 0.90-0.98) among the four mRDTs. That notwithstanding, Oscar-PfHRP2 agreed better with CareStart (κ = 0.94) and First Response (κ = 0.92) compared to the agreement between Standard Q and, CareStart (κ = 0.92) and First Response (κ = 0.90). Taken together, the diagnostic performance of the four mRDT kits were statistically similar. That notwithstanding, new mRDT kits should be evaluated prior to deployment for use.

Improving Malaria Case Management and Referral Relationships at the Primary Care Level in Ghana: Evaluation of a Quality Assurance Internship

In Ghana, Community-based Health Planning and Services (CHPS) compounds managed by trained nurses and midwives called community health officers (CHOs) play a major role in malaria service delivery. With heavy administrative burdens and minimal training in providing patient care, particularly for febrile illnesses, including malaria, CHOs struggle to comply with the World Health Organization's test, treat, and track initiative guidelines and appropriate referral practices. A clinical training and mentorship program was implemented for CHOs to prevent and manage uncomplicated malaria and offer appropriate pre-referral treatment and referrals to district hospitals. Medical officers, pharmacists, midwives, health information officers, and medical laboratory scientists at 52 district referral hospitals were trained as mentors; CHOs from 520 poorly performing CHPS compounds underwent a 5-day internship at their assigned district referral hospital to improve knowledge and clinical skills for malaria case management. Three months later, mentors conducted post-training mentoring visits to assess knowledge and skill retention and provide ongoing on-the-job guidance. Significant percentage-point increases were observed immediately post-internship for history taking (+12.0, 95% confidence interval [CI]=8.3, 15.1; P<.001); fever assessment (+24.9, 95% CI=20.9, 29.3; P<.001); severe malaria assessment and referral (+32.0, 95% CI=28.2, 35.8; P<.001); and knowledge assessment (+15.8, 95% CI=10.0, 21.3; P<.001). Three months later, a third assessment revealed these gains were largely maintained. Analysis of national health management information system data showed statistically significant improvements in testing, treatment, and referral indicators at intervention CHPS compounds after the intervention that were not observed in comparison CHPS compounds. This training and mentorship approach offers a replicable model to build primary care provider competencies in malaria prevention and management and demonstrates how developing relationships between primary care and first-level referral facilities benefits both providers and clients. More methodologically rigorous studies are needed to measure the impact of this approach.