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.

Robert W Snow,Philip Bejon,Beatrice Amboko,Beatrice Machini,Lucas Malla,Dejan Zurovac,Kasia Stepniewska

doi:10.1371/journal.pone.0259020

Abstract

BackgroundHealth workers’ compliance with outpatient malaria case-management guidelines has been improving in Africa. This study examined the factors associated with the improvements.MethodsData 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).ResultsAmong 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.ConclusionsTargeting 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.

Highlights

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
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 rapid diagnostic tests (RDTs) stock-outs, community health workers dispensing drugs, access to malaria case
This study is novel in applying regression models and Rowe’s framework [19] to assess the determinants of improvements in health workers’ performance over time using compliance to Determinants of the quality of outpatient malaria case-management outpatient malaria diagnosis and treatment guidelines trends

Summary

Introduction

Malaria continues to be a major public health problem in Africa and case-management is a key component to reducing the malaria burden [1, 2]. Health workers’ compliance with guidelines is one of the key aspects determining the costeffectiveness of the “test and treat” policy implementation [5–7]. Recent studies across Africa have suggested a variety of factors associated with health workers’ compliance with the test-based management of malaria [8, 22–24]. These studies were commonly undertaken at a single point in time [8, 22], focusing on only one of the outcomes (e.g. only testing) [23], and none examined determinants of the improvements in compliance with guidelines over time to assess the factors associated with long-term change in practices.

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Conclusion