Abstract
BackgroundIn 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Yet, evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. National surveys from 12 sub-Saharan African countries were used to examine the effect of diagnostic testing on medicines used by febrile children under five years at the population level, including stratification by malaria risk, transmission season, source of care, symptoms, and age.MethodsData were compiled from 12 Demographic and Health Surveys in 2010–2012 that reported fever prevalence, diagnostic test and medicine use, and socio-economic covariates (n = 16,323 febrile under-fives taken to care). Mixed-effects logistic regression models quantified the influence of diagnostic testing on three outcomes (artemisinin combination therapy (ACT), any anti-malarial or any antibiotic use) after adjusting for data clustering and confounding covariates. For each outcome, interactions between diagnostic testing and the following covariates were separately tested: malaria risk, season, source of care, symptoms, and age. A multiple case study design was used to understand varying results across selected countries and sub-national groups, which drew on programme documents, published research and expert consultations. A descriptive typology of plausible explanations for quantitative results was derived from a cross-case synthesis.ResultsSignificant variability was found in the effect of diagnostic testing on ACT use across countries (e.g., Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes emerged to explain results: available diagnostics and medicines; quality of care; care-seeking behaviour; and, malaria epidemiology.ConclusionsSignificant country variation was found in the effect of diagnostic testing on paediatric fever treatment at the population level, and qualitative results suggest the impact of diagnostic scale-up on treatment practices may not be straightforward in routine conditions given contextual factors (e.g., access to care, treatment-seeking behaviour or supply stock-outs). Despite limitations, quantitative results could help identify countries (e.g., Mozambique) or issues (e.g., malaria risk) where facility-based research or programme attention may be warranted. The mixed-methods approach triangulates different evidence to potentially provide a standard framework to assess routine programmes across countries or over time to fill critical evidence gaps.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-0709-0) contains supplementary material, which is available to authorized users.
Highlights
In 2010, World Health Organization (WHO) revised guidelines to recommend testing all suspected malaria cases prior to treatment
This study uses a mixed-methods approach to analyse the effect of diagnostic testing on paediatric fever treatment at the population level across multiple countries, and to plausibly explain findings in select countries
Results for other covariates included in the final country models are provided in additional files (Additional file 1 and Additional file 2). These results indicate that no studied country had significantly reduced odds of malaria treatment for tested paediatric fevers compared to untested, which is the opposite of the stated hypothesis
Summary
In 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. In 2010, the World Health Organization (WHO) revised guidelines to recommend diagnosis of all suspected malaria cases and treatment based on test results [1], which could greatly improve malaria surveillance, rational drug use and quality fever management [2]. In studies where first-line malaria treatment (artemisinin-based combination therapy (ACT)) was largely restricted to positive cases [13,14,15,16], some research shows widespread prescriptions of other anti-malarial [14,17] or antibiotic [13,15] drugs to test-negative patients and not according to established guidelines [18]. While a few countries have conducted national facility studies to examine case management practices across different sub-national contexts [9,20,21], there remains limited understanding of how these practices may differ across key sub-national groups, notably by malaria risk [6,7,12]
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