Abstract
BackgroundDeployment of highly effective artemisinin-based combination therapy for treating uncomplicated malaria calls for better targeting of malaria treatment to improve case management and minimize drug pressure for selecting resistant parasites. The Integrated Management of Malaria curriculum was developed to train multi-disciplinary teams of clinical, laboratory and health information assistants.MethodsEvaluation of training was conducted in nine health facilities that were Uganda Malaria Surveillance Programme (UMSP) sites. From December 2006 to June 2007, 194 health professionals attended a six-day course. One-hundred and one of 118 (86%) clinicians were observed during patient encounters by expert clinicians at baseline and during three follow-up visits approximately six weeks, 12 weeks and one year after the course. Experts used a standardized tool for children less than five years of age and similar tool for patients five or more years of age. Seventeen of 30 laboratory professionals (57%) were assessed for preparation of malaria blood smears and ability to interpret smear results of 30 quality control slides.ResultsPercentage of patients at baseline and first follow-up, respectively, with proper history-taking was 21% and 43%, thorough physical examination 18% and 56%, correct diagnosis 51% and 98%, treatment in compliance with national policy 42% and 86%, and appropriate patient education 17% and 83%. In estimates that adjusted for individual effects and a matched sample, relative risks were 1.86 (95% CI: 1.20,2.88) for history-taking, 2.66 (95%CI: 1.60,4.41) for physical examination, 1.77 (95%CI: 1.41,2.23) for diagnosis, 1.96 (95%CI: 1.46,2.63) for treatment, and 4.47 (95%CI: 2.68,7.46) for patient education. Results were similar for subsequent follow-up and in sub-samples stratified by patient age. Quality of malaria blood smear preparation improved from 21.6% at baseline to 67.3% at first follow-up (p < 0.008); sensitivity of interpretation of quality control slides increased from 48.6% to 70.6% (p < 0.199) and specificity increased from 72.1% to 77.2% (p < 0.736). Results were similar for subsequent follow-up, with the exception of a significant increase in specificity (94.2%, p < 0.036) at one year.ConclusionA multi-disciplinary team training resulted in statistically significant improvements in clinical and laboratory skills. As a joint programme, the effects cannot be distinguished from UMSP activities, but lend support to long-term, on-going capacity-building and surveillance interventions.
Highlights
Deployment of highly effective artemisinin-based combination therapy for treating uncomplicated malaria calls for better targeting of malaria treatment to improve case management and minimize drug pressure for selecting resistant parasites
To improve case management and minimize drug pressure for selecting resistant parasites, artemisinin-based combination therapy (ACT) should be targeted to patients who are parasite positive, and another diagnosis and treatment should be sought for patients who are not
Descriptive statistics From December 2006 to June 2007, 194 health professionals participated in the Integrated Management of Malaria course at the Infectious Diseases Institute (IDI) in Kampala, of whom 118 were clinicians, 30 were laboratory staff, 32 were records staff, and 14 were district health officers
Summary
Deployment of highly effective artemisinin-based combination therapy for treating uncomplicated malaria calls for better targeting of malaria treatment to improve case management and minimize drug pressure for selecting resistant parasites. In 2010, the World Health Organization (WHO) recommended a prompt parasitological confirmation of diagnosis “in all patients suspected of having malaria before treatment is started [2].” This recommendation has drawn attention to the poor quality of care for patients with fever in general and malaria in specific, and to a search for interventions to improve the quality of care. In a more detailed comparison of five studies with similar research design, in-service training improved the quality of treatment for children with uncomplicated malaria in one out of five studies, guidelines in one out of two studies, wall charts in two out of four studies, and supervision visits in two out of two studies. A more recent study in Tanzania on the effect of introducing malaria rapid diagnostic tests and a brief training course to guide fever case management found no improvement in clinician prescribing practices [6]
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