The Impact of an Intervention to Improve Malaria Care in Public Health Centers on Health Indicators of Children in Tororo, Uganda (PRIME): A Cluster-Randomized Trial.

Sarah G Staedke,Catherine Maiteki-Sebuguzi,Clare I R Chandler,Levi Mugenyi,Simon P Kigozi,Edith Mbabazi,Grant Dorsey,Emily L Webb,Barbara A Willey,Moses R Kamya,Samuel Gonahasa,Deborah D Diliberto

doi:10.4269/ajtmh.16-0103

Abstract

Optimizing quality of care for malaria and other febrile illnesses is a complex challenge of major public health importance. To evaluate the impact of an intervention aiming to improve malaria case management on the health of community children, a cluster-randomized trial was conducted from 2010–2013 in Tororo, Uganda, where malaria transmission is high. Twenty public health centers were included; 10 were randomized in a 1:1 ratio to intervention or control. Households within 2 km of health centers provided the sampling frame for the evaluation. The PRIME intervention included training in fever case management using malaria rapid diagnostic tests (mRDTs), patient-centered services, and health center management; plus provision of mRDTs and artemether–lumefantrine. Cross-sectional community surveys were conducted at baseline and endline (N = 8,766), and a cohort of children was followed for approximately 18 months (N = 992). The primary outcome was prevalence of anemia (hemoglobin < 11.0 g/dL) in children under 5 years of age in the final community survey. The intervention was delivered successfully; however, no differences in prevalence of anemia or parasitemia were observed between the study arms in the final community survey or the cohort. In the final survey, prevalence of anemia in children under 5 years of age was 62.5% in the intervention versus 63.1% in control (adjusted risk ratio = 1.01; 95% confidence interval = 0.91–1.13; P = 0.82). The PRIME intervention, focusing on training and commodities, did not produce the expected health benefits in community children in Tororo. This challenges common assumptions that improving quality of care and access to malaria diagnostics will yield health gains.

Highlights

Over the past decade, encouraging reductions in malaria burden have been documented worldwide, after heavy investment in malaria control measures.[1,2] these successes have been achieved primarily in lower transmission settings.[3]
Cross-sectional community surveys were conducted at baseline and endline (N = 8,766), and a cohort of children was followed for approximately 18 months (N = 992)
On the basis of this formative research and the priorities identified by local stakeholders, we developed an intervention to improve the quality of care delivered for malaria and other childhood febrile illnesses by training health workers in public health centers, and ensuring adequate supplies of malaria rapid diagnostic tests (mRDTs) and artemisinin-based combination therapies (ACTs).[22]

Summary

Introduction

Over the past decade, encouraging reductions in malaria burden have been documented worldwide, after heavy investment in malaria control measures.[1,2] these successes have been achieved primarily in lower transmission settings.[3] In Uganda, despite some progress,[4] the burden of malaria has remained high, calling for an expansion in malaria control efforts.[5,6] Provision of good quality care, including accurate diagnosis and prompt effective antimalarial treatment, is a key malaria control strategy.[7,8] health system challenges limit access to good quality care and contribute to poor progress on malaria control.[9,10,11] Interventions to improve the quality of care provided in the public sector, and to improve health outcomes, are urgently needed.[12] the optimal approach to quality improvement and fever case management is not clear, in low- and middleincome countries.[9,13,14]

Objectives

Methods

Results

Conclusion