Abstract
BackgroundHealth workers' compliance with outpatient malaria case-management guidelines has been improving, specifically regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., ‘test and treat’). Whether the improvements in compliance with ‘test and treat’ guidelines are consistent across different malaria endemicity areas has not been examined.MethodsData from 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 were analysed. Four primary indicators (i.e., ‘test and treat’) and eight secondary indicators of artemether-lumefantrine (AL) dosing, dispensing, and counselling were measured. Mixed logistic regression models were used to analyse the annual trends in compliance with the indicators across the different malaria endemicity areas (i.e., from highest to lowest risk being lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission, and low risk).ResultsCompliance with all four ‘test and treat’ indicators significantly increased in the area with the highest malaria risk (i.e., lake endemic) as follows: testing of febrile patients (OR = 1.71 annually; 95% CI = 1.51–1.93), AL treatment for test-positive patients (OR = 1.56; 95% CI = 1.26–1.92), no anti-malarial for test-negative patients (OR = 2.04; 95% CI = 1.65–2.54), and composite ‘test and treat’ compliance (OR = 1.80; 95% CI = 1.61–2.01). In the low risk areas, only compliance with test-negative results significantly increased (OR = 2.27; 95% CI = 1.61–3.19) while testing of febrile patients showed declining trends (OR = 0.89; 95% CI = 0.79–1.01). Administration of the first AL dose at the facility significantly increased in the areas of lake endemic (OR = 2.33; 95% CI = 1.76–3.10), coast endemic (OR = 5.02; 95% CI = 2.77–9.09) and semi-arid seasonal transmission (OR = 1.44; 95% CI = 1.02–2.04). In areas of the lowest risk of transmission and highland epidemic zone, none of the AL dosing, dispensing, and counselling tasks significantly changed over time.ConclusionsThere is variability in health workers' compliance with outpatient malaria case-management guidelines across different malaria-risk areas in Kenya. Major improvements in areas of the highest risk have not been seen in low-risk areas. Interventions to improve practices should be targeted geographically.
Highlights
Health workers’ compliance with outpatient malaria case-management guidelines has been improving, regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., ‘test and treat’)
The present analysis aims to examine 2010–2016 compliance trends within and between malaria epidemiological zones in Kenya to identify sub-national deficiencies in compliance with guidelines
The trend analysis across five epidemiological zones included a range of 932 to 2,766 febrile patients aged between 1 month and 98 years, 129 to 1,178 test positive, 321 to 882 test negative, 191 to 1,620 AL prescribed and 184 to 1,570 patients who had AL dispensed at facilities with available ‘test and treat’ commodities across 11 survey rounds conducted from 2010 to 2016
Summary
Health workers’ compliance with outpatient malaria case-management guidelines has been improving, regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., ‘test and treat’). In 2010, the globally recommended practice was universal testing of all suspected malaria patients and treatment of only test-positive patients with artemisinin-based combination therapy (ACT). This standard is referred to as ‘test and treat’ policy [4]. Effective supply chains must ensure universal and continuous availability of malaria testing and ACT as a basic pre-requisite for the policy implementation at health facilities. The effectiveness of test-based management depends on how well healthcare workers comply with malaria case-management guidelines when attending to suspected cases [5,6,7,8,9]
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