Adherence to malaria rapid diagnostic test result among healthcare workers in Sokoto metropolis, Nigeria

This study was conducted in Sokoto metropolis, Sokoto State, Nigeria. Sokoto State is located in North-West, Nigeria between longitude 3° and 7° E and latitude 10° and 14° N of the Equator (Fig. 1). According to the 2018 projected population, the metropolis has a total population of 858,005 (based on 2006 population census) distributed in 3 Local Government Areas (namely: Sokoto-North, Sokoto-South and Wamakko). The predominant tribes are Hausa and Fulani while Islam is the main religion. Agriculture, petty trading and craftsmanship are the main occupations of the people [12].

The prevalence of malaria in Nigeria has been found to be 22.6% by RDT [13]. This varies across the six geopolitical zones of the country and across the various states in the zones. In the north-west zone of the country malaria prevalence is 33.8%. In Sokoto State, malaria is hyper-endemic with RDT prevalence of 36.4% and transmission season from January to August [13, 14]. The arrangement of houses within the metropolis is irregular with poor environmental sanitation. This leads to the development of water pools/retention sites during the rainy season, thus providing favourable breeding sites for mosquitoes. Sokoto metropolis has 1379 health care workers of different cadres spread across both public and private health facilities.

The Nigerian health system classifies the public health facilities into primary, secondary and tertiary health facilities. In Sokoto metropolis there are 33 Primary Health Care Centres, 3 secondary health care centres and a tertiary health care centre providing care to over a million people. In the Primary Health Centres (PHCs), malaria is treated by community extension workers, nurses, laboratory scientist and pharmacy technicians while physicians do same in secondary and tertiary heath centres.

Beginning in 2010, over 68 million RDT kits have been deployed for use in Nigeria by the National Malaria Elimination Program (NMEP) to various states in the country [15]. Malaria rapid diagnostic test kits are supplied periodically to the Sokoto State Ministry of Health by NMEP and the United State President’s Malaria Initiative (PMI) through United States Agency for International Development (USAID). From the Central Medical Store, the RDT kits are distributed to health facilities using the Direct Delivery and Information Capture ‘DDIC’ to quantify what each health facility requires. By using the retrospective data in prior month, RDTs were supplied subsequently to each health facility based on surveillance data (average number of fever cases) and logistic data (consumption data available in bi-monthly health facility stock reporting forms). At the time of the study, SD-Bioline malaria RDT Histidine-rich protein (HRP-2) kits were in use. The kits detect the presence of HRP-2 antigen of Plasmodium falciparum; which accounts for 94% of malaria infection in Nigeria [2]. As done in other states in Nigeria, training and retraining of health care workers on RDT is implemented periodically by the Sokoto State Ministry of Health with the support of PMI/USAID in both private and public health sectors since the adoption of the test and treat policy in 2010 [16]. State Logistic Management Coordinating Unit, Sokoto State Ministry of Health with guidance from Global Fund-funded Nigeria Supply Chain Integration Project (NSCIP) of National Product Supply Chain Management Programme ‘NPSCMP’ Federal Ministry of Health—Nigeria, implements the supply chain system for RDT kits. An RDT positive result in a febrile patient suspected of malaria, qualifies for the use of ACT as the first-line of therapy as recommended by the WHO.

This was a cross-sectional study conducted among health care workers in Sokoto Metropolis. The study population comprises Doctors, Nurses, Medical laboratory Scientist, Pharmacy technicians and Community Health Workers (CHWs) in primary and secondary public health facilities within the metropolis. At the PHCs, the CHWs are in three categories each with a specific qualification obtained at the end of their training. The Junior Community Health Extension Worker (JCHEW) are the lowest in the ladder and are awarded a certificate at the end of their training. The next are the Community Health Extension Workers (CHEWs) who obtains a national diploma at the end of their training. The last being the Community Health Officers (CHOs) who are equally awarded higher national diploma at the end of their training. The CHEWs constitute the majority of the healthcare workers in the Primary Health Care Centres. The study was carried out from 1st March to 31st May, 2018.

The inclusion criterion were HCWs whose job prescription in the health facility included diagnosis and treatment of febrile illnesses. HCWs from private and tertiary health facilities were excluded from the study.

A sample size of 276 was calculated using a prevalence of 76.5% [17]. At Zα of 1.96, and a precision of 5%. The sampling frame of all the public health facilities in Sokoto metropolis was obtained from the Sokoto state ministry of health. To ensure representativeness, five- primary and one secondary health facilities were randomly selected from each of the three LGAs in the metropolis. Using a sampling frame (N) of all the health care workers providing care to febrile patients, proportionate to size allocation was applied to determine the proportion of each cadre of HCWs. This was multiplied by the sample size to ascertain the actual number of respondents per cadre(n). The sampling interval was calculated by dividing “N” with “n” (N/n). The first HCW was selected randomly using a table of random numbers and subsequently, every nth HCW was selected until the sample size was completed, see Table 1.

The interview was conducted at the primary and secondary health care facilities in Sokoto metropolis. Data were collected with a pre-tested, semi-structured interviewer-administered questionnaire using mobile data capturing device (Open Data Kit). The questionnaire collected information on respondents’ demographic variables (age, gender, level of education, marital status), cadre, years of practice, previous training on malaria case management, adherence to RDT results in the treatment of malaria and what influenced the treatment of fever with anti-malarial medicine (an artemisinin-based combination) whenever RDT result is negative. Being a cross-sectional study, participants were interviewed once during the survey (Additional file 1).

The primary outcome was the proportion of healthcare workers that adhered to RDT result when treating patient suspected of malaria in the study facility. Adherence to test result was defined as HCW administering ACT to RDT positive patient and withholding such to RDT negative patients. The primary outcome was assessed using five questions as follows: (1) Is RDT result available at the time of treating the patient [Yes/No]. (2) In the last 6 months, would you say you always complied with the test result when treating your patient with suspected malaria [Yes/No]. (3) In the last 6 months, when prescribing medications to your patients suspected of malaria, do you use RDT result to determine who receives or does not receive ACT [Yes/No]. (4) are you confident of treating patient suspected of malaria using the national malaria treatment guideline [Yes/No] and lastly (5) Do you think treatment of malaria according to the test results will reduce unnecessary use of ACTs [Yes/No].

Data were summarized using descriptive statistics such as frequency and proportions for categorical variables. Measures of central tendency were computed for continues variables namely: mean and standard deviation for age and median and interquartile range (IQR) for years of practice. Responses to adherence related questions were coded as 1 for a positive response and zero for a negative one. The maximum obtainable score was five. A score of at least 80% of the maximum possible score was considered as good adherence and poor if otherwise. Association between adherence and sociodemographic/HCW related characteristics were examined using Chi-square test. The odds ratio and the 95% confidence intervals of the odds ratio were reported. To identify the predictors of adherence, variables found to be statistically significant at 10% level using bivariate logistic regression were included in the multiple logistic regression model. However, the prediction model was based on 5% level of significance. Four models were used to predict the factors associated with HCW adherence to test results. The factors were categorized into socio-demographic and HCW related factors. Model 1 contained the crudes odds ratio of both group of predictive factors, model 2 contained socio-demographic factors that were significant at 10% in model 1, model 3 included HCW-related factors significant in model 1, and model 4 included all the predictors of adherence. To evaluate for the model fit, Hosmer & Lemeshow goodness of fit tests was assessed.

About 211 (81%) of the respondents had good adherence. Being a certificate holder (OR: 4.38, 95% CI 1.31–14.61), having had training on malaria case management (OR: 3.07, 95% CI 1.54-6.08), presence of fever in the patient consulted by the HCW (OR: 4.59, 95% CI 2.29–9.21) and patients’ expectation to be given anti-malarial (OR: 4.36, 95% CI 2.12–8.95) were statistically significantly associated with adherence to RDT result (Table 3).

The model 1 of the logistic regression revealed that HCWs who were certificate holders in Junior Community Extension Worker were 4 times (OR: 4.4, 95% CI 1.3–14.6) more likely to have good adherence to RDT results than those with tertiary degree holders (B.Sc. or H.N.D). Similarly, HCWs who had attained diploma were 2 times (OR: 2.3, 95% CI 1.1–4.7) more likely to have good adherence to RDT results than those with tertiary degree holders. The likelihood of good adherence to RDT result was higher among HCWs who had received training on malaria case management (OR: 3.0, 95% CI 1.5–6.1) than their counterparts who were not previously exposed to such training. Similarly, HCWs whose patient presented with fever were 4.5 times more likely to have good adherence (OR: 4.59, 95% CI 2.29–9.21). The predictors of adherence to RDT results (model 4) among health care workers were prior training on malaria case management (aOR: 2.63, 95% CI 1.26–5.44), the presence of fever in the patient being consulted by the HCW (aOR: 2.53, 95% CI 1.18–5.43) and expectation of the patient to be given anti-malarial medicine by the HCW even when RDT result is negative (aOR: 3.06, 95% CI 1.42–6.58), see Table 4.