Intervention activities for this study will be: facilities invited to supply RDTs; demonstration on how to use RDTs; provider training and supervision; and school-based intervention.
Facilities invited to supply RDTs
RDTs for diagnosing malaria will be made available to all health facilities that participate in the study and attend the demonstration by the research team on how to use RDTs. The RDT that will be provided is SD Bioline Malaria Ag Pf, which was chosen in conjunction with the States Malaria Control Programme, and is reported to have a minimum detection rate for
P. falciparum of 97.5% even at low levels of parasitaemia (200 parasites/μL) [
30].
Estimates of RDTs required at each facility will be determined in discussion with the facility head and based on routine records for the number of febrile patients that a facility can expect during 1 month (taking into account seasonal variations) as well as data gathered during the formative research. The research team will procure adequate quantities of RDT kits to last throughout the evaluation phase. The project will also be responsible for distributing the RDTs to health facilities. Facilities will be able to request stocks from the research team when they run out or collect them from the research team’s office. Stock management records will be kept by the research team to monitor the distribution of RDTs. The RDT kits will be stamped for identification and facilities will be advised to store them in a cool, dry place. The research team has developed a commodity tracking system involving the use of stock issuing and stock receiving vouchers to keep track of the kits so they know when there is likely to be a stock-out.
Currently, the state government advises that RDTs should be available without charge in primary health centers for pregnant women and children under 5 years old. Hence, the project will not charge any fee for RDTs in the public sector. However, RDTs will be distributed to providers of private facilities at a subsidized cost of 50 Naira (US$0.3) per testa. Facilities are asked not to sell kits beyond 100 (US$0.6) to their clients so that the test can remain affordable. These facilities will reimburse the study team when they finish using the test kits. The study team will not supply ACTs to health facilities.
Provider training intervention (including support visits)
In addition to the supply of RDTs and the demonstration of how to use RDTs, facilities in clusters randomized to arms 2 and 3 will receive additional provider training and support visits. Provider training on malaria diagnosis and treatment will be conducted over 2 days and contains six training modules on: (1) Knowledge on malaria; (2) Introduction of the updated guidelines for malaria diagnosis and treatment; (3) Appropriate diagnosis; (4) Appropriate treatment when test is positive; (5) Appropriate treatment when test is negative; and (6) Effective communication. Together these training modules will improve providers’ knowledge and skills on why it is important to test for malaria, how to use a RDT, and the effective implementation of clinical guidelines. The first module describes the current burden of malaria in Nigeria, in addition to its causes, signs, and symptoms. The second module reviews the clinical guidelines and highlights the importance of malaria testing in febrile patients before treatment is prescribed. The module on appropriate diagnosis includes a practical session in which all providers will get hands-on experience of the steps involved in using an RDT. This is equivalent to the intervention ‘demonstration on how to use RDTs’ that is delivered to participants in Arm 1. Module 4 provides training on what treatment to give when a test is positive, the recommended types of antimalarial drugs, including the dosage regimens for different age groups and types of ACT. Module 5 provides advice on other causes of febrile illness which should be investigated if the malaria test is negative. The objective of the last module on communication is to improve health provider knowledge of the importance of patient communication and barriers to effective communication. Providers will learn how to discuss different treatment options with patients especially when the test result is negative.
Training will be conducted in different venues depending on the study site. In Enugu, the Laboratory of the Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu will be the venue. In Udi, the district hospital conference center and local government area headquarters hall will be used. The following types of providers will be invited to the training: in the public facilities, the officer in charge and one other health worker who is involved in prescribing treatment; and in the private, the head of the facility or whoever s/he appoints. It is anticipated that two providers from each public facility and one from each private facility will attend. The training will be conducted by eight people from the research team and four people from the state malaria control programme. The trainers will receive extensive briefing by the research team and be given a trainers’ manual in addition to the participants’ manual which provides details of the material for each module and how it should be delivered.
Each training workshop will aim to train 20 to 25 providers. The training primarily takes a seminar style in which the trainer delivers the training material, though there will be discussions, practical sessions, and question and answer sessions using short case scenarios. A participants training manual will be given to providers that attend the training course and this includes all essential reference material such as the malaria treatment guidelines. Participants will also be provided with job aides on how to perform RDTs, a treatment algorithm which can be displayed in their facilities and a poster describing all categories of nationally recommended drugs for the treatment of malaria, their generic names, and dosage regimens. While not enforced, all participants of the provider training will be strongly encouraged to train others who are involved in malaria treatment at their facilities.
Members of the research team will provide support visits to each facility every month during the implementation phase (3 months) and the subsequent evaluation phase (approximately 2 months) to monitor and assess what they are doing and to reinforce the skills acquired by providers during the earlier training workshops. During the support visits, where possible, providers will be observed delivering treatment to patients who have sought treatment for fever, and questions on the different aspects of the training will also be asked. Based on the responses, guidance will be provided on areas where the provider is experiencing difficulty. Providers will also be asked about any challenges implementing what they were taught during the training.
School-based intervention
This intervention will be implemented in selected primary and secondary schools in communities randomized to arm 3. Peer health education has been shown to influence the knowledge, attitudes, and practice of school children and their families as well as the wider community [
31]. In Enugu State, school-based health education helped to improve community awareness and participation in onchocerciasis control activities [
32‐
34]. In Ghana [
35], Lao PDR [
36], and Thailand [
37], school-based malaria interventions have also been shown to improve overall control of malaria within the communities where the schools were located.
One of the documented advantages of school-based interventions is their ability to reach a relatively large proportion of any given community [
38]. The reach of a school-based intervention in Nigeria is expected to be comparable. About 75% of households have school-aged children (either their direct children or wards) and about 44% of school-aged children (6–17 years) are in schools (50% in primary school, 42% in junior secondary school, and 36% in senior secondary school) [
32].
The research team will train two teachers per school (one health teacher and one social teacher) who will in turn train six school children as peer health educators (PHEs) with the support from the research team, giving 130 teachers and 390 peer-health educators in total. The PHEs will be responsible for implementing a range of activities designed to raise awareness about diagnosing malaria using RDTs and that ACTs are the recommended antimalarial. Activities including dramas, songs, card games, and health talks, will be undertaken during morning assembly, Parent Teachers Association (PTA) meetings, and at some school events such as prize-giving days. In addition, teachers and PHEs are supported to hold their own school malaria events involving parents, guardians, and other community members that will be invited to participate in card games, dramas, songs, and health talks. Handbills, posters, T-shirts, and baseball caps promoting the school-based intervention will be distributed at all events. A short description of each type of activity is given below.
A short drama will emphasize the rational use of antimalarial drugs, including the use of ACTs and the need to test before treatment. The school children will perform the drama in school. Each drama session will last for no more than 15 minutes. Transportation and costumes will be procured by the research team and T-shirts will be given to the drama team with the inscription ‘REACT AGAINST MALARIA’. A drama sketch has been developed by a local theater artist for training purposes.
The research team provides teachers with malaria songs that they in turn will communicate to PHEs. The songs will emphasize the need to go for a test when one has a fever or headache and to take an ACT when the test is positive. Three different songs have been composed by local artists. Each of the songs will last for 5 minutes and contain up to four verses.
A card game will be introduced to school children and community members, which teaches and reinforces components of appropriate treatment of malaria. Between four and six participants take turns in collecting cards and achieve a point when they present three cards that show a patient has received treatment in line with guidelines. This can be achieved by presenting a ‘patient with fever’ card accompanied by a ‘RDT positive’ card and an ‘ACT’ card, or alternatively by presenting a ‘patient with fever’ card accompanied with an ‘RDT negative’ card and a ‘further investigation’ card. The game ends when a participant has treated five patients in line with the guidelines and scored 5 points.
Health talks will be given by the PHEs to the schoolchildren in selected primary and secondary schools in the intervention clusters. The health talk will include issues about appropriate treatment of malaria including the need to have a malaria test before taking treatment, asking for ACTs when the malaria test is positive, not asking for an antimalarial when the malaria test is negative, not to take monotherapies, and and the importance of sharing the knowledge they have gained with other members of their households.
PHEs will place posters in classrooms, head teachers’ offices, staff common rooms, assembly grounds, and other strategic places. Handbills will be shared with community members during malaria events in schools and also be given to providers at the facilities so they can distribute to patients who visit the facilities. The posters will also be displayed at health facilities and at prominent places in the intervention clusters such as market places, village squares, and village halls. The key messages contained in the posters and handbills include steps towards appropriate treatment of malaria (that is the need to have a diagnostic test before taking malaria treatment; people should ask for or receive ACTs when a test is positive; people should not receive an antimalarial when a test is negative; and people should not receive monotherapy).
The research team will conduct support visits to each school every month during the implementation phase and the subsequent evaluation phase to guide and encourage teachers and PHEs involved in the school-based malaria education. During these visits they will check to see if teachers have created PHEs and if possible attend a meeting of the PHEs. Where PHEs have not been set up, the research team will encourage and support their establishment. Also during support visits, the team will review preparations for the school malaria event and attempt to observe the drama group rehearsals and health talk presentations, and check if posters have been displayed.