Background
Methods
Study design and data collection
Malaria case definitions
1. Suspect uncomplicated malaria categories by age and pregnancy status |
Children <5 years of age or pregnant women in the first trimester: |
History of fevera or measured axillary temperature ≥37.5 °C |
Patients ≥5 years of age |
History of fevera or measured axillary temperature ≥37.5 °C AND at least one additional sign or symptom suggestive of malaria (i.e., chills, muscle or joint pain, headache, vomiting, diarrhoea, weakness, nausea, dizziness, fatigue or abdominal pain) |
2. Suspect severe malaria |
Patients with any of the following: history of convulsions, lethargy, no urine output, jaundice, coca-cola-coloured urine, palmar pallor, or vomiting everything |
For patients <5 years of age, neck stiffness or unable to drink or breastfeed were also included |
Definition of outcomes
Statistical analyses
Results
Descriptive summary
Health facility characteristics
n | % | |
---|---|---|
Operation of health facility | ||
Ministry of Health | 84 | 80.0 |
CHAM | 21 | 20.0 |
Health facility type | ||
Health centre | 90 | 85.7 |
Community hospital | 9 | 8.6 |
District hospital | 6 | 5.7 |
Diagnostic capacity | ||
Microscopy service functional for full day of survey | 26 | 24.8 |
RDTs in stock for full day of survey | 83 | 79.1 |
Either microscopy or RDT functional for day of surveya
| 94 | 89.5 |
Haemoglobin testing functional for full day | 11 | 10.5 |
Infrastructure and equipment available on day of survey | ||
Clean drinking water | 93 | 88.6 |
Cups for administering oral medications available | 69 | 65.7 |
Functioning hanging or standing scale | 98 | 90.5 |
Functioning thermometer | 69 | 65.7 |
Availability of 2013 malaria treatment guidelines on day of survey | ||
Copy of 2013 national or other reference material on malaria treatment guidelines | 50 | 47.6 |
Wall flowchart with 2013 malaria treatment guidelines | 14 | 13.3 |
Anti-malarial drugs in stock for the full day on day of survey | ||
---|---|---|
A. First-line treatment for uncomplicated malaria in pregnant women (1st trimester) and children <5 kg | ||
Quinine tablets | 37 | 35.2 |
B. First-line treatment for uncomplicated malaria in all other patients | ||
At least one artemether-lumefantrine (AL) formulation | 96 | 91.4 |
AL 1 × 6 dose-pack (regular or dispersible) | 88 | 83.8 |
AL 2 × 6 dose-pack (regular or dispersible) | 77 | 73.3 |
AL 3 × 6 dose-pack | 83 | 79.1 |
AL 4 × 6 dose-pack | 77 | 73.3 |
C. Second-line treatment for uncomplicated malaria (treatment failure or when AL is contra-indicated) | ||
Artesunate-amodiaquine (co-formulated or co-blistered) | 32 | 30.5 |
Any first- or second-line anti-malarial treatment for uncomplicated malaria | 98 | 93.3 |
D. Pre-referral treatment for severe malaria | ||
Any injectable pre-referral treatment (artesunate or quinine) | 103 | 98.1 |
Parenteral artesunate | 88 | 83.8 |
Parenteral quinine | 94 | 89.5 |
Artesunate suppositories | 6 | 5.7 |
Health worker characteristics
n | % | |
---|---|---|
Cadre of health worker caring for patients in sampled outpatient department | ||
Medical assistant (2 years of formal training plus 1 year internship) | 100 | 66.7 |
Clinical officer (3 years of formal training plus 1 year internship) | 23 | 15.3 |
Nurseb (at least 3 years of formal training) | 21 | 14.0 |
Patient attendant (no formal training) | 4 | 2.7 |
Pharmacy technician (2 years of formal training) | 1 | 0.7 |
Health surveillance assistant (6 weeks of formal training) | 1 | 0.7 |
Training and guidelines | ||
Malaria case management (in-service)c training ≥2013 | 113 | 75.3 |
Malaria case management (on-the-job)d training ≥2013 | 53 | 35.3 |
Either in-service or on-the-job malaria case management training ≥2013 | 128 | 85.3 |
Integrated management of childhood illness (IMCI) training within the last 5 years | 27 | 18.0 |
Has a copy of the latest malaria treatment guidelines (dated ≥2013) | 70 | 46.7 |
Supervision | ||
Received any supervision in the past 6 months | 101 | 67.3 |
Received at least two supervisory visits in the past 6 months | 67 | 44.7 |
Supervision visits that included observation of patient consultations | 55 | 36.7 |
At least one supervisory visit with observation of patient consultations that involved assessing health workers’ knowledge and prescription practices of anti-malarial drugse
| 36 | 24.0 |
Other characteristics | Median (IQR) | Min–Max |
Age | 29.0 (26.0, 36.0) | 21–75 |
Years of experience | 4.0 (2.0, 7.0) | 0–45 |
Patient characteristics
n/N | Weighted percent (95% CI) | |
---|---|---|
Demographics (years) | ||
<5 | 723/2342 | 28.3 (21.8, 34.8) |
≥5 | 1619/2342 | 71.7 (65.2, 78.2) |
Suspect malaria classification | ||
Suspect malaria cases (both uncomplicated and severe) | 1695/2342 | 73.4 (70.2, 76.6) |
Suspect uncomplicated malaria | 1605/1695 | 95.4 (94.2, 96.6) |
Suspect severe malaria | 90/1695 | 4.6 (3.4, 5.8) |
Symptoms spontaneously reported to HW by suspect malaria patients | ||
Fever | 1146/1695 | 68.5 (64.0, 73.0) |
When patient did not spontaneously report fever, HW asked about fever | 295/549 | 51.6 (46.0, 57.2) |
Headache | 553/1695 | 33.4 (28.6, 38.2) |
Vomiting | 284/1695 | 16.9 (14.3, 19.5) |
Skin problem | 99/1695 | 5.5 (3.9, 6.9) |
Testing for suspect uncomplicated malaria patients who attended HFs with diagnostic tests | ||
Tested by either microscopy or RDT | 1072/1427 | 75.7 (68.9, 82.5) |
Positive RDT or microscopy | 547/1072 | 53.2 (46.0, 60.4) |
Medications administered, prescribed or dispensed to confirmed uncomplicated malaria patients | ||
Treated with first- or second-line antimalarial (AM)a
| 511/547 | 92.7 (85.4, 99.9) |
Treated with other anti-malarialb
| 12/547 | 4.7 (0.0, 11.9) |
No anti-malarial | 24/547 | 2.6 (1.2, 4.0) |
Medications administered, prescribed or dispensed to presumed uncomplicated malaria patients | ||
Treated with first- or second-line AMa
| 98/178 | 60.3 (45.1, 75.5) |
Treated with other anti-malarialc
| 5/178 | 2.8 (0.0, 8.3) |
No anti-malarial | 75/178 | 36.8 (22.8, 50.8) |
Suspect severe malaria | ||
Received recommended pre-referral anti-malariald
| 8/90 | 5.7 (0.3, 11.0) |
Referred or told to get in-patient admission right away | 11/90 | 6.9 (1.9, 11.9) |
Received pre-referral anti-malarial plus immediate referral/admission | 3/90 | 1.6 (0.0, 3.6) |
Treated with other anti-malariale
| 46/90 | 59.6 (46.4, 72.8) |
No anti-malarial | 36/90 | 34.7 (22.4, 47.0) |
Malaria testing and treatment practices among suspect malaria patients
Dispensing and dosing practices and patient knowledge among uncomplicated malaria patients who had an ACT dispensed at the HF
n/N | Weighted percent (95% CI) | |
---|---|---|
1. ACT dispensing and dosing
| ||
Total number of uncomplicated (confirmed and presumed) malaria patients | 725/2342 | 33.0 (27.2, 38.8) |
Received an ACT (AL or ASAQ)a
| 609/725 | 84.9 (77.2, 92.5) |
ACT dispensed | 534/609 | 88.9 (80.1, 97.7) |
ACT correctly dosed when dispensedb
| 505/534 | 94.9 (92.7, 97.2) |
Type of ACT dispensed | ||
AL dispensed | 517/534 | 97.2 (93.3, 100.0) |
AL correctly dosed when dispensed | 490/534 | 92.5 (88.2, 96.8) |
ASAQ dispensed | 17/534 | 2.8 (0.0, 6.7) |
ASAQ correctly dosed when dispensedc
| 16/17 | 93.6 (3.7, 100.0) |
HWs provided patients with the following ACT counselling information | ||
First dose of ACT given at HF | 72/534 | 16.8 (3.2, 30.3) |
HW explained how to take ACT at home | 495/534 | 91.8 (88.7, 94.8) |
HW advised what to do in case of vomiting within 30 min of taking ACT | 36/534 | 7.5 (4.8, 10.1) |
HW instructed to complete all doses of ACT even if he/she feels better | 316/534 | 60.9 (52.7, 69.1) |
HW instructed to take AL with food, milk or milk containing drinkd
| 141/517 | 27.9 (20.2, 35.7) |
2. Patient ACT dosing knowledge
| ||
Correct knowledge regarding all aspects of ACT dosinge
| 404/534 | 78.1 (72.3, 83.8) |
Knows correct amount of ACT (tablet or syrup) to take per dose | 460/534 | 85.9 (81.3, 90.6) |
Knows total number of days to complete ACT dose | 473/534 | 90.6 (86.8, 94.3) |
Knows correct number of AL doses to take per day | 474/534 | 89.5 (86.0, 93.0) |
Factors associated with appropriate testing among suspect uncomplicated malaria patients
Factors | Number of patients | Number tested (weighted %) | Unadjusted OR (95% CI) |
p value | Adjusted OR (95% CI) |
p value |
---|---|---|---|---|---|---|
Patient spontaneously reported these complaints to the HW | ||||||
Fever | ||||||
Yes | 950 | 784 (81.8) | 2.6 (1.6–4.3) | <0.0001 | 2.6 (1.7–4.0) | <0.0001 |
No | 477 | 288 (62.9) | Ref | Ref | ||
Headache | ||||||
Yes | 481 | 380 (79.4) | 1.4 (0.9–1.9) | 0.055 | 1.5 (1.1–2.2) | 0.017 |
No | 946 | 692 (73.8) | Ref | Ref | ||
Vomiting | ||||||
Yes | 223 | 194 (86.1) | 2.2 (1.2–4.2) | 0.016 | 2.0 (1.0–4.0) | 0.040 |
No | 1204 | 878 (73.8) | Ref | Ref | ||
Skin problem | ||||||
Yes | 80 | 37 (49.0) | 0.3 (0.2–0.5) | <0.0001 | 0.4 (0.2–0.6) | 0.0001 |
No | 1347 | 1035 (77.1) | Ref | Ref |
n/N | Weighted percent (95% CI) | OR (95% CI) | p value | |
---|---|---|---|---|
Interaction term included in the model: supervision * 2013 malaria treatment guidelines available | ||||
Supervision * Guidelines | 299/389 | 75.9 (66.1, 85.8) | 2.2 (0.8, 6.6) | 0.143 |
Supervision * No guidelines | 438/559 | 78.8 (69.5, 88.0) | 2.7 (0.9, 8.0) | 0.073 |
No supervision * Guidelines | 161/190 | 87.4 (77.6, 97.2) | 6.2 (1.6, 24.7) | 0.009 |
No supervision * No guidelines | 174/289 | 56.8 (36.2, 77.4) | Ref |
Factors associated with appropriate treatment among presumed uncomplicated malaria patients
Factors | Number of patients | Number treated (weighted %) | Unadjusted OR (95% CI) |
p value | Adjusted OR (95% CI) |
p value |
---|---|---|---|---|---|---|
Patient spontaneously reported fever to the HW | ||||||
Yes | 126 | 79 (68.6) | 3.5 (1.7–7.3) | 0.001 | 5.7 (1.9–17.6) | 0.002 |
No | 52 | 19 (38.4) | Ref | Ref | ||
Patient temperature (°C)—surveyor measured | 1.3 (1.0–1.7) | 0.032 | 1.5 (1.1–1.9) | 0.005 | ||
HW age (years) | 1.0 (1.0–1.1) | 0.001 | 1.1 (1.0–1.1) | <0.0001 | ||
Number of supervision visits | 1.1 (0.9–1.3) | 0.135 | 1.2 (1.0–1.4) | 0.029 |