Exploring health providers’ and community perceptions and experiences with malaria tests in South-East Nigeria: a critical step towards appropriate treatment

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Abstract

Background

The adoption of ACT as the first line treatment for uncomplicated malaria in Nigeria has concentrated attention on the role of testing in appropriate malaria treatment. There are calls at both national and global level for malaria treatment to be based on test result, but it is still unclear how testing can be incorporated into treatment-seeking and practices of health providers. This study explored community members and health providers’ perceptions and experiences with malaria tests in south east Nigeria.

Methods

The study was conducted in urban and rural areas of Enugu state in south-eastern Nigeria. A total of 18 focus group discussions with 179 community members including sub-groups of primary caregivers, adult men and adult women aged 15 years and above. Twenty- six (26) In-depth interviews were held with public and private health providers involved in prescribing medicines at public and private health facilities in the study area.

Results

Both providers and community members were familiar with malaria tests and identified malaria tests as an important step to distinguish malaria from other illnesses with similar symptoms and as a means of delivering appropriate treatment. However, the logic of test-directed treatment was undermined by cost of test and a lack of testing facilities but above all concerns over the reliability of negative test results, with community members and providers observing inconsistencies between results and symptoms, and providers attributing inaccurate results to incompetencies of technicians. Recognition of malaria symptoms was deemed most important in determining the use of antimalarial drugs rather than the result of a malaria test.

Conclusion

The results highlight important areas of intervention to promote appropriate malaria treatment. If tests are to play a role in patient management, demand and supply side interventions are needed to change people’s attitude towards malaria test results.

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Most cited references 20

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Laboratory medicine in Africa: a barrier to effective health care.

Cathy Petti, Christopher Polage, Thomas C Quinn … (2006)

Providing health care in sub-Saharan Africa is a complex problem. Recent reports call for more resources to assist in the prevention and treatment of infectious diseases that affect this population, but policy makers, clinicians, and the public frequently fail to understand that diagnosis is essential to the prevention and treatment of disease. Access to reliable diagnostic testing is severely limited in this region, and misdiagnosis commonly occurs. Understandably, allocation of resources to diagnostic laboratory testing has not been a priority for resource-limited health care systems, but unreliable and inaccurate laboratory diagnostic testing leads to unnecessary expenditures in a region already plagued by resource shortages, promotes the perception that laboratory testing is unhelpful, and compromises patient care. We explore the barriers to implementing consistent testing within this region and illustrate the need for a more comprehensive approach to the diagnosis of infectious diseases, with an emphasis on making laboratory testing a higher priority.

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Rapid diagnostic tests compared with malaria microscopy for guiding outpatient treatment of febrile illness in Tanzania: randomised trial.

Hugh Reyburn, Hilda Mbakilwa, Rose Mwangi … (2007)

To compare rapid diagnostic tests (RDTs) for malaria with routine microscopy in guiding treatment decisions for febrile patients. Randomised trial. Outpatient departments in northeast Tanzania at varying levels of malaria transmission. 2416 patients for whom a malaria test was requested. Staff received training on rapid diagnostic tests; patients sent for malaria tests were randomised to rapid diagnostic test or routine microscopy Proportion of patients with a negative test prescribed an antimalarial drug. Of 7589 outpatient consultations, 2425 (32%) had a malaria test requested. Of 1204 patients randomised to microscopy, 1030 (86%) tested negative for malaria; 523 (51%) of these were treated with an antimalarial drug. Of 1193 patients randomised to rapid diagnostic test, 1005 (84%) tested negative; 540 (54%) of these were treated for malaria (odds ratio 1.13, 95% confidence interval 0.95 to 1.34; P=0.18). Children aged under 5 with negative rapid diagnostic tests were more likely to be prescribed an antimalarial drug than were those with negative slides (P=0.003). Patients with a negative test by any method were more likely to be prescribed an antibiotic (odds ratio 6.42, 4.72 to 8.75; P<0.001). More than 90% of prescriptions for antimalarial drugs in low-moderate transmission settings were for patients for whom a test requested by a clinician was negative for malaria. Although many cases of malaria are missed outside the formal sector, within it malaria is massively over-diagnosed. This threatens the sustainability of deployment of artemisinin combination treatment, and treatable bacterial diseases are likely to be missed. Use of rapid diagnostic tests, with basic training for clinical staff, did not in itself lead to any reduction in over-treatment for malaria. Interventions to improve clinicians' management of febrile illness are essential but will not be easy. Clinical trials NCT00146796 [ClinicalTrials.gov].

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Improving community health worker use of malaria rapid diagnostic tests in Zambia: package instructions, job aid and job aid-plus-training

Steven Harvey, Larissa Jennings, Masela Sekeseke-Chinyama … (2008)

Background Introduction of artemisinin combination therapy (ACT) has boosted interest in parasite-based malaria diagnosis, leading to increased use of rapid diagnostic tests (RDTs), particularly in rural settings where microscopy is limited. With donor support, national malaria control programmes are now procuring large quantities of RDTs. The scarcity of health facilities and trained personnel in many sub-Saharan African countries means that limiting RDT use to such facilities would exclude a significant proportion of febrile cases. RDT use by volunteer community health workers (CHWs) is one alternative, but most sub-Saharan African countries prohibit CHWs from handling blood, and little is known about CHW ability to use RDTs safely and effectively. This Zambia-based study was designed to determine: (i) whether Zambian CHWs could prepare and interpret RDTs accurately and safely using manufacturer's instructions alone; (ii) whether simple, mostly pictorial instructions (a "job aid") could raise performance to adequate levels; and (iii) whether a brief training programme would produce further improvement. Methods The job aid and training programme were based on formative research with 32 CHWs in Luangwa District. The study team then recruited three groups of CHWs in Chongwe and Chibombo districts. All had experience treating malaria based on clinical diagnosis, but only six had prior RDT experience. Trained observers used structured observation checklists to score each participant's preparation of three RDTs. Each also read 10 photographs showing different test results. The first group (n = 32) was guided only by manufacturer's instructions. The second (n = 21) used only the job aid. The last (n = 26) used the job aid after receiving a three-hour training. Results Mean scores, adjusted for education, age, gender and experience, were 57% of 16 RDT steps correctly completed for group 1, 80% for group 2, and 92% for group 3. Mean percentage of test results interpreted correctly were 54% (group 1), 80% (group 2), and 93% (group 3). All differences were statistically significant (p < 0.05). Conclusion Manufacturer's instructions like those provided with the RDTs used in this study are insufficient to ensure safe and accurate use by CHWs. However, well-designed instructions plus training can ensure high performance. More study is underway to determine how well this performance holds up over time.

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Author and article information

Contributors

Ogochukwu P Ezeoke

Nkoli N Ezumah

Clare CI Chandler

Lindsay J Mangham-Jefferies

Obinna E Onwujekwe

Virginia Wiseman

Benjamin S Uzochukwu

Journal

Journal ID (nlm-ta): Malar J

Journal ID (iso-abbrev): Malar. J

Title: Malaria Journal

Publisher: BioMed Central

ISSN (Electronic): 1475-2875

Publication date Collection: 2012

Publication date (Electronic): 6 November 2012

Volume: 11

Page: 368

Affiliations

[1 ]Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria

[2 ]Department of Sociology/Anthropology, University of Nigeria, Nsukka, Nigeria

[3 ]Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

[4 ]Department of Health Administration and Management, University of Nigeria, Enugu Campus, Nsukka, Nigeria

[5 ]Department of Community Medicine, College of Medicine, University of Nigeria, Enugu Campus, Nsukka, Nigeria

Article

Publisher ID: 1475-2875-11-368

DOI: 10.1186/1475-2875-11-368

PMC ID: 3507662

PubMed ID: 23130706

SO-VID: 0d464111-334d-41a2-9fad-3493e3390832

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Exploring health providers’ and community perceptions and experiences with malaria tests in South-East Nigeria: a critical step towards appropriate treatment

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Abstract

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Most cited references 20

Laboratory medicine in Africa: a barrier to effective health care.

Rapid diagnostic tests compared with malaria microscopy for guiding outpatient treatment of febrile illness in Tanzania: randomised trial.

Improving community health worker use of malaria rapid diagnostic tests in Zambia: package instructions, job aid and job aid-plus-training

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