Does test-based prescription of evidence-based treatment for malaria improve treatment seeking and satisfaction? Findings of repeated cross-sectional surveys in Papua New Guinea

Abstract

IntroductionThe presumptive treatment of febrile illness with antimalarial medication is becoming less common in low-income and middle-income countries as access to reliable diagnostic tests improves. We explore whether the shift towards test-based antimalarial prescription, and the introduction of highly efficacious artemisinin combination therapies (ACTs), reduces critical delays in seeking treatment for febrile illness or increases patient satisfaction.MethodsWe conducted countrywide repeat, cross-sectional surveys in 118 randomly selected primary healthcare services in Papua New Guinea. The clinical case management of 1765 consecutively presenting febrile patients was observed and exit interviews were completed at discharge. This was done prior to implementation of test-based ACT prescription (2011) and at 12 (2012) and 60 months (2016) postimplementation. We conducted multiple logistic regressions. Treatment response time was dichotomised as <24 hours from symptom onset vs 24+ hours. Satisfaction was dichotomised as a ‘high’ vs ‘low’ rating based on participant response to a visual, 7-point Likert-type scale.Results62% (322/517) of febrile patients reported seeking treatment within 24 hours of symptom onset in 2011 compared with 53% (230/434) in 2012 and 42% (339/814) in 2016. Adjusted ORs for reporting a treatment response time <24 hours in the postimplementation surveys were 0.77 (95% CI 0.48 to 1.26) and 0.45 (95% CI 0.31 to 0.65), respectively when compared with the preimplementation period. 53% (230/533) of febrile patients reported ‘high’ satisfaction with the service received in 2011 compared with 32% (143/449) in 2012 and 35% (278/803) in 2016. Adjusted ORs for reporting high satisfaction in the postimplementation surveys were 0.52 (95% CI 0.32 to 0.85) and 0.65 (95% CI 0.39 to 1.10), respectively when compared with the preimplementation period.ConclusionNationwide implementation of test-based ACT prescription in Papua New Guinea has increased the likelihood of critical treatment seeking delays and decreased patient satisfaction with the service received.

Repeated mosquito net distributions, improved treatment, and trends in malaria cases in sentinel health facilities in Papua New Guinea

“…In the two sites in which an increase in the number of malaria cases was observed following the introduction of ACT, overall facility attendance did not suggest an availability effect resulting from the introduction of free intervention, as documented elsewhere [41,42]. A recent study in PNG even suggests that the shift to test-based ACT treatment may have negatively impacted treatment seeking and patient satisfaction, possibly related to low perceived quality of care provided to patients with non-malarial illness [43]. Differences in the length of post-intervention periods used for the regression model may have affected the reliability of estimates for Dreikikir as the period preceding ACT introduction was only 3 months (Additional file 2), most likely not enough to gain reliable estimates for both interventions.…”

Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa

“…However, these advances may come at a serious clinical cost if true malaria cases in vulnerable groups at risk of poor outcomes are left untreated. It is well known that changing one health care practice can have unintended consequences for other practices; for example, mRDT introduction also tends to drive more prescription of antibiotics [35,54], and it can also influence patient satisfaction with care and affect the likelihood of treatment seeking [54,55]. The introduction of diagnostic technology is not always straightforward, and future interventions should emphasise the importance of following recommendations for both test-positive and test-negative patients.…”