Prescriber and patient-oriented behavioural interventions to improve use of malaria rapid diagnostic tests in Tanzania: facility-based cluster randomised trial

Abstract

BackgroundThe increasing investment in malaria rapid diagnostic tests (RDTs) to differentiate malarial and non-malarial fevers, and an awareness of the need to improve case management of non-malarial fever, indicates an urgent need for high quality evidence on how best to improve prescribers’ practices.MethodsA three-arm stratified cluster-randomised trial was conducted in 36 primary healthcare facilities from September 2010 to March 2012 within two rural districts in northeast Tanzania where malaria transmission has been declining. Interventions were guided by formative mixed-methods research and were introduced in phases. Prescribing staff from all facilities received standard Ministry of Health RDT training. Prescribers from facilities in the health worker (HW) and health worker-patient (HWP) arms further participated in small interactive peer-group training sessions with the HWP additionally receiving clinic posters and patient leaflets. Performance feedback and motivational mobile-phone text messaging (SMS) were added to the HW and HWP arms in later phases. The primary outcome was the proportion of patients with a non-severe, non-malarial illness incorrectly prescribed a (recommended) antimalarial. Secondary outcomes investigated RDT uptake, adherence to results, and antibiotic prescribing.ResultsStandard RDT training reduced pre-trial levels of antimalarial prescribing, which was sustained throughout the trial. Both interventions significantly lowered incorrect prescribing of recommended antimalarials from 8% (749/8,942) in the standard training arm to 2% (250/10,118) in the HW arm (adjusted RD (aRD) 4%; 95% confidence interval (CI) 1% to 6%; P = 0.008) and 2% (184/10,163) in the HWP arm (aRD 4%; 95% CI 1% to 6%; P = 0.005). Small group training and SMS were incrementally effective. There was also a significant reduction in the prescribing of antimalarials to RDT-negatives but no effect on RDT-positives receiving an ACT. Antibiotic prescribing was significantly lower in the HWP arm but had increased in all arms compared with pre-trial levels.ConclusionsSmall group training with SMS was associated with an incremental and sustained improvement in prescriber adherence to RDT results and reducing over-prescribing of antimalarials to close to zero. These interventions may become increasingly important to cope with the wider range of diagnostic and treatment options for patients with acute febrile illness in Africa.Trial registrationClinicalTrials.gov (#NCT01292707) 29 January 2011.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0346-z) contains supplementary material, which is available to authorized users.

Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings

“…§Tanz1 recorded medicines actually obtained by patients; other studies recorded medicines prescribed. ¶Figure is lower than that reported in primary paper 39 because the present analysis included all patients with data, rather than only patients defined by study as mRDT-eligible. **Only subset of patients (n=497) in Uga-priv followed up after consultation to collect data on medicines prescribed.…”

“…Detailed descriptions of the individual studies are available in open access publications. [36][37][38][39][40][41][42][43] We included in the analysis studies that met the following criteria: evaluated an intervention to implement rapid diagnostic tests for malaria in settings where participating providers could prescribe both antimalarials and antibiotics, compared sites with and without the intervention, documented prescriber behaviour as a primary outcome, and collected individual patient data on diagnostic test results and treatments prescribed including antibiotics. Tables 1 and 2 present descriptions of the nine studies meeting these criteria.…”

“…Rapid diagnostic tests were introduced among government sponsored community health workers (Afgh-com (T Leslie, et al, in preparation)), in public health facilities only (Afghpub, 36 Cam-pub, 37 Ghan-pub, 38 Tanz1-pub, 40 Tanz2pub, 39 Uga-pub 43 ), in private drug shops only (Uga-priv 41 ), and in a combination of public facilities, private pharmacies, and drug shops (Nige-mix 42 ). Most studies included were cluster randomised trials of interventions, with the exception of two individually randomised trials (Afgh-pub, 36 Ghan-pub 38 ), and one descriptive study before and after national implementation of rapid diagnostic tests (Tanz1-pub 40 ).…”

Compliance with Malaria Rapid Diagnostic Test Results and Correlates among Clinicians in Uyo, Akwa Ibom State, Nigeria: 2018

“…They also demonstrated that enhanced training has no effect on compliance with RDT positive result and adherence to treatment guidelines [23]. Cundill et al in another study conducted in Tanzania also demonstrated that training may influence compliance with RDT negative result, but has no effect on compliance with RDT positive result [24]. Some other related study conducted in Burkina Faso revealed that even enhanced training has no effect on compliance with RDT negative results [25] but rather the availability and access to alternative diagnostic methods for other common febrile illnesses [14].…”

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

“…The eight studies included in this analysis were conducted between 2007 and 2013 in Cameroon, Ghana, Nigeria, Tanzania, and Uganda [20][21][22][23][24][25][26][27]. The studies assessed the introduction of mRDTs among health care providers in public health centres (Cam1, Ghan1, Tanz1, Tanz2, Uga1), public and private facilities (Nige1), private drug shops (Uga3), and community health programmes (Uga2).…”