Trends in health workers’ compliance with outpatient malaria case-management guidelines across malaria epidemiological zones in Kenya, 2010–2016

Abstract

Background Health workers' compliance with outpatient malaria case-management guidelines has been improving, specifically regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., ‘test and treat’). Whether the improvements in compliance with ‘test and treat’ guidelines are consistent across different malaria endemicity areas has not been examined. Methods Data from 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 were analysed. Four primary indicators (i.e., ‘test and treat’) and eight secondary indicators of artemether-lumefantrine (AL) dosing, dispensing, and counselling were measured. Mixed logistic regression models were used to analyse the annual trends in compliance with the indicators across the different malaria endemicity areas (i.e., from highest to lowest risk being lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission, and low risk). Results Compliance with all four ‘test and treat’ indicators significantly increased in the area with the highest malaria risk (i.e., lake endemic) as follows: testing of febrile patients (OR = 1.71 annually; 95% CI = 1.51–1.93), AL treatment for test-positive patients (OR = 1.56; 95% CI = 1.26–1.92), no anti-malarial for test-negative patients (OR = 2.04; 95% CI = 1.65–2.54), and composite ‘test and treat’ compliance (OR = 1.80; 95% CI = 1.61–2.01). In the low risk areas, only compliance with test-negative results significantly increased (OR = 2.27; 95% CI = 1.61–3.19) while testing of febrile patients showed declining trends (OR = 0.89; 95% CI = 0.79–1.01). Administration of the first AL dose at the facility significantly increased in the areas of lake endemic (OR = 2.33; 95% CI = 1.76–3.10), coast endemic (OR = 5.02; 95% CI = 2.77–9.09) and semi-arid seasonal transmission (OR = 1.44; 95% CI = 1.02–2.04). In areas of the lowest risk of transmission and highland epidemic zone, none of the AL dosing, dispensing, and counselling tasks significantly changed over time. Conclusions There is variability in health workers' compliance with outpatient malaria case-management guidelines across different malaria-risk areas in Kenya. Major improvements in areas of the highest risk have not been seen in low-risk areas. Interventions to improve practices should be targeted geographically.

Determinants of improvement trends in health workers’ compliance with outpatient malaria case-management guidelines at health facilities with available “test and treat” commodities in Kenya

“…Such improvements have been well described in Kenya, where between 2010 and 2016, health workers' compliance with all key outpatient case-management indicators significantly increased [23,26,27]. The differences in compliance trends across malaria epidemiological zones in Kenya have been previously reported [28]. In this paper, the effects of 31 interventional and non-interventional determinants that might be associated with the improvement trends in health workers' compliance with malaria case-management guidelines at health facilities with available diagnostic and treatment commodities for malaria were examined.…”

“…The number of assessed facilities ranged between 169 and 176 facilities per survey round. At each of the surveyed facilities, data collection methods included health facility assessments, interviews with health workers, and exit interviews with all eligible outpatients during one survey day when they were ready to leave the facility [23,26,28]. The patients' exit interviews…”

Malaria micro-stratification using routine surveillance data in Western Kenya

“…information on the quality of slide and reading was unavailable. The quality of diagnosis was not taken into account at the facility levels or the differences in fever testing rates, which is only possible through direct observational audits (54)(55)(56). Finally, the quality of DHIS2 documentation is known to vary (48), and the reliability of individual records cannot be quantified without substantial health facility audits.…”

“…Recent evidence shows that over 90% of suspected malaria cases are subjected to a malaria parasitological test in Western Kenya (31). Malaria rapid diagnostic tests (mRDTs) were introduced to scale-up fever testing of all age groups in 2012 in Kenya (32).…”

Malaria micro-stratification using routine surveillance data in Western Kenya

“…Recent evidence shows that over 90% of suspected malaria cases are subjected to a malaria parasitological test in Western Kenya [ 31 ]. Malaria rapid diagnostic tests (RDTs) were introduced to scale-up fever testing of all age groups in 2012 in Kenya [ 32 ].…”