Factors affecting adherence to national malaria treatment guidelines in management of malaria among public healthcare workers in Kamuli District, Uganda

The World Health Organization (WHO) estimated that there were 214 million cases of malaria in 2015 and 438,000 deaths mostly young children in sub-Saharan Africa [1]. On the African continent, at least 12 billion US dollars are spent in malaria costs of illness, treatment and premature death [2]. A prompt and accurate diagnosis of malaria is the key to effective management of malaria [3–6]. Effective case management of malaria is a major strategy that has been adopted by several countries. It entails proper clinical assessment, laboratory confirmation of the disease either by light microscopy or rapid diagnostic test (RDT) prior to treatment with an effective anti-malarial [1, 4]. In Uganda, malaria remains the leading cause of morbidity (30.4 %) and mortality (12.8 %) in its hospitals [7], with an estimated 12 million clinical cases treated annually in the public health system alone [3]. Clinical diagnosis, using fever as the major symptom, is the most widely used approach by practitioners at all levels of training. This approach has been practice in Uganda for a long time [8]. Moreover, a large number of outpatients do not have malaria parasitaemia. This creates a diagnostic dilemma and reduces the accuracy of this criterion for diagnosis of malaria [5]. The Uganda Ministry of Health (MOH) recommends the WHO parasitological confirmation of malaria either by microscopy or RDT before initiation of treatment as per the national malaria treatment guidelines (NMTG) [5, 6].

Of all malaria-endemic countries in Africa, Uganda ranked third with an average of 30 % of all outpatient department (OPD) clinic visits due to malaria (with most diagnoses made clinically) and with between 20 and 50 % of all hospital admissions a consequence of malaria [9].These admissions are due to late presentation, inadequate management and unavailability or stock-outs of effective drugs [8]. This high burden may be partly a result of misdiagnosis, since many facilities lack laboratory capacity and it is often difficult to clinically distinguish malaria from other infectious diseases. However, malaria remains responsible for a high proportion of public health expenditure on curative treatment, and efforts to reduce malaria incidence would free up available health resources and facilities and health workers’ time to tackle other health issues. Experiences from other countries in sub-Saharan Africa that revised their malaria case management to artemisinin combination therapy (ACT) suggest that health workers’ adherence may be problematic [10–14]. In Kenya, 3 years after the implementation of a protocol stipulating routine malaria microscopy or RDT testing of all adults presenting with fever and prescription of artemether/lumefantrine (AL) to only those who test positive, the testing rates in health facilities with diagnostic malaria services available did not exceed 54 % and nearly a third of test negative cases were prescribed AL [15]. Although a Ugandan study showed use of ACT prevailing over non-recommended therapy, the quality of case management of malaria was not optimal [15]. However, in another review it was noted that health workers’ adherence to revised anti-malarial prescription protocols generally improves over time [16]. Low laboratory staff numbers, non-use of standard treatment guidelines, delay in producing laboratory results, and belief that patients with negative malaria results improved upon treatment with anti-malarials, were some of the factors responsible for low adherence to laboratory results [17, 18].

In Uganda, clinical diagnosis using fever as the major symptom is the most widely used approach by practitioners at all levels of training. Despite fever being a major symptom of malaria, it can occur in other illnesses as well. This creates a diagnostic dilemma and reduces the accuracy of this criterion for diagnosis of malaria [3, 5]. Effective translation of new guidelines into clinical practice is of critical importance to maximize the potential of improved, efficacious therapy and curtail the cost of malaria health care. Despite changes in policy recommendations and reported benefits, reports indicate varying levels of healthcare workers’ adherence to new malaria management guidelines [10–19]. This study was conducted to determine levels of adherence to the national guidelines in the management of uncomplicated malaria in a rural district in Uganda and explore possible reasons for health workers’ adherence or non-adherence.

The study aimed to assess clinician, health system and patient factors affecting adherence to guidelines in management of malaria among public healthcare workers. The results provide some explanations to help understand where possible interventions could improve the level of adherence to national guidelines. Adherence to the national guidelines is quite low at just above 50.6 %. Despite availability of clear guidelines and supervision, health workers do not follow recommended guidelines because of health system and health worker-related reasons. The factors associated with adherence to guidelines were: level of facility, cadre of health worker, presence of job aides in consultation rooms, recent attendance of a CME session on malaria and presence of a functional laboratory.

Better adherence to guidelines was more common practice at lower-level facilities. Related to this was the finding that lower-level cadres, such as nurses and nurse aides, adhered to guidelines better than higher-level cadres, such as clinical officers. This finding was similar to that observed in many other African countries where ACT was introduced [11–15, 17–19, 21, 23]. A study in Kenya by Zurovac et al. showed that nursing aides complied more closely to treatment guidelines than clinical officers [15]. Previous Ugandan studies have shown similar findings with most showing better adherence by clinical officers and nurses than doctors, who are considered better trained [16, 17, 21]. Possible explanations for this could be that higher level trained workers such as medical officers and clinical officers believe they have higher medical acumen and hence a tendency not to use the guidelines. Indeed, many of the clinical officers interviewed reported that their reasons for not adhering to these guidelines were because either the laboratory was not reliable or they could rely on presence of “typical” malaria signs to make a decision.

It could also be that higher-level cadres tend to be in administrative positions and are often missed out for supervision and training. This could be reflective of the pre-service training gaps that include non-alignment of medical school curriculum to national standards.

Unlike most of the previous studies in Uganda and the rest of Africa, this study found presence of job aides and recent participation in a facility-based medical education session was associated with improved adherence to guidelines. This could be explained by there being an ongoing project supporting the district to improve its capacity to manage malaria. As part of the project, in-facility education sessions were conducted and RDTs supplied. It will be interesting to re-assess this after the end of the project.

Thirdly, awareness by clinicians that there was a functional laboratory on most days was associated with better adherence to guidelines. This has not been explored by most of the other studies on this subject [11–19]. Many health workers who did not adhere to guidelines reported that this was because of the delay in getting results from the laboratory. It appears that the key factor in improving diagnostics for malaria was the introduction of RDTs as the vast majority of tests were done with RDTs. Others have shown the availability of RDTs improved malaria case management [21, 23, 24]. Widespread provision of malaria RDTs could well play a significant role in reducing the persistent problem of malaria overdiagnosis and contribute to reduced risk of malaria under-treatment. This is more so in a setting in the most affected parts of the world where microscopic diagnosis is hampered by unavailability of microscopes and electricity.

An important key finding was that prescription of ACT when a malaria diagnosis was made was almost universal with only about 5 % not prescribing ACT. This is a much higher rate than that seen in previous Ugandan studies [18, 19, 21, 23, 25]. This could have been affected by local factors such as limited ACT stocks, ongoing malaria project in the district, and the fact that this was limited to the public sector. Private facilities have been known to be more likely to prescribe non-ACT. This study was limited to the public sector unlike other studies that have included some private sector facilities [24, 25].

This study highlights the significant shortage of human resources in rural districts. More than 60 % of the patients were attended to by nurses and nursing aides. This, despite the fact that nursing aides are not expected to be managing patients according to current health guidelines in Uganda [20].

The lack of association of age of health worker, duration of employment, supervision, educational level and age of patient, in-service training is consistent with the majority of other studies on this subject [11–19, 22, 23, 26].

This study had a number of limitations. First, the study was conducted in public health facilities; this limits generalizability to these facilities. Second, it was conducted in one district in which there was an ongoing project addressing malaria management. This might not be replicated in other districts without such support. Third, despite targeting clients at exit, the study results might have been subject to bias from the Hawthorne effect, since the health workers were aware that their facilities and actions were being observed. The study did not assess impact of patient demands and the study was conducted over a short period of time. Additionally HC IIs were not studied yet they do manage malaria cases. This limits generalizability of findings to all levels of the healthcare system.

This study found that health worker case management decisions were associated with health system and health worker-related factors that are potentially modifiable. Although some recent evidence suggests that use of text message reminders to health workers might improve provider behaviours at low cost, evidence-based interventions to improve rural health worker adherence to management guidelines are generally lacking or show mixed results [26–28]. This study strengthens the case for provision of aides, targeted, facility-based, continuing medical education on malaria, and targeting higher level, trained, health cadres. Another key issue is the need to ensure laboratories or at the very least RDT testing services are readily available to reduce waste of resources due to over-diagnosis [29–31]. Given the lack of good evidence on what works, interventional studies to evaluate the impact of these approaches is required to provide definitive guidance on what interventions best translate into better malaria treatment practices in Uganda.