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

Abstract

Background: The 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.

Methods: A 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.

Results: Standard 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.

Conclusions: Small 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 registration: ClinicalTrials.gov NCT01292707.

Figure 1

Flow of facilities through assessment of eligibility, selection and randomization. ^† Strata 1 and 3 had fewer malaria cases in Kilimanjaro and Tanga, respectively, while strata 2 and 4 had more malaria cases when dividing the districts into two equal categories based on the proportion of malaria consultations. Equal numbers of facilities were randomized to each arm within strata. ^‡ Control represents the standard RDT training arm. HW represents the health worker intervention arm. HWP represents the health worker and patient-oriented intervention arm.

Figure 2

Flow of facilities, health workers (prescribers) and patients through different stages of the intervention and evaluation. The outcome data collection periods include eligible patients presenting at the facilities between the intervention implementation activities. For example, evaluation period 1 commences after the standard RDT training and initial RDT supply until the start of the intervention training. See Table 1 for further details on timing of intervention implementation and evaluation. The total data collection is based on all eligible patients presenting at the facilities following the standard RDT training until the final exit survey. It, therefore, includes patients presenting during the intervention implementation activities which were excluded in the outcome data collection periods. RDT, rapid diagnostic test.

Figure 3

Flow chart defining the primary outcome and showing prescribing practices. ^† Fever status not known for 40 patients in the control arm, 14 in the HW arm and 6 in the HWP arm. Of these patients, five (13%) in the control, four (29%) in the HW arm and three (50%) in the HWP arm also had alternate diagnosis missing. Data on whether or not they had an RDT and the result is known for all patients with missing fever status but are not included in the analysis. ^‡ Obvious alternate diagnosis (soft tissue, ear or urine infection) not known for four patients in each arm among those with a history of fever, and one in the control arm and five in the HW arm for those with no history of fever. Data on whether or not they had an RDT (and the result) is known for all these patients but are not included in the analysis. ^⋄ Whether or not an RDT was taken is unknown for one patient in the control arm. ^# RDT result is unknown for 77 (1%) in the control arm, 94 (1%) in the HW arm and 92 (2%) in the HWP arm. ^∫ Recommended antimalarial (rAM) defined as quinine for children under 2 months, Artemether Lumefantrine (ALu) or quinine for women of childbearing age, and ALu for all others. Abx represents antibiotics; HW, health worker; HWP, health worker plus patient-oriented; RDT, rapid diagnostic test.