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.

Keywords: Case-management; Compliance; Kenya; Malaria; Malaria endemicity; Outpatient; ‘Test and treat’.

Fig. 1

Malaria endemicity zones in Kenya and the sampled facilities as purple dots

Fig. 2

The annual mean PfPR_2-10 by malaria epidemiological zones and the test-based policy implementation activities, 2010–2016. To characterize the annual malaria parasite prevalence in the five malaria epidemiological zones of Kenya (lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission and low risk) we used previously published modelling work [36]. In brief, 5020 Plasmodium falciparum parasite prevalence (PfPR) surveys at 3701 communities undertaken in Kenya between 1980 and 2015 were assembled. A spatio-temporal geostatistical model was fitted to predict the annual mean malaria risk and corresponding 2.5–97.5% interquartile credibility range (ICR) for children aged 2–10 years (PfPR_2–10) at 1 × 1 km spatial resolution. The model accounted for unmeasured spatio-temporal risk factors (structured random effects) and unexplained variation within communities (unstructured random effects) while standardizing for age. The annual average PfPR_2–10 and ICR by zone from 2010 to 2015 was then computed for populated areas where malaria transmission is possible. Areas that do not support malaria transmission were defined based on a temperature suitability index (TSI) (TSI zero areas) constructed using land surface temperatures, the average survival of Anopheles mosquitoes and the length of sporogony that must be completed within the lifetime of one Anopheline generation [41]. Populated areas were defined as locations with at least 1 person per km² based on population density maps [42] available at Worldpop data geoportal [43]. The annual mean PfPR_2-10 in populated areas able to support transmission in each of the five MoH epidemiological zones (Fig. 1) were extracted and mapped using ArcMap 10.5 (ESRI Inc., Redlands, CA, USA) and shown for each year 2010–2015 in Fig. 2, against the major milestones of the policy change and implementation

Fig. 3

Outpatient malaria case-management recommendation algorithm

Fig. 4

Time trends in health workers' compliance with outpatient malaria ‘test and treat’ policy by malaria epidemiological zones

Fig. 5

Time trends in health workers’ compliance with AL dosing, dispensing, and counselling by malaria endemicity