CITATION: Why do health workers give anti-malarials to patients with negative rapid test results? A qualitative study at rural health facilities in western Uganda

by Robin Altaras, Anthony Nuwa, Bosco Agaba et al.

Malaria Journal 2016, 15:23 (11 January 2016)

http://www.malariajournal.com/content/pdf/s12936-015-1020-9.pdf

Correspondence: clarestrachan10@gmail.com

ABSTRACT: ‘The large-scale introduction of malaria rapid diagnostic tests (RDTs) promises to improve management of fever patients and the rational use of valuable anti-malarials. However, evidence on the impact of RDT introduction on the overprescription of anti-malarials has been mixed. The study found high provider adherence to RDT results, but that providers believed in certain clinical exceptions and felt they lacked alternative options. Guidance on how the RDT works and testing following partial treatment, better methods for assisting providers in diagnostic decision-making, and a context-appropriate provider behaviour change intervention package are needed.’

SELECTED EXTRACTS (selected by Neil PW)

Analysis of observation data and provider interview transcripts identified a number of factors that appeared to affect provider decision-making to prescribe anti-malarials to patients who tested negative. These were grouped into three intersecting thematic areas: clinical beliefs (what providers believe is the right thing to do), capacity constraints and the ability to make an alternative diagnosis (what providers have the means to do), and perception of patient demand (what providers think the patient wants them to do)…

A few providers did however raise doubts over test accuracy, citing patients who tested negative by RDT and then later positive by blood smear examination, which they sometimes attributed to “other strains of malaria” that could not be detected by the RDT…

“Generally I also have some doubts because one time my child fell sick, had all symptoms of malaria, when I did an RDT test, it turned out to be negative. Then the next day, I repeated the test, it again showed negative. Then I took the baby to hospital and that very night, the baby convulsed, they tested her… and the baby had malaria plus plus. Automatically, we put the baby on quinine IV, and the baby improved. So because of that experience, I have some doubts about the RDT results because that was really scaring and worrying.” [HW02, Nurse-midwife, HCIII]

… in cases where patients had already taken ACT prior to coming to the health facility, some providers seemed to presume treatment failure due to resistance, even when there was no prior confirmation that the patient had malaria. In such cases, providers reported shifting ‘automatically’ to prescribing a second-line antimalarial…

“There are some times when I give quinine injection when the patient has signs like shivering, vomiting, headache, very high temperature, etc. yet the patient had taken [AL], but is still very sick. At that point I can give quinine injection even if the RDT was negative because in most cases if the patient takes any anti-malaria drugs before testing, there is a possibility of the results turning out negative… [HW20, Nurse in charge, HCII]

While providers appeared to value RDTs as a confirmatory diagnostic, in observed practice they demonstrated limited capacity to diagnose non-malarial fevers…

Providers’ limited ability to make an alternative diagnosis for patients with negative RDT results appeared to be associated with three main constraints: a lack of know-how and low level of clinical skills, a lack of other point-of-care diagnostics and insufficient time due to understaffing and high workloads… Most providers tended to conflate symptoms and disease aetiology; cough and headache were frequently referred to as “causes of fever”.

“The most challenging part is communicating the results to the patient because some patients come here with a belief that they have malaria and expect to get treatment, so telling them a negative result is a disappointment on their side”. [HW20, Nurse in charge, HCII]

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