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"It could be viral, but you don't know. You have not diagnosed it": Health worker challenges in managing non-malaria pediatric fevers in the low transmission area of Mbarara District, Uganda
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere University School of Public Health, College of Health Sciences.
Makerere University School of Public Health, College of Health Sciences.
Makerere University School of Public Health, College of Health Sciences.
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2016 (English)In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 15, 197Article in journal (Refereed) Published
Abstract [en]

Background: In 2012, Uganda initiated nationwide deployment of malaria rapid diagnostic tests (RDT) as recommended by national guidelines. Yet growing concerns about RDT non-compliance in various settings have spurred calls to deploy RDT as part of enhanced support packages. An understanding of how health workers currently manage non-malaria fevers, particularly for children, and challenges faced in this work should also inform efforts.

Methods: A qualitative study was conducted in the low transmission area of Mbarara District (Uganda). In-depth interviews with 20 health workers at lower level clinics focused on RDT perceptions, strategies to differentiate non-malaria pediatric fevers, influences on clinical decisions, desires for additional diagnostics, and any challenges in this work. Seven focus group discussions were conducted with caregivers of children less than five years in facility catchment areas to elucidate their RDT perceptions, understandings of non-malaria pediatric fevers and treatment preferences. Data were extracted into meaning units to inform codes and themes in order to describe response patterns using a content analysis approach. 

Findings: Differential diagnosis strategies included studying fever patterns, taking histories, assessing symptoms and analyzing other factors such as child’s age or home environment. If no alternative cause was found, malaria treatment was reportedly often prescribed despite a negative result. Other reasons for malaria over-treatment stemmed from RDT perceptions, system constraints and provider-client interactions. RDT perceptions included mistrust driven largely by expectations of false negative results due to low parasite/antigen loads, previous anti-malarial treatment or test detection of only one species. System constraints included poor referral systems, working alone without opportunity to confer on difficult cases, and lacking skills and/or tools for differential diagnosis. Provider-client interactions included reported caregiver RDT mistrust, demand for certain drugs, and desire to know the ‘exact’ disease cause if not malaria. Many health workers expressed uncertainty about how to manage non-malaria pediatric fevers, feared doing wrong and patient death, worried caregivers would lose trust, or felt unsatisfied without a clear diagnosis.  

Conclusions: Enhanced support is needed to improve RDT adoption at lower level clinics that focuses on empowering providers to successfully manage non-severe non-malaria pediatric fevers without referral. This includes building trust in negative results, reinforcing integrated care initiatives (e.g. Integrated Management of Childhood Illness) and fostering communities of practice according to the Diffusion of Innovation model.

 

Place, publisher, year, edition, pages
2016. Vol. 15, 197
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:uu:diva-274261DOI: 10.1186/s12936-016-1257-yISI: 000373663400003PubMedID: 27066829OAI: oai:DiVA.org:uu-274261DiVA: diva2:896210
Available from: 2016-01-20 Created: 2016-01-20 Last updated: 2017-11-30Bibliographically approved
In thesis
1. Beyond “test and treat”: Malaria diagnosis for improved pediatric fever management in sub-Saharan Africa
Open this publication in new window or tab >>Beyond “test and treat”: Malaria diagnosis for improved pediatric fever management in sub-Saharan Africa
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis examined malaria test use, adherence and integration into clinical practice for improved pediatric fever management in sub-Saharan African countries and explored Access, Facility Readiness and Clinical Practice bottlenecks to achieve this program goal.

Study I examined diagnostic testing rates and its determinants for pediatric fevers across 13 countries in 2009-2012 including Access bottlenecks. Study II evaluated the effect of testing on treatment decisions at the population level in 12 countries in 2010-2012 and explored reasons for varying country results across Access, Facility Readiness and Clinical Practice bottlenecks. Study III explored Facility Readiness and Clinical Practice bottlenecks for using malaria diagnosis for improved pediatric fever management in Mbarara District Uganda. Study IV examined integrated pediatric fever management using RDT and IMCI in Malawi health facilities in 2013-2014 including Facility Readiness and Clinical Practice bottlenecks.

Malaria testing of pediatric fevers was low (17%) and inequitable at the outset of new guidelines with febrile children in least poor household more often tested than in poorest (OR: 1.63, 95% CI: 1.39-1.91) (Study I). Significant variability was found in the effect of testing on ACT use across countries (e.g. Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes explained varying results: available diagnostics and medicines; quality of care; care-seeking behavior; and malaria epidemiology (Study II). In Mbarara District Uganda malaria over-treatment for RDT-negative results reportedly occurred and was driven by RDT perceptions, system constraints and provider-client interactions (Study III). In Malawi health facilities, there was common compliance to malaria treatment guidelines in sick child consultations. 72% were tested or referred for malaria diagnosis and 85% with RDT-confirmed malaria were prescribed first-line anti-malarials. Yet integrated pediatric fever management was sub-optimal in terms of other assessments completed and antibiotic targeting. 28% with IMCI-pneumonia were not prescribed any antibiotic and 59% ‘without antibiotic need’ were prescribed any antibiotic. Few eligible clients had respiratory rates counted to identify antibiotic need for IMCI-pneumonia (18%). RDT-negative children had 16.8 (95% CI: 8.6-32.7) times higher antibiotic over-treatment odds compared to positive cases and this effect was conditioned by cough or difficult breathing complaints (Study IV).

Thesis findings highlight Access, Facility Readiness and Clinical Practice bottlenecks that need to be addressed to use malaria diagnosis for improved pediatric fever management. Programs must move beyond malaria-focused ‘test and treat’ strategies towards ‘IMCI with testing’ in order to conceptualize RDT as one part of the established algorithm for managing sick children in an integrated manner. RDT should also be viewed as an important entry point for contributing to ongoing health system strengthening efforts.  

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. 88 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1173
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-273678 (URN)978-91-554-9455-1 (ISBN)
Public defence
2016-03-04, Rosénsalen, Akademiska sjukhuset, ing 95/96, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2016-02-12 Created: 2016-01-16 Last updated: 2016-02-19

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Johansson, Emily WhiteKitutu, FreddyPeterson, Stefan

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