Over half of malaria treatments occur without test – Study

Over half of malaria treatments in Nigeria still occur without diagnosis despite widespread availability of malaria rapid diagnostic test (mRDT).

More physicians trivialise test-based verification to assume that every patient presenting with fever or a history of fever should be prescribed malaria treatment, usually with artemisinin-based combination therapy (ACT), an expert study published in the journal, Global Health: Science and Practice shows.

It found that knowledge is enough as even well-informed health providers prefer to overlook established guidelines for treatment and follow unproven bias in decision making.

The study blamed what it termed behavioural tendencies of physicians on factors including limited attention, tunneling, base-rate neglect, and salience.

High client loads discourage providers from requesting time-consuming malaria tests for every fever case (limited attention) in an effort to see as many clients as possible (tunneling), the study states.

Also, the knowledge that malaria is prevalent leads providers to assume that some malaria rapid diagnostic test (mRDT) results are false negatives, overlooking the fact that mRDTs have high sensitivities and specificities and therefore have low false-negative rates (base-rate neglect).

The researchers found that providers may also face pressure from clients to prescribe treatments. Lacking any other sources of feedback or accountability (salience) for their treatment decisions, providers may find it challenging to base treatments strictly on clients’ test results.

“We have the HIV rapid test kits, and when they come back positive, nobody doubts it. So, if you have a malaria rapid test kit, why would you doubt the result when it says it is negative? We had to try to convince them that the same science that produced the HIV rapid test kits produced the rapid malaria test kits as well. And when the test is negative for malaria, then you have to look for other causes of fever in the client,” Bolatito Aiyenigba, deputy project director for malaria and tuberculosis, the Breakthrough ACTION-Nigeria said in a report by the Johns Hopkins Center for Communication Programs.

The Breakthrough ACTION-Nigeria launched the study with a view to develop new solutions for specific factors driving provider behaviour and improve fever case management in Nigeria.

The goal was to encourage health care providers to conduct malaria parasitological tests for every patient presenting with fever or a history of fever and provide malaria treatment only to those who test positive for malaria.

Between September 2018, 92 health facility staff and 56 clients at 29 hospitals and clinics in Akwa Ibom, Kebbi, and Nasarawa states were interviewed.

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The researchers found that there was hardly any justification to for to ignore treatment guidelines and that lack of adherence varied with individuals, depending on cadre, number of years of experience, and perceptions of malaria and mmRDTs.

Also the size, staffing, and operating hours of facilities matters.

According to the National Guidelines for Diagnosis and Treatment of Malaria 2015, a parasitological confirmation is required before the prescription of antimalarial drugs.

However, earlier studies show that between 23 to 51 percent of healthcare providers in the public sector prescribe ACTs to clients who test negative for malaria.

The 2018 Nigeria Demographic and Health Survey also found that of 7,466 children younger than 5 years with fever in the two weeks preceding the survey, only 1,030 had blood drawn for malaria testing. Yet, 3,244 children took antimalarial drugs, suggesting test-based treatments was not widespread.

On average, primary health centers demonstrated higher levels of adherence than hospitals. However, hospitals demonstrated greater improvements in adherence over the course of the pilot than primary health centers, suggesting that larger facilities may have more potential to benefit from interventions that streamline processes and establish new workplace norms, the study by the Breakthrough ACTION-Nigeria team stated.

It recommended that solutions that eliminate hassles or simplify complex procedure can be powerful, allowing providers to be more effective and productive in their work.

“By streamlining malaria testing, giving providers clients’ malaria test results at the start of their consultation, and integrating algorithms for non-malaria fever cases into providers’ case notes, we intended to reduce the cognitive burden on providers of having to await confirmation of diagnosis in suspected malaria cases,” the researchers said.

“This, in turn, would allow providers to devote more of their attention to diagnosing other possible illnesses, especially in cases that were confirmed not to be malaria. It should be noted that solutions that themselves require effort to administer may prove to be less impactful, especially when evaluated over a longer period than the three months for this project.”