Assessment of health workers’ adherence to guidelines for parasitological diagnosis and treatment of uncomplicated and severe malaria in public health facilities in Mukono District

Abstract

Background: Uganda national malaria treatment policy guidelines recommend a malaria laboratory test in all patients presenting with fever (history of fever or an axillary temperature≥37.5 °C), and only those with a positive test receive anti-malarial treatment. However, adherence to these guidelines remains suboptimal amongst clinicians in public health facilities with clinical assessment of typical symptoms continuing to account for a significant proportion of malaria diagnosis and treatment practices that contravenes test results. Clinically diagnosed malaria remains the leading cause of morbidity and mortality in Mukono district in Uganda Objective: The study aim was to assess health workers’ parasitological testing and treatment practices for uncomplicated and suspect severe malaria and to determine the factors associated with adherence to the guidelines in public health facilities in Mukono District. Methods: A cross sectional mixed method study design was used. Between July and September 2020, 765 records of suspect malaria patients for the year 2019 were reviewed from across nine health centers in Mukono district. Descriptive data analysis was used to determine the proportion of malaria suspect patients subjected to a malaria diagnostic test and determination of the prescription practices for malaria patients by the clinicians. Multivariable logistic regression and triangulation with qualitative analysis methods were used to explore the factors explaining prescription practices of the clinicians. Results: Of the 765 malaria suspect patient records reviewed, 620 (81%) had a malaria parasitological test done by the clinician. Of the 578 patients diagnosed with uncomplicated malaria, (68%) were treated in accordance with national malaria treatment guidelines with 89% of those tested and confirmed, treated with the recommended first or second line antimalarial drug. Nearly 38% of the patients with negative parasitological test results were given either the first or the second line antimalarial drug, as were 56% of those without a malarial blood test prescribed an antimalarial drug. Of the patients with suspect severe malaria referred for further treatment 56% were provided an appropriate pre-referral treatment while 21% were referred without any. Factors associated with the continued non-adherent prescription practices for malaria patients included; patient age (aOR=1.30, 95% CI: 1.14- 2.06, P=0.023), patient signs and symptoms of fever (aOR = 0.19; 95% CI: 0.52-0.76, P= 0.048), nausea (aOR = 0.48; 95% CI: 0.24-0.92, P=0.026), and sweating (aOR = 0.72; 95% CI: 0.26-0.84, P= 0.036). Conclusion: A considerable proportion of patients presumptively diagnosed and those with negative test results still receive antimalarials. Recommendations: District health authorities should enhance support supervision across all health facilities. The district service commission should allocate more health workers to urban centers to handle high patient volumes. Efforts should also focus on improving the quality of malaria data from public health centers to ensure accurate estimates of medicines and supplies, while scaling up training for health providers in integrated malaria/fever management to improve adherence to diagnostic results.