Assessment of Knowledge and Adherence to the National Guidelines for Malaria Case Management in Pregnancy among Healthcare Providers and Drug Outlet Dispensers in rural, western Kenya 公开
Riley, Christina Marie (2014)
Published
Abstract
Although prompt and effective treatment is a cornerstone of malaria control, information on healthcare provider adherence to malaria treatment guidelines in pregnancy is lacking. Incorrect or sub-optimal treatment can cause adverse consequences to the mother and fetus.
We conducted a cross-sectional study from September to November 2013, in all health facilities and randomly selected drug outlets in the Siaya County HDSS catchment area in western Kenya, to assess provider adherence to and knowledge of case management for uncomplicated malaria in pregnancy, including diagnosis, pregnancy assessment, and treatment. In health facilities, we used exit interviews of women of childbearing age, including pregnant women, who had been assessed for fever. Simulated clients posing as 1st trimester pregnant women or as relatives of women in 3rd trimester collected information from drug outlets. Information on treatment was recorded from prescriptions or after reviewing medications in patient's possession. Standardized questionnaires were used to assess provider knowledge of treatment guidelines.
Correct provider case management for malaria in pregnancy was observed in 32% of health facility cases and 3% of drug outlets; provider knowledge was 45% and 0%, respectively. Prescription of the correct drug for pregnancy trimester at the correct dosage was observed in 62% of cases in health facilities and 42% in drug outlets. Prescribing of correct drug and dosage was observed less often in 1st trimester than in 2nd/3rd (27% vs. 0%, p<0.01, and 65% vs. 32%, p<0.01, at health facilities and drug outlets, respectively). Sulfadoxine-pyrimethamine, which is not recommended for treatment of acute malaria, was prescribed in 3% of cases in health facilities and 18% of simulations in drug outlets (p<0.01). Exposure to artemether-lumefantrine in 1st trimester, which is contraindicated due to its unknown safety, occurred in 27% and 49% of cases in health facilities and drug outlets, respectively (p=0.04); none were a result of quinine stock-out.
This study highlights knowledge inadequacies and incorrect prescribing practices in the treatment of malaria in pregnancy. These should be addressed through comprehensive trainings and adequate supervision by the Kenya Ministry of Health to improve the quality of patient care and maximize therapeutic outcomes.
Table of Contents
Table of Contents
CHAPTER I 13
LITERATURE REVIEW 13
CHAPTER II 17
Assessment of Knowledge and Adherence to the National Guidelines for Malaria Case Management in Pregnancy among Healthcare Providers and Drug Outlet Dispensers in rural, western Kenya 17
Assessment of Knowledge and Adherence to the National Guidelines for Malaria Case Management in Pregnancy among Healthcare Providers and Drug Outlet Dispensers in rural, western Kenya 18
ABSTRACT 18
INTRODUCTION 20
METHODS 21
Study Site & Sampling 22
Data Collection 23
Data Management & Analysis 24
Ethics 26
RESULTS 26
Prescribing Practice and Dispensing Behaviours: Exit Interviews in Health Facilities 26
Prescribing Practice and Dispensing Behaviours: Simulated Clients in Drug Outlets 28
Knowledge of the National Malaria Treatment Guidelines among Providers 30
DISCUSSION 33
Limitations & Challenges 37
CONCLUSION 38
Disclaimer 39
Acknowledgements 39
Financial support 39
Potential conflicts of interest 39
REFERENCES 40
TABLES 42
Table 1. Definitions of Correct Practice & Adequate Knowledge 42
Table 2a. Exit Interview: Health Facility Characteristics 43
Table 2b. Health Facility Exit Interview: Respondent Characteristic 44
Table 3. Malaria Diagnostics practice in Health Facilities as observed through exit interviews stratified across facility type 45
Table 4. Pregnancy assessment practice in Health Facilities as observed in exit interviews stratified across pregnancy status 46
Table 5. Malaria treatment practice in Health Facilities as observed through exit interviews stratified across pregnancy status 47
Table 6. Malaria Case Management Practice in Health Facilities as observed through Exit Interviews, stratified across Health Facility Type 48
Table 7. Predictors of correct prescribing and diagnostic practice in health facilities 48
Table 8. Drug Outlet & Simulation Characteristics 49
Table 9. Malaria Diagnostics practice in drug outlets as observed through simulated clients across pregnancy status 50
Table 10. Pregnancy assessment practice in drug outlets as observed through simulated clients across pregnancy status 51
Table 11. Correct Treatment and Dosage Characteristics by Pregnancy Status in Drug Outlets 52
Table 12. Malaria Case Management practice in drug outlets as observed via simulated clients stratified across Drug Outlet Type53
Table 13. Facility characteristics from the provider survey on national malaria treatment guidelines 54
Table 13b. Provider characteristics from the provider survey on national malaria treatment guidelines 55
Table 14. Malaria Treatment Guideline Awareness, comparing Health Facilities vs. Drug Outlets 56
Table 14 Extended. Malaria Treatment Guideline Awareness, comparing all facility types 57
Table 15. Adequate Provider Knowledge of Malaria in Pregnancy based on National treatment guidelines comparing HFs to DOs 58
Table 16. Comprehensive Care Practices Provided during Pregnancy, comparing Health Facilities vs. Drug Outlets 59
Table 17. Provider Characteristic Predictors of Adequate Knowledge of Malaria in Pregnancy Case-Management 60
Table 18. Other Knowledge Predictors of Adequate Case-Management Knowledge of Malaria in Pregnancy 60
Table 19. Pearson Correlation Coefficients for Provider Practice Scores vs Provider Knowledge Scores for all Providers, stratified by Pregnancy 61
FIGURES 62
Figure 1. Drug Outlet & Simulation Algorithm 62
CHAPTER III 63
Summary, Public Health Implications, Possible Future Directions 63
Improving Healthcare Provider Case Management Practices for Malaria in Pregnancy in Western Kenya: A Clustered Randomized Control Trial 64
Background Information and Scientific Rationale 64
Background Information 64
Rationale 65
Objectives 66
Study Objectives 66
Study Outcome Measures 67
Primary Outcome Measures 67
Secondary Outcome Measures 67
Study Design 67
Study Area 68
Study Population 68
Methodology 69
Phase 1 69
Before-and-after comparison of a simplified memo to improve provider adherence to treatment guidelines for malaria in pregnancy in health facilities 69
Phase 2 69
Before-and-after comparison and between-arm comparison of improved registers and improved registers plus SMS text message reminders to improve provider adherence to treatment guidelines for malaria in pregnancy in health facilities 69
Data Collection 70
Assessment of Correct MiP Case Management Practice in Health Facilities 71
Assessment of MiP Case Management Knowledge and Interventional Tool-Usage in Health Facilities 71
Interim Interventional Tool-Usage Assessment in Health Facilities 72
Data Management 72
Study Enrollment and Withdrawal 72
Subject Inclusion Criteria 72
Subject Exclusion Criteria 73
Treatment Assignment Procedures 73
Randomization Procedures 74
Study Schedule 74
Screening 74
Enrollment/Baseline 74
Follow-up 75
Assessment of Safety 75
Specification of Safety Parameters 75
Methods and Timing for Assessing, Recording, and Analyzing Safety Procedures 75
Adverse Events 75
Reporting Procedures 76
Type and Duration of Follow-up of Subjects after Adverse Events 76
Halting Rules 76
Safety Oversight 76
Statistical Considerations 77
Study Hypotheses 77
Phase 1 77
Phase 2 77
Sample Size Considerations 78
Planned Interim Analysis 79
Safety Review 79
Efficacy Review 79
Final Analysis Plan 79
Ethics/Protection of Human Subjects 81
Ethics Standard 81
Institutional Review Board 82
Informed Consent Process 82
Informed Consent/Assent 82
Exclusion of Women, Minorities, and Children (Special Populations) 83
Subject Confidentiality 83
Study Discontinuation 83
Appendix A 85
Study Design Schematic 85
Schedule of Events 85
National Guidelines for MiP Case Management 86
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