Abstract:
Background: Febrile children seen in malaria hypo-endemic settings, such as the Greater Accra region (GAR) of
Ghana are more likely to be suffering from a non-malarial febrile illness compared to those seen in hyper-endemic
settings. The need for prescribers to rely on malaria test results to guide treatment practices in the GAR is even greater.
This study was designed to investigate the factors associated with inappropriate artemisinin-based combination
therapy (ACT) prescription.
Methods: A survey was conducted in six health facilities in the region in 2015. Treatment practices for febrile outpatient
department (OPD) patients were obtained from their records. Prescribers were interviewed and availability of
malaria commodities were assessed. The primary outcome was the proportion of patients prescribed ACT inappropriately.
Independent variables included patient age and access to care, prescriber factors (professional category, work
experience, access to guidelines, exposure to training). Data were analysed using Stata at 95% CI (α-value of 0.05).
Frequencies and means were used to describe the characteristics of patients and prescribers. To identify the predictors
of inappropriate ACT prescription, regression analyses were performed accounting for clustering.
Results: Overall, 2519 febrile OPD records were analysed; 45.6% (n = 1149) were younger than 5 years. Only 40.0%
of patients were tested. The proportion of patients who were prescribed ACT inappropriately was 76.4% (n = 791 of
1036). Of these 791 patients, 141 (17.8%) were prescribed anti-malarial injections. Patients seen in facilities with rapid
diagnostic tests (RDT) in stock were less likely to be prescribed ACT inappropriately, (AOR: 0.04, 95% CI 0.01–0.14,
p < 0.001) compared to those seen in facilities with RDT stock-outs. Prescribers who had been trained on malaria case
management within the past year were 4 times more likely to prescribe ACT inappropriately compared to those who
had not been trained (AOR: 4.1; 95% CI (1.5–11.6); p < 0.01). Patients seen by prescribers who had been supervised
were 8 times more likely to be prescribed ACT inappropriately.
Conclusion: Inappropriate ACT prescription to OPD febrile cases was high. Training and supervision of health workers
appears not to be yielding the desired outcomes. Further research is needed to understand this observation.
