Noguchi Memorial Institute for Medical Research
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Item Sms Intervention and Prescriber Adherence to Uncomplicated Malaria Case Management Guidelines in Three Municipalities In The Greater Accra Region of Ghana(University of Ghana, 2017-10) Bonful, H. A.Introduction: Failure to test for malaria before treatment and failure to follow negative test results are still prevalent despite the traditional in-service training strategy deployed by the National Malaria Control Program (NMCP) of Ghana to improve prescriber adherence to malaria case management guidelines. Deploying Short Message Service (SMS) text messaging after in-service training can improve adherence by enabling prescribers to retain knowledge and skills taught during training. The study aimed to develop and assess effectiveness of a one-way text messaging intervention on prescriber adherence to malaria case management guidelines in the Greater Accra Region (GAR). Methods: Stakeholder engagement through an iterative process led to the development of the text messaging program. They included experts from the NMCP, prescribers, researchers in academia, a local bulk messaging company and the research team. A three arm trial with a pre-post design and controls was conducted in three municipalities in the GAR. They included La-Nkwantanang Madina (Arm 1), Ga South (Arm 2) and La Dade-Kotopon (Arm 3). Prescribers in Arms 1 and 2 received a three-day standard training on malaria case management. Within 8 weeks, prescribers in Arm 1 were repeatedly sent 10 SMS messages every other week. Prescribers in Arm 3 were neither trained nor sent SMS messages. Facility surveys were conducted before and after deployment of the interventions. Data were entered, validated and analysed using Stata version 13.0. The primary outcome was the proportion of febrile patient records with negative malaria tests results prescribed ACTs. Analysis was by intention to treat. The effects of the interventions were estimated using differences in difference analysis after adjusting for confounding. Results: 2519 prescriber-patient interactions (records) at baseline were compared with 2356 interactions at end line. At baseline, 40.0% of the febrile patients were tested whilst 42.7% of the remaining febrile patients were treated presumptively. 93.0% of 158 febrile patients with University of Ghana http://ugspace.ug.edu.gh iv confirmed malaria were treated with ACTs and 21.4% of 679 febrile patients with negative malaria test results were prescribed ACTs at baseline. Neither the training alone intervention nor the training plus SMS intervention was effective in reducing overtreatment. The training alone intervention resulted in only a 21.2% percentage point increase in the proportion of febrile patients tested for malaria without a corresponding increase in the rational use of ACTs. The training plus SMS intervention did not improve malaria case management practices but rather resulted in a 34.9 percentage point increase in overtreatment. The added SMS intervention was ineffective in improving prescriber practices for febrile patients. RDT stock-outs and lack of access to health insurance cards promoted presumptive treatment. Conclusion: Setting up a text messaging platform is feasible with stakeholder engagement. The current in-service training in malaria case management alone strategy may improve testing rates with virtually no effect on overtreatment. The training plus SMS intervention appears to be ineffective in encouraging prescribers to act appropriately following negative malaria tests. This may be due to lack of alternative treatment options for prescribers. Recommendation: To increase malaria testing rates and reduce subsequent overtreatment, the NMCP should engage stakeholders to identify the bottlenecks with the current in- service training intervention. Promoting RDT availability and access to a health insurance card can potentially improve prescriber adherence to guidelines. Aside malaria testing, the diagnostic capacities of facilities for other febrile illnesses and alternative treatment options for prescribers should be prioritized. Other strategies to sustain prescriber adherence to guidelines must be a priority to the NMCP and other stakeholders.