London School of Hygiene & Tropical Medicine

Health providers trained to perform malaria rapid diagnostic tests (RDT) are still prescribing valuable malaria medicines to patients who do not have malaria, according to new research published in PLOS ONE.

Almost 5,000 participants from 40 communities took part in the study, at a variety of public health facilities, pharmacies and drug stores in the Nigerian state of Enugu. Despite the three different training interventions that they received and their satisfaction with the courses and materials, rates of rapid diagnostic test use remained less than 50%.

The researchers from the Artemisinin-based Combination Therapy (ACT) Consortium at the University of Nigeria and the London School of Hygiene & Tropical Medicine in the UK split the health workers into three groups, to either receive a comprehensive rapid diagnostic test training or the same training plus a health campaign in schools, while the control arm received basic instructions to use RDTs. The first group had the highest rate of testing (48%), especially in public health facilities.

Professor Obinna Onwujekwe from the University of Nigeria, lead author of the study, said: "This study confirms that treating malaria based on signs and symptoms alone remains an ingrained behaviour that is difficult to change. If governments want rapid diagnostic tests to effectively target the use of ACTs and avoid their misuse, then they must be supported by varieties of intensive and sustained interventions aimed at changing the behaviour of health providers and the expectations of patients and their families."

Dr Virginia Wiseman, health economist at the London School of Hygiene & Tropical Medicine and also a principal investigator in the study, said: "Many studies have investigated the performance of RDTs in ideal settings. With this research we aimed to see how our interventions influenced behaviours, according to the different health services and contexts. We have shown that training alone is not enough to realise the full potential of a rapid diagnostic test. We must continue to explore alternative ways of encouraging providers to deliver appropriate treatment and avoid the misuse of valuable medicines especially in the private sector where we found levels of testing to be lowest".

At present, many health workers in malaria endemic countries usually treat patients based on their signs and symptoms without testing their blood for the presence of malaria parasites, as recommended by the World Health Organization. This can result in patients with a fever being overdiagnosed with malaria and receiving an ACT which they don't need.

Microscopy is a method that requires laboratory equipment and qualified staff, while RDTs are alternative, simple tools that require minimal training to diagnose malaria. These rapid tests can help health workers and vendors in remote locations to prescribe the correct treatment for malaria.

The ACT Consortium is funded by a grant from the Bill & Melinda Gates Foundation to London School of Hygiene & Tropical Medicine.

Video: the investigators explain the research

Cost and effects of strategies to improve malaria diagnosis and treatment in Cameroon and Nigeria from ACT Consortium on Vimeo.

Publication:

• Onwujekwe O, Mangham-Jefferies L, Cundill B, Alexander N, Langham J, Ibe O, et al, Effectiveness of Provider and Community Interventions to Improve Treatment of Uncomplicated Malaria in Nigeria: A Cluster Randomized Controlled Trial. PLOS ONE. DOI: 10.1371/journal.pone.0133832

Related links:

• Find out more, download resources and watch a video with the investigators.
• Learn more about a parallel study conducted in Cameroon published in The Lancet Global Health.
• Watch an animation about the wider problem of malaria diagnosis (also in French and Portuguese).
• Français: Le gaspillage des antipaludéens par les personnels de santé au Nigéria coûte cher.
• Português: Funcionários de saúde na Nigéria desperdiçam medicamentos para a malária dispendiosos.
• Malaria Centre.