Does test-based prescription of treatment for malaria improve treatment seeking and satisfaction?

News article 19 Nov 2018

LSTM’s Dr Justin Pulford is first author on a new study published today in the journal BMJ Global Health, which examines the impact of an improved malaria treatment protocol on patient treatment seeking behaviour and satisfaction in Papua New Guinea.

The improved treatment protocol, based on the introduction of reliable and rapid malaria diagnostic tests and more effective artemisinin combination therapies (ACTs), replaced the former practice of presumptively treating all fever cases with a less effective antimalarial regimen. The team used countrywide cross-sectional surveys to determine if the introduction of these diagnostics tests and ACTs reduces critical delays in seeking treatment for febrile illness and improves patient satisfaction. Dr Pulford said: “The paper presents data from three repeat surveys conducted in 2011, 2012 and 2016, with 2011 being before the introduction of test-based ACT prescription. We wanted to understand if, in addition to the immediate benefit to the test-confirmed malaria patient, the introduction of the new and improved malaria treatment protocol had ‘knock on’ positive effects such as earlier clinic presentation following the onset of febrile symptoms or greater patient satisfaction.

The researchers found that the nationwide implementation of test-based ACT prescription actually led to more delays in treatment seeking for febrile illness and to a decrease in patient satisfaction. Delays and patient dissatisfaction increased between 2011 and 2012, and again between 2012 and 2016 in terms of delays with satisfaction increasing again in this period but not to the levels of 2011.

“The results seem almost counter intuitive,” continued Dr Pulford. “Arguably the decline in reported satisfaction may be down to the fact that Previous studies have shown that health workers rarely conduct further investigations once malaria has been ruled out, with antibiotics widely oversubscribed to this group of patients. This coupled with the fact that diagnostic tests for febrile illnesses that are not malaria are scarce in these settings, could decrease satisfaction in this patient group and may lead to a delay in them seeking treatment for their next febrile illness.”

The findings in the study raise the possibility that rather than improving treatment response time and satisfaction the introduction of test-based ACT prescription may contribute to further delays, probably due to the dissatisfaction with the subsequent service received by patients with a confirmed non-malaria febrile illness. The potential consequences of these findings are significant given that test-based ACT prescription guidelines have been adopted in 96 out of 97 countries with ongoing malaria transmission. It is for this reason that the team feel that test-based ACT prescription protocols should, therefore, be introduced alongside resources to support the accurate identification of non-malaria illnesses as well as public health messaging encouraging people to seek timely medical treatment. This, they say, is of particular importance in contexts of declining malaria transmission.

Pulford JSaweri OPMJeffery C, et al Does test-based prescription of evidence-based treatment for malaria improve treatment seeking and satisfaction? Findings of repeated cross-sectional surveys in Papua New Guinea