title: Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of Cameroon.
abstract: BACKGROUND
  The scale-up of malaria rapid diagnostic tests (RDTs) is intended to improve case management of fever and targeting of artemisinin-based combination therapy. Habitual presumptive treatment has hampered these intentions, suggesting a need for strategies to support behaviour change. We aimed to assess the introduction of RDTs when packaged with basic or enhanced clinician training interventions in Cameroon.
  
  
  METHODS
  We did a three-arm, stratified, cluster-randomised trial at 46 public and mission health facilities at two study sites in Cameroon to compare three approaches to malaria diagnosis. Facilities were randomly assigned by a computer program in a 9:19:19 ratio to current practice with microscopy (widely available, used as a control group); RDTs with a basic (1 day) clinician training intervention; or RDTs with an enhanced (3 days) clinician training intervention. Patients (or their carers) and fieldworkers who administered surveys to obtain outcome data were masked to study group assignment. The primary outcome was the proportion of patients treated in accordance with WHO malaria treatment guidelines, which is a composite indicator of whether patients were tested for malaria and given appropriate treatment consistent with the test result. All analyses were by intention to treat. This study is registered at ClinicalTrials.gov, number NCT01350752.
  
  
  RESULTS
  The study took place between June 7 and Dec 14, 2011. The analysis included 681 patients from nine facilities in the control group, 1632 patients from 18 facilities in the basic-training group, and 1669 from 19 facilities in the enhanced-training group. The proportion of patients treated in accordance with malaria guidelines did not improve with either intervention; the adjusted risk ratio (RR) for basic training compared with control was 1·04 (95% CI 0·53-2·07; p=0·90), and for enhanced training compared with control was 1·17 (0·61-2·25; p=0·62). Inappropriate use of antimalarial drugs after a negative test was reduced from 84% (201/239) in the control group to 52% (413/796) in the basic-training group (unadjusted RR 0·63, 0·28-1·43; p=0·25) and to 31% (232/759) in the enhanced-training group (0·29, 0·11-0·77; p=0·02).
  
  
  CONCLUSIONS
  Enhanced clinician training, designed to translate knowledge into prescribing practice and improve quality of care, has the potential to halve overtreatment in public and mission health facilities in Cameroon. Basic training is unlikely to be sufficient to support the behaviour change required for the introduction of RDTs.
authors.affiliation: Laboratory for Public Health Research Biotechnologies, University of Yaoundé I, Yaoundé, Cameroon.
authors.forename: Wilfred F
authors.initials: WF
authors.lastname: Mbacham
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Mangham-Jefferies
authors.affiliation: Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Cundill
authors.affiliation: Laboratory for Public Health Research Biotechnologies, University of Yaoundé I, Yaoundé, Cameroon.
authors.forename: Olivia A
authors.initials: OA
authors.lastname: Achonduh
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Clare I R
authors.initials: CI
authors.lastname: Chandler
authors.affiliation: Laboratory for Public Health Research Biotechnologies, University of Yaoundé I, Yaoundé, Cameroon.
authors.forename: Joel N
authors.initials: JN
authors.lastname: Ambebila
authors.affiliation: Division of Health Operational Research, Ministry of Public Health Cameroon, Yaoundé, Cameroon.
authors.forename: Armand
authors.initials: A
authors.lastname: Nkwescheu
authors.affiliation: National Malaria Control Programme, Ministry of Public Health Cameroon, Yaoundé, Cameroon.
authors.forename: Dorothy
authors.initials: D
authors.lastname: Forsah-Achu
authors.affiliation: Regional Delegation, Ministry of Public Health, Bamenda, Cameroon.
authors.forename: Victor
authors.initials: V
authors.lastname: Ndiforchu
authors.affiliation: Malaria Unit, Ministry of Public Health, Bamenda, Cameroon.
authors.forename: Odile
authors.initials: O
authors.lastname: Tchekountouo
authors.affiliation: Laboratory for Public Health Research Biotechnologies, University of Yaoundé I, Yaoundé, Cameroon.
authors.forename: Mbuh
authors.initials: M
authors.lastname: Akindeh-Nji
authors.affiliation: Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon; Center for Best Practices in Health, Yaoundé, Cameroon.
authors.forename: Pierre
authors.initials: P
authors.lastname: Ongolo-Zogo
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health and Community Medicine, University of New South Wales, Kensington, NSW, Australia. Electronic address: virginia.wiseman@lshtm.ac.uk.
authors.forename: Virginia
authors.initials: V
authors.lastname: Wiseman
mesh_terms: D000328:Adult; D000962:Antimalarials / Q000627:therapeutic use*; D002163:Cameroon; D002983:Clinical Competence; D016000:Cluster Analysis; D003695:Delivery of Health Care / Q000592:standards*; D004502:Education, Medical, Continuing / Q000379:methods*; D005260:Female; D005334:Fever / Q000188:drug therapy; D019983:Guideline Adherence; D006801:Humans; D008288:Malaria / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D016903:Drug Monitoring
chemical_list: D000962:Antimalarials