title: Mind the gap: knowledge and practice of providers treating uncomplicated malaria at public and mission health facilities, pharmacies and drug stores in Cameroon and Nigeria.
abstract: BACKGROUND
  Artemisinin combination therapy (ACT) has been the first-line treatment for uncomplicated malaria in Cameroon since 2004 and Nigeria since 2005, though many febrile patients receive less effective antimalarials. Patients often rely on providers to select treatment, and interventions are needed to improve providers' practice and encourage them to adhere to clinical guidelines.
  
  
  METHODS
  Providers' adherence to malaria treatment guidelines was examined using data collected in Cameroon and Nigeria at public and mission facilities, pharmacies and drug stores. Providers' choice of antimalarial was investigated separately for each country. Multilevel logistic regression was used to determine whether providers were more likely to choose ACT if they knew it was the first-line antimalarial. Multiple imputation was used to impute missing data that arose when linking exit survey responses to details of the provider responsible for selecting treatment.
  
  
  RESULTS
  There was a gap between providers' knowledge and their practice in both countries, as providers' decision to supply ACT was not significantly associated with knowledge of the first-line antimalarial. Providers were, however, more likely to supply ACT if it was the type of antimalarial they prefer. Other factors were country-specific, and indicated providers can be influenced by what they perceived their patients prefer or could afford, as well as information about their symptoms, previous treatment, the type of outlet and availability of ACT.
  
  
  CONCLUSIONS
  Public health interventions to improve the treatment of uncomplicated malaria should strive to change what providers prefer, rather than focus on what they know. Interventions to improve adherence to malaria treatment guidelines should emphasize that ACT is the recommended antimalarial, and it should be used for all patients with uncomplicated malaria. Interventions should also be tailored to the local setting, as there were differences between the two countries in providers' choice of antimalarial, and who or what influenced their practice.
authors.affiliation: Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, lindsay.mangham-jefferies@lshtm.ac.uk.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Mangham-Jefferies
authors.affiliation: Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Kara
authors.initials: K
authors.lastname: Hanson
authors.affiliation: Laboratory for Public Health Research Biotechnologies, University of Yaoundé 1, Nkolbisson, Yaoundé, Cameroon.
authors.forename: Wilfred
authors.initials: W
authors.lastname: Mbacham
authors.affiliation: Department of Health Administration and Management, College of Medicine, University of Nigeria (Enugu Campus), Enugu, Nigeria.
authors.forename: Obinna
authors.initials: O
authors.lastname: Onwujekwe
authors.affiliation: Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Virginia
authors.initials: V
authors.lastname: Wiseman
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D002163:Cameroon / Q000453:epidemiology; D002675:Child, Preschool; D004359:Drug Therapy, Combination; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008288:Malaria / Q000188:drug therapy* / Q000453:epidemiology; D008297:Male; D009549:Nigeria / Q000453:epidemiology; D010594:Pharmacies / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D017150:Public Sector / Q000706:statistics & numerical data*; D008921:Religious Missions / Q000706:statistics & numerical data*
chemical_list: D000962:Antimalarials
keywords: Cameroon; Nigeria; malaria; multilevel analysis; multiple imputation; provider practice