title: Prescriber and patient-oriented behavioural interventions to improve use of malaria rapid diagnostic tests in Tanzania: facility-based cluster randomised trial.
abstract: BACKGROUND
  The increasing investment in malaria rapid diagnostic tests (RDTs) to differentiate malarial and non-malarial fevers, and an awareness of the need to improve case management of non-malarial fever, indicates an urgent need for high quality evidence on how best to improve prescribers' practices.
  
  
  METHODS
  A three-arm stratified cluster-randomised trial was conducted in 36 primary healthcare facilities from September 2010 to March 2012 within two rural districts in northeast Tanzania where malaria transmission has been declining. Interventions were guided by formative mixed-methods research and were introduced in phases. Prescribing staff from all facilities received standard Ministry of Health RDT training. Prescribers from facilities in the health worker (HW) and health worker-patient (HWP) arms further participated in small interactive peer-group training sessions with the HWP additionally receiving clinic posters and patient leaflets. Performance feedback and motivational mobile-phone text messaging (SMS) were added to the HW and HWP arms in later phases. The primary outcome was the proportion of patients with a non-severe, non-malarial illness incorrectly prescribed a (recommended) antimalarial. Secondary outcomes investigated RDT uptake, adherence to results, and antibiotic prescribing.
  
  
  RESULTS
  Standard RDT training reduced pre-trial levels of antimalarial prescribing, which was sustained throughout the trial. Both interventions significantly lowered incorrect prescribing of recommended antimalarials from 8% (749/8,942) in the standard training arm to 2% (250/10,118) in the HW arm (adjusted RD (aRD) 4%; 95% confidence interval (CI) 1% to 6%; P = 0.008) and 2% (184/10,163) in the HWP arm (aRD 4%; 95% CI 1% to 6%; P = 0.005). Small group training and SMS were incrementally effective. There was also a significant reduction in the prescribing of antimalarials to RDT-negatives but no effect on RDT-positives receiving an ACT. Antibiotic prescribing was significantly lower in the HWP arm but had increased in all arms compared with pre-trial levels.
  
  
  CONCLUSIONS
  Small group training with SMS was associated with an incremental and sustained improvement in prescriber adherence to RDT results and reducing over-prescribing of antimalarials to close to zero. These interventions may become increasingly important to cope with the wider range of diagnostic and treatment options for patients with acute febrile illness in Africa.
authors.affiliation: Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel St, London, WCIE 7HT, UK. bonnie.cundill@lshtm.ac.uk.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Cundill
authors.affiliation: Joint Malaria Programme, Kilimanjaro Christian Medical Centre, Box 2228, Moshi, Tanzania. tufuwage@hotmail.com.
authors.forename: Hilda
authors.initials: H
authors.lastname: Mbakilwa
authors.affiliation: Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel St, London, WCIE 7HT, UK. clare.chandler@lshtm.ac.uk.
authors.forename: Clare Ir
authors.initials: CI
authors.lastname: Chandler
authors.affiliation: National Institute for Medical Research, Amani Centre, Tanga, Tanzania. mtoveg2002@gmail.com.
authors.forename: George
authors.initials: G
authors.lastname: Mtove
authors.affiliation: Joint Malaria Programme, Kilimanjaro Christian Medical Centre, Box 2228, Moshi, Tanzania. mailfrankmt@yahoo.com.
authors.forename: Frank
authors.initials: F
authors.lastname: Mtei
authors.affiliation: Wellsense International Public Health Consultants, P.O. Box 788, Kilifi, Kenya. awilletts44@gmail.com.
authors.forename: Annie
authors.initials: A
authors.lastname: Willetts
authors.affiliation: Joint Malaria Programme, Kilimanjaro Christian Medical Centre, Box 2228, Moshi, Tanzania. emilyfoster@doctors.org.uk.
authors.forename: Emily
authors.initials: E
authors.lastname: Foster
authors.affiliation: Joint Malaria Programme, Kilimanjaro Christian Medical Centre, Box 2228, Moshi, Tanzania. floridajm@yahoo.com.
authors.forename: Florida
authors.initials: F
authors.lastname: Muro
authors.affiliation: National Institute for Medical Research, Amani Centre, Tanga, Tanzania. rahimumohamedi@yahoo.com.
authors.forename: Rahim
authors.initials: R
authors.lastname: Mwinyishehe
authors.affiliation: National Malaria Control Programme, Ministry of Health and Social Welfare, Ocean Road, Dar es Salaam, Tanzania. renata@nmcp.go.tz.
authors.forename: Renata
authors.initials: R
authors.lastname: Mandike
authors.affiliation: Joint Malaria Programme, Kilimanjaro Christian Medical Centre, Box 2228, Moshi, Tanzania. raimosolomi@yahoo.com.
authors.forename: Raimos
authors.initials: R
authors.lastname: Olomi
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London, WCIE 7HT, UK. Christopher.whitty@lshtm.ac.uk.
authors.forename: Christopher Jm
authors.initials: CJ
authors.lastname: Whitty
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London, WCIE 7HT, UK. hugh.reyburn@lshtm.ac.uk.
authors.forename: Hugh
authors.initials: H
authors.lastname: Reyburn
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa; D002648:Child; D002675:Child, Preschool; D003955:Diagnostic Tests, Routine / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008288:Malaria / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic / Q000379:methods*; D012424:Rural Population; D013636:Tanzania; D055815:Young Adult