title: Effectiveness of Provider and Community Interventions to Improve Treatment of Uncomplicated Malaria in Nigeria: A Cluster Randomized Controlled Trial.
abstract: The World Health Organization recommends that malaria be confirmed by parasitological diagnosis before treatment using Artemisinin-based Combination Therapy (ACT). Despite this, many health workers in malaria endemic countries continue to diagnose malaria based on symptoms alone. This study evaluates interventions to help bridge this gap between guidelines and provider practice. A stratified cluster-randomized trial in 42 communities in Enugu state compared 3 scenarios: Rapid Diagnostic Tests (RDTs) with basic instruction (control); RDTs with provider training (provider arm); and RDTs with provider training plus a school-based community intervention (provider-school arm). The primary outcome was the proportion of patients treated according to guidelines, a composite indicator requiring patients to be tested for malaria and given treatment consistent with the test result. The primary outcome was evaluated among 4946 (93%) of the 5311 patients invited to participate. A total of 40 communities (12 in control, 14 per intervention arm) were included in the analysis. There was no evidence of differences between the three arms in terms of our composite indicator (p = 0.36): stratified risk difference was 14% (95% CI -8.3%, 35.8%; p = 0.26) in the provider arm and 1% (95% CI -21.1%, 22.9%; p = 0.19) in the provider-school arm, compared with control. The level of testing was low across all arms (34% in control; 48% provider arm; 37% provider-school arm; p = 0.47). Presumptive treatment of uncomplicated malaria remains an ingrained behaviour that is difficult to change. With or without extensive supporting interventions, levels of testing in this study remained critically low. Governments and researchers must continue to explore alternative ways of encouraging providers to deliver appropriate treatment and avoid the misuse of valuable medicines.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01350752.
authors: Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria.
authors: Obinna
authors: O
authors: Onwujekwe
authors: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, United Kingdom.
authors: Lindsay
authors: L
authors: Mangham-Jefferies
authors: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom; Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom.
authors: Bonnie
authors: B
authors: Cundill
authors: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors: Neal
authors: N
authors: Alexander
authors: Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors: Julia
authors: J
authors: Langham
authors: Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria.
authors: Ogochukwu
authors: O
authors: Ibe
authors: Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria.
authors: Benjamin
authors: B
authors: Uzochukwu
authors: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, United Kingdom; School of Public Health and Community Medicine, University of New South Wales, Sydney, 2052, Australia.
authors: Virginia
authors: V
authors: Wiseman
mesh_terms: D000293:Adolescent; D000328:Adult; D000962:Antimalarials / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D008297:Male; D009549:Nigeria / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D012111:Residence Characteristics; D012574:Schools; D055815:Young Adult
chemical_list: D000962:Antimalarials