title: Health worker adherence to malaria treatment guidelines at outpatient health facilities in southern Malawi following implementation of universal access to diagnostic testing.
abstract: Appropriate diagnosis and treatment are essential for reducing malaria mortality. A cross-sectional outpatient health facility (HF) survey was conducted in southern Malawi from January to March 2015 to determine appropriate malaria testing and treatment practices four years after implementation of a policy requiring diagnostic confirmation before treatment.
  
  
  
  Enrolled patients were interviewed, examined and had their health booklet reviewed. Health workers (HWs) were asked about training, supervision and access to the 2013 national malaria treatment guidelines. HFs were assessed for malaria diagnostic and treatment capacity. Weighted descriptive analyses and logistic regression of patient, HW and HF characteristics related to testing and treatment were performed.
  
  
  
  An evaluation of 105 HFs, and interviews of 150 HWs and 2342 patients was completed. Of 1427 suspect uncomplicated malaria patients seen at HFs with testing available, 1072 (75.7%) were tested, and 547 (53.2%) tested positive. Testing was more likely if patients spontaneously reported fever (odds ratio (OR) 2.6; 95% confidence interval (CI) 1.7-4.0), headache (OR 1.5; 95% CI 1.1-2.1) or vomiting (OR 2.0; 95% CI 1.0-4.0) to HWs and less likely if they reported skin problems (OR 0.4; 95% CI 0.2-0.6). Altogether, 511 (92.7%) confirmed cases and 98 (60.3%) of 178 presumed uncomplicated malaria patients (at HFs without testing) were appropriately treated, while 500 (96.6%) of 525 patients with negative tests did not receive anti-malarials. Only eight (5.7%) suspect severe malaria patients received appropriate pre-referral treatment. Appropriate treatment was more likely for presumed uncomplicated malaria patients (at HFs without testing) with elevated temperature (OR 1.5/1 °C increase; 95% CI 1.1-1.9), who reported fever to HWs (OR 5.7; 95% CI 1.9-17.6), were seen by HWs with additional supervision visits in the previous 6 months (OR 1.2/additional visit; 95% CI 1.0-1.4), or were seen by older HWs (OR 1.1/year of age; 95% CI 1.0-1.1).
  
  
  
  Correct testing and treatment practices were reasonably good for uncomplicated malaria when testing was available. Pre-referral treatment for suspect severe malaria was unacceptably rare. Encouraging HWs to elicit and appropriately respond to patient symptoms may improve practices.
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA. Rnamuyinga@cdc.gov.
authors.forename: Ruth J
authors.identifier: 0000-0002-3549-0965
authors.initials: RJ
authors.lastname: Namuyinga
authors.affiliation: Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi.
authors.forename: Dyson
authors.initials: D
authors.lastname: Mwandama
authors.affiliation: National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi.
authors.forename: Dubulao
authors.initials: D
authors.lastname: Moyo
authors.affiliation: National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi.
authors.forename: Austin
authors.initials: A
authors.lastname: Gumbo
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Lilongwe, Malawi.
authors.forename: Peter
authors.initials: P
authors.lastname: Troell
authors.affiliation: National Center for Immunization and Respiratory Diseases, Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Miwako
authors.initials: M
authors.lastname: Kobayashi
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Monica
authors.initials: M
authors.lastname: Shah
authors.affiliation: Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi.
authors.forename: Andrew
authors.initials: A
authors.lastname: Bauleni
authors.affiliation: Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Jodi
authors.initials: J
authors.lastname: Vanden Eng
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Alexander K
authors.initials: AK
authors.lastname: Rowe
authors.affiliation: Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi.
authors.forename: Don P
authors.initials: DP
authors.lastname: Mathanga
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Laura C
authors.initials: LC
authors.lastname: Steinhardt
mesh_terms: D000554:Ambulatory Care Facilities; D019090:Case Management / Q000592:standards; D003430:Cross-Sectional Studies; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006282:Health Personnel / Q000706:statistics & numerical data*; D006801:Humans; D008288:Malaria / Q000188:drug therapy*; D008295:Malawi
keywords: Adherence; Case management; Guidelines; Health worker; Malaria; Malawi; Outpatient; Testing; Treatment