title: Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence.
abstract: The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts.
  
  
  
  A comparative case study approach, analysing variation in outcomes across different settings.
  
  
  
  Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case.
  
  
  
  28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria.
  
  
  
  The interventions included different mRDT training packages, supervision, supplies and community sensitisation.
  
  
  
  Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (%Plasmodium falciparumpositive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (%P. falciparumnegative not prescribed/given antimalarial).
  
  
  
  Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs.
  
  
  
  Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Helen E D
authors.identifier: 0000-0002-8380-2476
authors.initials: HE
authors.lastname: Burchett
authors.affiliation: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Baptiste
authors.initials: B
authors.lastname: Leurent
authors.affiliation: Epidemiology Unit, Ensign College of Public Health, Kpong, Ghana.
authors.forename: Frank
authors.initials: F
authors.lastname: Baiden
authors.affiliation: Department of Family Health Care Nursing, and Global Health Science, University of California, Berkeley, California, USA.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Baltzell
authors.affiliation: Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: Björkman
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Katia
authors.initials: K
authors.lastname: Bruxvoort
authors.affiliation: Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Siân
authors.initials: S
authors.lastname: Clarke
authors.affiliation: Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Deborah
authors.initials: D
authors.lastname: DiLiberto
authors.affiliation: Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden.|Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden.|Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Kristina
authors.initials: K
authors.lastname: Elfving
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Goodman
authors.affiliation: Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Heidi
authors.initials: H
authors.lastname: Hopkins
authors.affiliation: Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Sham
authors.initials: S
authors.lastname: Lal
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Marco
authors.initials: M
authors.lastname: Liverani
authors.affiliation: Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Pascal
authors.initials: P
authors.lastname: Magnussen
authors.affiliation: Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
authors.forename: Andreas
authors.initials: A
authors.lastname: Mårtensson
authors.affiliation: Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé, Yaoundé, Cameroon.
authors.forename: Wilfred
authors.initials: W
authors.lastname: Mbacham
authors.affiliation: School of Public Health- Makerere University and Commissioner Health Services, Ministry of Health, Uganda.
authors.forename: Anthony
authors.initials: A
authors.lastname: Mbonye
authors.affiliation: Department of Pharmacology and Therapeutics, University of Nigeria Enugu-Campus, Nigeria.
authors.forename: Obinna
authors.initials: O
authors.lastname: Onwujekwe
authors.affiliation: Centers for Disease Control and Prevention (CDC), USA.
authors.forename: Denise
authors.initials: D
authors.lastname: Roth Allen
authors.affiliation: Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden.|Department of Medicine, Kungälv Hospital, Sweden.
authors.forename: Delér
authors.initials: D
authors.lastname: Shakely
authors.affiliation: Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Staedke
authors.affiliation: Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital Rigshospitalet, Denmark.|Department of Infectious Disease Epidemiology, Statens Serum Institut, Denmark.
authors.forename: Lasse S
authors.initials: LS
authors.lastname: Vestergaard
authors.affiliation: Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Christopher J M
authors.initials: CJ
authors.lastname: Whitty
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.|School of Public Health and Community Medicine, Australia.
authors.forename: Virginia
authors.initials: V
authors.lastname: Wiseman
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Clare I R
authors.initials: CI
authors.lastname: Chandler
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use*; D037621:Artemisinins / Q000627:therapeutic use*; D019468:Disease Management; D011307:Drug Prescriptions; D005334:Fever / Q000175:diagnosis; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D010963:Plasmodium falciparum; D010818:Practice Patterns, Physicians'; D000067490:Prescription Drug Overuse / Q000517:prevention & control; D011933:Reagent Kits, Diagnostic / Q000706:statistics & numerical data; D012698:Serologic Tests; D013997:Time Factors
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D011933:Reagent Kits, Diagnostic; C031327:artemisinin
keywords: TROPICAL MEDICINE