Prescribers’ adherence to national guidelines for Malaria case management among under-fives and associated factors in Tabora, Tanzania, 2024

Abstract

ABSTRACT Background: Adherence to prompt and accurate case management of malaria by parasitological confirmation and treatment with standard antimalarials in areas that have maintained high malaria transmission is particularly important for the most vulnerable populations such as young children in whom Plasmodium falciparum malaria can rapidly be fatal. Parasitological confirmation and adherence to test results will reduce unnecessary treatment with antimalarials and prompt the search for the other causes of febrile illnesses. Despite the reported benefits of test-treat policy, non-adherence to guidelines is still a common practice among prescribers, posing a threat to malaria control efforts, especially with the growing concerns of antimalarial drug resistance in several countries. This study aimed to determine prescribers’ level of adherence to guidelines for malaria case management among under-fives and explore factors influencing adherence or non-adherence in Tabora region. Methodology: Facility-based explanatory sequential mixed-methods design was conducted. Exit interviews with caregivers of 487 under-five patients and a review of their clinical records were conducted to evaluate the adherence of prescribers to malaria management guidelines. Adherence was assessed based on three criteria: performing a malaria test, prescribing antimalarials for positive cases, and using Artemether-Lumefantrine (ALu) as the first-line treatment. For quantitative analysis, caregivers’ exit interviews and clinical records reviews of 487 under-fives were conducted to determine the proportion of under-fives that were managed per guidelines. Patient-related predictors of guidelines adherence were subjected to bivariable and multivariable analysis using a modified Poisson regression model to determine crude and adjusted Prevalence Ratios and their 95% Confidence intervals, with statistical significance set at p < 0.05. Using modified grounded theory, qualitative data analysis involved in-depth interviews (IDIs) with 14 prescribers to identify factors for non-adherence to guidelines. Results: Out of 487 enrolled under-fives, the majority (469/487, or 96.5%) presented with fever, and 241/487 (49.5%) had one or more comorbidities, most commonly acute respiratory tract infections, 136/241 (56.4%). All 487 under-fives were prescribed antimalarials, but only 353/487 (72.5%) were tested for malaria using either a malaria Rapid Diagnostic Test (mRDT) or microscopy, and 134/487 (27.5%) were not tested. Of those tested, 273/353 (77.3%) were positive, while 80/353 (22.7%) were negative. Out of all tested positive, 262/273 (96.0%) were prescribed the first-line antimalarial Artemether-Lumefantrine (ALu). Overall, 53.2% of the children were managed in adherence to malaria treatment guidelines, with private health facilities showing 21% higher compliance compared to public ones (aPR = 1.21, 95% CI: 1.05–1.40). Factors influencing non-adherence included inconsistent availability of medical supplies, staff shortages, lack of alternative diagnostic tests, distrust in mRDT results, clinical experience, perceptions of malaria prevalence, previous IMCI training, and caregiver expectations. Conclusion: Prescribers’ level of adherence to malaria case management guidelines is sub-optimal. Non-adherence to guidelines was influenced by factors related to prescribers, health systems, and patients/caregivers. Improving health system challenges, conducting supportive supervision and mentorship to prescribers, and community education to align their expectations with evidence-based practices will enhance guideline adherence, improve quality of care, and reduce unjudicial use of anti-malaria medications.