The Impact of an Intervention to Improve Malaria Care in Public Health Centers on Health Indicators of Children in Tororo, Uganda (PRIME): A Cluster-Randomized Trial
Am. J. Trop. Med. Hyg.
The Impact of an Intervention to Improve Malaria Care in Public Health Centers on Health Indicators of Children in Tororo, Uganda (PRIME): A Cluster-Randomized Trial
Sarah G. Staedke 1 2 3
Catherine Maiteki-Sebuguzi 1 2
Deborah D. DiLiberto 2 3
Emily L. Webb 2 3
Levi Mugenyi 0 1 2
Edith Mbabazi 1 2
Samuel Gonahasa 1 2
Simon P. Kigozi 1 2
Barbara A. Willey 2 3
Grant Dorsey 2 5
Moses R. Kamya 1 2 4
Clare I. R. Chandler 2 3
0 I-Biostat, Hasselt University , Diepenbeek , Belgium
1 Infectious Diseases Research Collaboration , Kampala , Uganda
2 Research Collaboration , P.O. Box 7475, Kampala , Uganda
3 Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine , London , United Kingdom
4 Makerere University College of Health Sciences , Kampala , Uganda
5 Department of Medicine, University of California , San Francisco, California , USA
Optimizing quality of care for malaria and other febrile illnesses is a complex challenge of major public health importance. To evaluate the impact of an intervention aiming to improve malaria case management on the health of community children, a cluster-randomized trial was conducted from 2010-2013 in Tororo, Uganda, where malaria transmission is high. Twenty public health centers were included; 10 were randomized in a 1:1 ratio to intervention or control. Households within 2 km of health centers provided the sampling frame for the evaluation. The PRIME intervention included training in fever case management using malaria rapid diagnostic tests (mRDTs), patient-centered services, and health center management; plus provision of mRDTs and artemether-lumefantrine. Cross-sectional community surveys were conducted at baseline and endline (N = 8,766), and a cohort of children was followed for approximately 18 months (N = 992). The primary outcome was prevalence of anemia (hemoglobin < 11.0 g/dL) in children under 5 years of age in the final community survey. The intervention was delivered successfully; however, no differences in prevalence of anemia or parasitemia were observed between the study arms in the final community survey or the cohort. In the final survey, prevalence of anemia in children under 5 years of age was 62.5% in the intervention versus 63.1% in control (adjusted risk ratio = 1.01; 95% confidence interval = 0.91-1.13; P = 0.82). The PRIME intervention, focusing on training and commodities, did not produce the expected health benefits in community children in Tororo. This challenges common assumptions that improving quality of care and access to malaria diagnostics will yield health gains.
INTRODUCTION
Over the past decade, encouraging reductions in malaria
burden have been documented worldwide, after heavy
investment in malaria control measures.1,2 However, these successes
have been achieved primarily in lower transmission settings.3
In Uganda, despite some progress,4 the burden of malaria has
remained high, calling for an expansion in malaria control
efforts.5,6 Provision of good quality care, including accurate
diagnosis and prompt effective antimalarial treatment, is a key
malaria control strategy.7,8 However, health system challenges
limit access to good quality care and contribute to poor
progress on malaria control.9–11 Interventions to improve the
quality of care provided in the public sector, and ultimately to
improve health outcomes, are urgently needed.12 However,
the optimal approach to quality improvement and fever case
management is not clear, particularly in low- and
middleincome countries.9,13,14
Use of rapid diagnostic tests for malaria (mRDTs) to
target antimalarial treatment and improve health outcomes
has been strongly advocated,7,8,15 and mRDTs have been
rapidly scaled up, particularly in Africa.1 Significant
progress has been made toward understanding the performance
and impact of mRDTs in different sites.16,17 However,
introducing mRDTs into clinical settings is not simple, and
evidence that mRDTs improve health outcomes is limited.17 The
training package and support supervision implemented
alongside mRDTs appear to be as important as provision of the
tests themselves,18–20 and even if high quality care and
accurate diagnosis are provided, patients only stand to benefit if
they choose to access this care.12
In preparation for the PRIME trial, we conducted
extensive formative research in Tororo aiming to understand the
local population, barriers to providing high quality health
care, and options for interventions that could be feasibly and
sustainably implemented in the public sector.12,21 On the
basis of this formative research and the priorities
identified by local stakeholders, we developed an intervention to
improve the quality of care delivered for malaria and other
childhood febrile illnesses by training health workers in
public health centers, and ensuring adequate (...truncated)