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

The American Journal of Tropical Medicine and Hygiene, Aug 2016

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.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://www.ajtmh.org/content/95/2/358.full.pdf

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)


This is a preview of a remote PDF: https://www.ajtmh.org/content/95/2/358.full.pdf

Sarah G. Staedke, Catherine Maiteki-Sebuguzi, Deborah D. DiLiberto, Emily L. Webb, Levi Mugenyi, Edith Mbabazi, Samuel Gonahasa, Simon P. Kigozi, Barbara A. Willey, Grant Dorsey, Moses R. Kamya, Clare I. R. Chandler. 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, The American Journal of Tropical Medicine and Hygiene, 2016, pp. 358-367, 95/2, DOI: 10.4269/ajtmh.16-0103