Designing and implementing interventions to change clinicians' practice in the management of uncomplicated malaria: lessons from Cameroon

Abstract

Background: Effective case management of uncomplicated malaria is a fundamental pillar of malaria control. Little is known about the various steps in designing interventions to accompany the roll out of rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). This study documents the process of designing and implementing interventions to change clinicians' practice in the management of uncomplicated malaria.

Methods: A literature review combined with formative quantitative and qualitative research were carried out to determine patterns of malaria diagnosis and treatment and to understand how malaria and its treatment are enacted by clinicians. These findings were used, alongside a comprehensive review of previous interventions, to identify possible strategies for changing the behaviour of clinicians when diagnosing and treating uncomplicated malaria. These strategies were discussed with ministry of health representatives and other stakeholders. Two intervention packages - a basic and an enhanced training were outlined, together with logic model to show how each was hypothesized to increase testing for malaria, improve adherence to test results and increase appropriate use of ACT. The basic training targeted clinicians' knowledge of malaria diagnosis, rapid diagnostic testing and malaria treatment. The enhanced training included additional modules on adapting to change, professionalism and communicating effectively. Modules were delivered using small-group work, card games, drama and role play. Interventions were piloted, adapted and trainers were trained before final implementation.

Results: Ninety-six clinicians from 37 health facilities in Bamenda and Yaounde sites attended either 1-day basic or 3-day enhanced training. The trained clinicians then trained 632 of their peers at their health facilities. Evaluation of the training revealed that 68% of participants receiving the basic and 92% of those receiving the enhanced training strongly agreed that it is not appropriate to prescribe anti-malarials to a patient if they have a negative RDT result.

Conclusion: Formative research was an important first step, and it was valuable to engage stakeholders early in the process. A logic model and literature reviews were useful to identify key elements and mechanisms for behaviour change intervention. An iterative process with feedback loops allowed appropriate development and implementation of the intervention.

Trial registration: ClinicalTrials.gov: NCT01350752.

Figures

Figure 1

Intervention design, development and implementation process. Steps in designing an intervention to improve clinician’s practice in the management of uncomplicated malaria. RCT = Randomized Clinical Trial. NMCP = National Malaria Control Programme. RDT = Rapid diagnostic test. REACT = Research on the economics of artemisinin-based combination therapy.

Figure 2

Logic models. Logical framework of an intervention to change clinicians’ practice in the management of uncomplicated malaria. HW = Health Worker (Clinician). RDT = Rapid diagnostic test. FGDs = Focus group discussions. IDIs = In-depth interviews.

Figure 3

Appropriate treatment card game. Rules of the game (3 to 5 players). Step 1: Deal 3 cards per person and place the remaining in a pile face down. Step 2: The first player picks up one card from the pile and then determines if he can give “appropriate treatment” using the correct combination of 3 cards (Fever & RDT positive & ACT OR Fever & RDT negative & Further investigation). If he/she can, the player places 3 cards on the table. If not, his/her turn ends. Step 3: Play passes to the next player and follows from step 2. Step 4: Play continues until someone has given appropriate treatment to five patients. Fever = Patient has a fever. RDT + = Rapid diagnostic test is positive. RDT- = Rapid diagnostic test is negative. ACT = Artemisinin-based combination therapy. Examen Complementaire = Further Investigation.