June 21, 2024

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Improved adherence to test, treat, and track (T3) malaria strategy among Over-the-Counter Medicine Sellers (OTCMS) through interventions implemented in selected rural communities of Fanteakwa North district, Ghana | Malaria Journal

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Study area

The study was conducted in Fanteakwa North and Fanteakwa South districts in the eastern region of Ghana. The two districts were previously one (Fanteakwa district) until March 2018 when the southern part of the district was split off to create Fanteakwa South district and the remaining part renamed Fanteakwa North district. The area has been described elsewhere [10]. Briefly, Fanteakwa North district has 1 hospital, no health centre, 1 clinic, 31 community health-based planning services (CHPS) compounds, and 28 OTCMS, while the Fanteakwa South has no hospital, 2 health centres, 1 clinic, 15 CHPS compounds, and 19 OTCMS. Begoro, the capital town of Fanteakwa North district acted as a buffer between the two districts in this study.

Study design

This implementation research study was conducted between September 2019 and November 2020. A quantitative approach using household questionnaire surveys targeting caregivers of children under 10 years in the intervention arm only and mystery clients visiting the OTCMS in both intervention and control arms. Interventions were evaluated using a two-arm (intervention and control), cluster randomized trial across 8 rural clusters (4 clusters per arm), in two adjacent districts of Ghana. This study evaluated the combined effectiveness of different interventions. The intervention arm has 8 clusters, and out of these, 4 were randomly selected using a computer-generated list. The control arm had 4 clusters, and all these were included in the study. An urban sub-district (Begoro) in the intervention district acted as a buffer between the two arms. A total of 7 OTCMS in the intervention arm and 5 OTCMS in the control arm participated in the study. The aim of the study was to evaluate the combined effectiveness of provider and community interventions on the proportion of children under 10 years who receive treatment for malaria without testing at OTCMS as well as the level of service provider (OTCMS) adherence to malaria case management guidelines. This was accomplished by comparing malaria RDT testing rates between pre-intervention and post-intervention periods.

Study procedures

The study had 4 phases. These are preparatory, baseline, intervention, and evaluation.

Preparatory phase

In the preparatory phase, meetings were scheduled with relevant stakeholders including the district and regional health directorates, the National Malaria Control Programme (NMCP), relevant non-governmental organizations such as Strengthening Health Outcomes through the Private Sector (SHOPS), OTCMS, and traditional leaders in the selected communities. Houses in the selected clusters were mapped and lists of households with children under 10 years old were generated with corresponding GPS coordinates.

Baseline phase

The baseline phase involved conducting community entry and household surveys in each of the intervention clusters, and in-depth interviews of OTCMS in both the intervention and control clusters.

Baseline household survey: The survey was conducted in the intervention arm to document preintervention malaria testing rates among children under 10 years visiting OTCMS for malaria treatment in the past 1 month preceding the survey.

In-depth interviews: In-depth interviews with OTCMS in the selected clusters/communities in both study arms were conducted to determine possible factors preventing the effective management of malaria at their level.

The findings of the baseline phase had been reported elsewhere [13].

Intervention phase

The interventions implemented in this study included:

  1. (i)

    Provision of subsidized RDT kits for OTCMS- The RDT kits were obtained from the National Malaria Control Programme and supplied to OTCMS at no cost. The OTCMS were instructed to test their febrile clients at a subsidized rate of GH¢2.40/kit (~ $0.44), a means of providing incentive for the OTCMS.

  2. (ii)

    Training of OTCMS: A 2 day training workshop was conducted for OTCMS in the selected intervention clusters on malaria management protocol, appropriate treatment, and follow-ups on their clients. Malaria management protocol in this study is referred to when:

  3. (a)

    OTCMS sight every patient suspected of malaria for examination and diagnosis. This includes requesting caregivers of febrile children (visiting the OTCMS for prescription without the child physically present) to bring the child to his/her outlet.

  4. (b)

    OTCMS conducts a malaria blood test on patients suspected of uncomplicated malaria before prescription of medicine.

  1. (iii)

    Quarterly supportive visits to OTCMS: the OTCMS in the intervention arm were visited quarterly during the implementation phase to monitor and assess their malaria management practices. The skills acquired during the earlier training workshop was reinforced, and technical guidance provided on challenges experienced.

  2. (iv)

    Community sensitization on malaria focusing on the T3 strategy: the intervention communities were sensitized on malaria and importance of demanding malaria testing before treatment. Community health workers and town criers (‘Gongong’) were engaged to carry out this activity at churches, mosques, community durbars and on market days.

  3. (v)

    Introduction of malaria surveillance tool for use by OTCMS: the OTCMS were enlightened and trained on how to keep accurate record of all suspected malaria cases attended to using this tool. The communities were also sensitized on the surveillance tool.

Evaluation phase

The primary outcome was measured using mystery client surveys and end-line household survey conducted in the evaluation phase.

Mystery client survey: Mystery client surveys were used to evaluate OTCMS conduct in implementing the T3 strategy. Mystery client data collection covered 9th to 11th months of the intervention period. The mystery clients also assessed the process of RDT use in the two study arms. A total of 13 mystery clients were recruited and given intensive training (including practical sessions) over 3 days on the clinical scenario, how to conduct and interpret a malaria blood test using RDT, and how to fill the assessment checklist/form. Each OTCMS was visited twice a month by a different mystery client for 3 months (August 2020–October 2020). Two different clinical scenarios were presented by the mystery clients during the visits to the OTCMS:

  1. (i)

    Pretending to have fever in the past 24 h.

  2. (ii)

    A caregiver seeking medical care on behalf of his/her febrile child (who is not physically present at the OTCMS shop at the time of the visit).

The mystery client then observed the OTCMS’ response whether RDT will be proposed or not before treatment. The mystery client filled the assessment checklist based on outcome of his/her visit, but when out of sight of the OTCMS.

A total of 72 visits (42 and 30 visits in the intervention and control arms respectively) were conducted in the mystery client survey.

End-line household survey: The survey was conducted in the intervention arm to document post-intervention malaria testing rates among children under 10 years visiting OTCMS for malaria treatment in the past 1 month preceding the survey. A semi-structured questionnaire was developed, pre-tested for validity and administered by trained data collectors to respondents (caregivers/mothers of children under 10 years old). The questionnaire covered topics such as: Socio-demographics of respondent; knowledge of malaria and its transmission; history of fever among children under 10 years in the past 1 month; caregiver’s treatment-seeking behaviour; and insecticide-treated bed net usage.

Data collection

Data collection team The study employed data collectors (school teachers) from each community who could conduct the mystery client survey. The data collectors were trained on the purpose of the study and questionnaire administration. Following the training, the data collection tools were pretested, and adjustments were made where necessary.

Data analysis

Data were double entered and cleaned using Microsoft Access 2010 (Microsoft Inc., Redmond, Washington) and analysed using STATA version 11.0. Variables of interest were summarized using descriptive statistics. Proportions between groups were compared using chi-square test or fisher exact test (p ≤ 0.05 considered statistically significant).

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