Basic or Enhanced Clinician Training to Improve Adherence to Malaria Treatment Guidelines: A Cluster-Randomised Trial in Two Areas of Cameroon

"We compared a conventional, knowledge-based and skills-oriented, didactic training approach (the basic-training intervention) with a mindset-oriented, interactive training approach (the enhanced-training intervention)."

Interactive training programmes for health workers could reduce overdiagnosis of malaria by half and help prevent valuable drugs from being wasted on patients who do not have the disease, according to this research report. Carried out in Cameroon by the ACT Consortium, which is funded through a grant from the Bill & Melinda Gates Foundation to the London School of Hygiene & Tropical Medicine, the research was conducted in response to calls from governments to provide evidence that helps to change the behaviour of clinicians, who often treat patients based on their signs and symptoms without testing their blood for the presence of malaria parasites. This study, Research on the Economics of Artemisinin-based Combination Therapy (REACT), shows that the roll-out of malaria rapid diagnostic tests (RDTs) in endemic countries should run alongside these new training programmes.

Researchers did a 3-arm, stratified, cluster-randomised trial at 46 public and mission health facilities at 2 study sites in Cameroon to compare 3 approaches to malaria diagnosis. The study took place between June 7 and Dec 14 2011. The analysis included 681 patients from 9 facilities in the control group (current practice with microscopy, which is widely available), 1,632 patients from 18 facilities in the basic training group (1-day training), and 1,669 from 19 facilities in the enhanced training group. The latter training package lasted 3 days and was designed to change prescribing practices by giving health workers not only training to diagnose and treat malaria but the confidence to put what they learn into practice and to communicate more effectively with patients about why they are tested and that fever is not always caused by malaria. In addition to the content of the basic package, which only provided conventional training on RDTs, malaria diagnosis and treatment, the comprehensive package had smaller groups and longer discussions about clinical guidelines, real-life scenarios, and effective communication with patients. These module on adapting to change, for example, sought to provide clinicians with the opportunity to reflect and discuss the World Health Organization (WHO) malaria treatment guidelines (which recommend universal parasitological confirmation before the use of artemisinin-based combination therapy, or ACT) and to learn from others. It included testimonials about the use of RDTs, and participants reflected on and discussed recommendations in the malaria guidelines. It was also more interactive, using card games for 4-6 players designed to reinforce the treatment algorithm, drama, and problem solving exercises.

The primary outcome was the proportion of patients treated in accordance with WHO malaria treatment guidelines, which is a composite indicator of whether patients were tested for malaria and given appropriate treatment consistent with the test result. The results showed that those undertaking the comprehensive programme were much less likely to overuse antimalarials. Inappropriate use of antimalarial drugs after a negative test was reduced from 84% (201/239) in the control group to 52% (413/796) in the basic-training group (unadjusted risk ratio (RR) 0·63, 0·28–1·43; p=0·25) and to 31% (232/759) in the enhanced-training group (0·29, 0·11–0·77; p=0·02). However, the proportion of patients treated in accordance with malaria guidelines did not improve with either intervention; the adjusted RR for basic training compared with control was 1·04 (95% confidence interval (CI) 0·53–2·07; p=0·90), and for enhanced training compared with control was 1·17 (0·61–2·25; p=0·62).

One of the study's author's Dr. Virginia Wiseman said, "If we are serious about improving the targeting of malaria medicines by using RDTs, then there needs to be a far greater focus on behaviour change....Our results suggest that a good training programme designed to translate knowledge into practice could dramatically reduce overdiagnosis of malaria in Cameroon and prevent the wastage of valuable medicines."

For the study training materials, click here.