Trends and Determinants of the Quality of Outpatient Malaria Case-Management in Kenya

Amboko, Beatrice Indimuli (2021). Trends and Determinants of the Quality of Outpatient Malaria Case-Management in Kenya. PhD thesis The Open University.



Background: Health workers' compliance with "test and treat" malaria case-management guidelines is not yet optimal despite improvement trends and the availability of diagnostic and therapeutic commodities. Whether these improvement trends differ by malaria endemicity, what factors influence the improvement trends, and what predicts compliance at a high level of performance without further improvements remain poorly defined.

Methods: I conducted a secondary analysis of 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 after cleaning, merging, linking, and restricting the datasets. Trends in compliance with four primary "test and treat" and eight secondary outcomes reflecting artemether-lumefantrine dosing, dispensing, and counselling were measured stratified by malaria endemicity. Logistic regression modelling of 31 multilevel factors associated with the 2010-2016 improvement trends in five compliance outcomes and compliance with three outcomes during the plateauing performance phase between 2014-2016 was performed.

Results: Improvements in all four "test and treat" and three dispensing and counselling outcomes were observed in the highest malaria risk areas around Lake Victoria. In low-risk areas (central Kenya), the only outcome that improved was compliance with no antimalarial treatment for test negative patients, while compliance with malaria testing showed declining trends. Malaria endemicity and 23 health facility, health worker, and patient-level factors were associated with improvement trends, compliance during the plateauing performance phase or both periods. The only interventional factors in the 2010-2016 dataset that I found associated with improving outcomes were RDT availability and access to guidelines. However, in the 2014-2016 analysis, training and supervision with feedback were also associated with compliance in addition to the access to guidelines.

Conclusions: Compliance with outpatient malaria "test and treat" guidelines is influenced by malaria endemicity, interventional factors including RDT availability, access to guidelines, training, and supervision with feedback and 17 non-interventional factors operating at different periods of the policy implementation.

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