Adherence of health workers to severe Malaria treatment guidelines and associated factors at Gulu Referral and Lacor Hospitals in Gulu District, Uganda

Abstract

Introduction: Severe malaria is a life-threatening medical emergency and requires prompt and effective treatment to prevent death. There is a paucity of published information on current adherence of health workers to guidelines for management of severe malaria in sub-Saharan Africa. It is important to know the role of patient, clinical and institutional factors in the adherence of health workers to severe malaria treatment guidelines. Objective: To assess adherence to National treatment guidelines for severe malaria and associated factors at Gulu Regional Referral Hospital and St. Mary’s Lacor hospitals, Gulu District. Methods: This was a cross-sectional study using both quantitative and qualitative methods. The study was conducted at GRRH and St. Mary’s Lacor hospital. We reviewed a total of 468 severe malaria case records for the period January 2019 to December 2020. Fourteen (14) key informant Interviews (KIIs) with the in-charges of outpatient department, medical department and pediatric department and 2 health workers who manage severe malaria cases from each of the wards and six (6) In-depth Interviews (IDIs) were conducted. Categorical variables are presented in tables and charts and reported in frequency and proportions while the continuous variables are summarized using medians and Interquartile ranges (IQR). Factors associated with adherence to the measured parameters contributing to adherence and the overall adherence were determined using modified Poisson regression adjusting for clustering at the two sites. Quantitative data were analyzed using STATA version 16. Qualitative data were analyzed using Atlas ti vr 6.0 software and the results presented under different themes. Results: Of the 468 patient files included, 48.1% (225/468) were from Gulu RRH. About 54.5% (225) of the cases were male. The proportion of patients with severe malaria who were appropriately managed was 60.3% (282/468), (95%CI 55.66 – 64.72) and ranged from 66.7% (150/225) at Gulu hospital to 54.3% (132/243) at Lacor hospital. Adherence was more likely among cases who complained of a fever (cPR = 1.18, 95%CI 1.072 – 1.290) and those who presented with high-grade fever (cPR = 1.18, 95%CI 1.068 – 1.302). Adherence was less likely in cases aged 11 to 15 years (cPR = 0.62, 95%CI 0.561 - 0.682) and 16 to 20 years (cPR = 0.80,

95%CI 0.772 - 0.893). Support supervision and accessibility to the Uganda Clinical Guidelines facilitated adherence to severe malaria treatment guidelines whereas stock-outs of drugs and diagnostics, lack of staff training, unaffordability of drugs, suspected resistance to ACTs, shortage of blood for transfusion, malfunction of the laboratory, inadequate staff and failure of junior doctors to consult their seniors hindered adherence to guidelines.

Conclusions: Adherence of health workers to national severe malaria treatment guidelines is still low (60.3%). Patient’s age, complaining of a fever, presentation with a body temperature >39.5°C and having other complaints were associated with appropriate management.

Recommendations: There is a need to make standard treatment guidelines available, organize regular staff trainings on the management of severe malaria by the Ministry of Health and malaria implementing partners to enable health workers to correctly treat severe malaria irrespective of the age bracket and when patients don’t present with the common signs of a temperature >39.5°C or any other common complaints.