Clinicians’ malaria diagnostic practices among patients presenting with fever in Kampala : an area of declining malaria transmission

Abstract

Uganda fever management guidelines recommend that all cases of fever should have a laboratory diagnosis for malaria before treatment. We sought to evaluate the clinicians’ malaria diagnostic practices, associated factors, and the risk of missing malaria cases when a diagnostic test is not done among patients presenting with fever at Kisenyi Health Centre IV in Kampala.Methods A cross-sectional study using qualitative and quantitative data collection methods was conducted between January and April 2020. A structured questionnaire (to capture demographics) and chart review (to capture clinical data) were conducted on a random sample of febrile patients during exit interviews. All study participants had a thick blood sample collected for microscopy to compare test positivity rates in the two groups. Key informant interviews were conducted with clinicians to assess their views on diagnostic practices. Results A total of 383 participants aged between 12 years and 69 years were enrolled in the study. Of the enrolled participants, 356 (93%) had a malaria diagnostic recommended. Participants, where a malaria diagnostic test was recommended, were more likely to test positive by study microscopy than those not recommended a test, although the difference was not statistically significant (18.8% versus 14.4%, p=0.607). Patient factors associated with increased likelihood of having a malaria test recommended by the attending clinician included; 1) History of overnight travel (adjusted prevalence ratio [aPR] 1.07, 95% confidence interval [95% CI] 1.02 – 1.13, p=0.011), 2) being married (aPR=1.07, 95% CI 1.01 – 1.13, p=0.022) and 3) having tertiary education (aPR=1.09 95% CI 1.01 – 1.17, p=0.031). The most occurring theme of not recommending a diagnostic stated by the clinicians was having an obvious alternative cause of fever. Other facilitators for adhering to the national malaria management guidelines identified were refresher training on the guidelines, availability of rapid malaria diagnostic kits, and strict facility supervision. Conclusion These findings highlight that in this area of declining malaria transmission, most of the clinicians still adhere to national malaria diagnostic guidelines, however, the few who do not are likely to miss malaria cases. Refresher training and support supervision should continue to ensure that all fever cases receive the right diagnosis and treatment.