Stakeholder perceptions on the deployment of multiple first-line therapies for uncomplicated malaria: a qualitative study in the health district of Kaya, Burkina Faso

BACKGROUND: In Burkina Faso, malaria remains the first cause of medical consultation and hospitalization in health centres. First-line case management of malaria in the country's health facilities is based on the use of artemisinin-based combination therapy (ACT). To optimize the use of these anti-malarial drugs in the perspective of mitigating the emergence of artemisinin resistance, which is a serious threat to malaria control and elimination, a pilot programme using multiple first-line therapies (MFTs) [three artemisinin-based combinations-pyronaridine-artesunate, dihydroartemisinin-piperaquine and artemether-lumefantrine] has been designed for implementation. As the success of this MFT pilot programme depends on the perceptions of key stakeholders in the health system and community members, the study aimed to assess their perceptions on the implementation of this strategy. METHODS: Semi-structured interviews, including 27 individual in-depth interviews and 41 focus groups discussions, were conducted with key stakeholders including malaria control policymakers and implementers, health system managers, health workers and community members. Volunteers from targets stakeholder groups were randomly selected. All interviews were recorded, transcribed and translated. Content analysis was performed using the qualitative software programme QDA Miner. RESULTS: The interviews revealed a positive perception of stakeholders on the implementation of the planned MFT programme. They saw the strategy as an opportunity to strengthen the supply of anti-malarial drugs and improve the management of fever and malaria. However, due to lack of experience with the products, health workers and care givers expressed some reservations about the effectiveness and side-effect profiles of the two anti-malarial drugs included as first-line therapy in the MFT programme (pyronaridine-artesunate, dihydroartemisinin-piperaquine). Questions were raised about the appropriateness of segmenting the population into three groups and assigning a specific drug to each group. CONCLUSION: The adherence of both populations and key stakeholders to the MFT implementation strategy will likely depend on the efficacy of the proposed drugs, the absence of, or low frequency of, side-effects, the cost of drugs and availability of the different combinations

Feasibility and acceptability of a strategy deploying multiple first-line artemisinin-based combination therapies for uncomplicated malaria in the health district of Kaya, Burkina Faso

(1) Background: Effective malaria case management relies on World Health Organization (WHO) recommended artemisinin-based combination therapies (ACTs), but partial resistance to artemisinin has emerged and is spreading, threatening malaria control and elimination efforts. The strategy of deploying multiple first-line therapies (MFT) may help mitigate this threat and extend the therapeutic life of current ACTs. (2) Methods: A district-wide pilot quasi-experimental study was conducted, deploying three different ACTs at the public health facility (PHF) level for uncomplicated malaria treatment from December 2019 to December 2020 in the health district (HD) of Kaya, Burkina Faso. Mixed methods, including household and health facility-based quantitative and qualitative surveys, were used to evaluate the pilot programme. (3) Results: A total of 2008 suspected malaria patients were surveyed at PHFs, of which 79.1% were tested by rapid diagnostic test (RDT) with 65.5% positivity rate. In total, 86.1% of the confirmed cases received the appropriate ACT according to the MFT strategy. The adherence level did not differ by study segment (p = 0.19). Overall, the compliance level of health workers (HWs) with MFT strategy was 72.7% (95% CI: 69.7-75.5). The odds of using PHF as the first source of care increased after the intervention (aOR = 1.6; 95% CI, 1.3-1.9), and the reported adherence to the 3-day treatment regimen was 82.1%; (95% CI: 79.6-84.3). Qualitative results showed a high acceptance of the MFT strategy with positive opinions from all stakeholders. (4) Conclusions: Implementing an MFT strategy is operationally feasible and acceptable by stakeholders in the health systems in Burkina Faso. This study provides evidence to support the simultaneous use of multiple first-line artemisinin combination therapies in malaria-endemic countries such as Burkina Faso

Attitudes, practices, and determinants of community care-seeking behaviours for fever/malaria episodes in the context of the implementation of multiple first-line therapies for uncomplicated malaria in the health district of Kaya, Burkina Faso

BACKGROUND: Malaria case management relies on World Health Organization (WHO)-recommended artemisinin-based combination therapy (ACT), and a continuous understanding of local community knowledge, attitudes, and practices may be a great support for the success of malaria disease control efforts. In this context, this study aimed to identify potential facilitators or barriers at the community level to inform a health district-wide implementation of multiple first-line therapies (MFT) as a new strategy for uncomplicated malaria case management. METHODS: A community-based cross-sectional study using a mixed-method design was carried out from November 2018 to February 2019, in the health district (HD) of Kaya in Burkina Faso. Quantitative data were collected using a standardized questionnaire from 1394 individuals who had fever/malaria episodes four weeks prior to the survey. In addition, 23 focus group discussions (FGDs) were conducted targeting various segments of the community. Logistic regression models were used to assess the predictors of community care-seeking behaviours. RESULTS: Overall, 98% (1366/1394) of study participants sought advice or treatment, and 66.5% did so within 24 h of fever onset. 76.4% of participants preferred to seek treatment from health centres as the first recourse to care, 5.8% were treated at home with remaining drug stock, and 2.3% preferred traditional healers. Artemether-lumefantrine (AL) was by far the most used anti-malarial drug (98.2%); reported adherence to the 3-day treatment regimen was 84.3%. Multivariate analysis identified less than 5 km distance travelled for care (AOR = 2.7; 95% CI 2.1-3.7) and education/schooling (AOR = 1.8; 95% CI 1.3-2.5) as determinants of prompt care-seeking for fever. Geographical proximity (AOR = 1.5, 95% CI 1.2-2.1), having a child under five (AOR = 4.6, 95% CI 3.2-6.7), being pregnant (AOR = 6.5, 95% CI 1.9-22.5), and living in an urban area (AOR = 2.8, 95% CI 1.8-4.2) were significant predictors for visiting health centres. The FGDs showed that participants had good knowledge about malaria symptoms, prevention tools, and effective treatment. Behaviour change regarding malaria treatment and free medication for children under five were the main reasons for participants to seek care at health centres. CONCLUSIONS: The study showed appropriate knowledge about malaria and positive community care-seeking behaviour at health centres for fever/malaria episodes. This could potentially facilitate the implementation of a MFT pilot programme in the district. CLINICALTRIALS: gov Identifier: NCT04265573

Household costs and time to treatment for children with severe febrile illness in rural Burkina Faso: the role of rectal artesunate

UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland [Project ID number: Burkina Faso: A80553

Quantifying and valuing community health worker time in improving access to malaria diagnosis and treatment

Background: Community health workers (CHWs) are members of a community who are chosen by their communities as first-line, volunteer health workers. The time they spend providing healthcare and the value of this time are often not evaluated. Our aim was to quantify the time CHWs spent on providing healthcare before and during the implementation of an integrated programme of diagnosis and treatment of febrile illness in three African countries. Methods: In Burkina Faso, Nigeria and Uganda, CHWs were trained to assess and manage febrile patients in keeping with Integrated Management of Childhood Illness recommendations to use rapid diagnostic tests, artemisinin-based combination therapy and rectal artesunate for malaria treatment. All CHWs provided healthcare only to young children usually under 5 years old, and hence daily time allocation of their time to child healthcare was documented for one day (in the high malaria season) before the intervention and at several time points following the implementation of the intervention. Time spent in providing child healthcare was valued in earnings of persons with similar experience. Results: During the high malaria season of the intervention, CHWs spent nearly 50 minutes more in daily healthcare provision (average daily time 30.2 minutes before the intervention versus 79.5 minutes during the intervention; test for difference in means p< 0.01). On average, the daily time spent providing healthcare during the intervention was 55.8 minutes (Burkina Faso), 77.4 minutes (Nigeria) and 72.2 minutes (Uganda). Using the country minimum monthly salary, CHWs time allocated to child healthcare for one year was valued at USD 52 in Burkina Faso, USD 295 in Nigeria and USD 141 in Uganda. Conclusion: CHWs spend up to an hour and a half daily on child healthcare in their communities. These data are informative in designing reward systems to motivate CHWs to continue providing good quality services

Impact of improving community-based access to malaria diagnosis and treatment on household costs

Background: Community health workers (CHWs) were trained in Burkina Faso, Nigeria and Uganda to diagnose febrile children using malaria rapid diagnostic tests (RDTs), treat positive malaria cases with artemisinin combination treatment (ACTs) and those who could not take oral medicines with rectal artesunate. We quantified the impact of this intervention on private household costs for childhood febrile illness. Methods: Households with recent febrile illness in a young child in previous two weeks were selected randomly before and during the intervention and data obtained on household costs for the illness episode. Household costs included consultation fees, registration costs, user fees, diagnosis, bed, drugs, food and transport costs. Private household costs per episode before and during the intervention were compared. The intervention’s impact on household costs per episode was calculated and projected to district-wide impacts on household costs. Results: Use of CHW increased from 35% of illness episodes before the intervention to 50% during the intervention (p<0.0001) and total household costs per episode decreased significantly in each country from 4.36 to 1.54 dollars in Burkina Faso, from 3.90 to 2.04 dollars in Nigeria and from 4.46 to 1.42 in dollars Uganda (all p<0.0001). There was no difference in the time used by the child’s caregiver to care for a sick child (59% before intervention vs. 51% during intervention spent 2 days or less). Using the most recent population figures for each study district, we estimate that the intervention could save households a total of 29,965, 254,268 and 303,467 dollars, respectively in the study districts in Burkina Faso, Nigeria and Uganda. Conclusions: Improving access to malaria diagnostics and treatments in malaria endemic areas substantially reduces private household costs. The key challenge is to develop and strengthen community human resources to deliver the intervention, and ensure adequate supplies of commodities and supervision. We demonstrate feasibility and benefit to populations living in difficult circumstances

Impact of improving community-based access to malaria diagnosis and treatment on household costs

Background: Community health workers (CHWs) were trained in Burkina Faso, Nigeria and Uganda to diagnose febrile children using malaria rapid diagnostic tests (RDTs), treat positive malaria cases with artemisinin combination treatment (ACTs) and those who could not take oral medicines with rectal artesunate. We quantified the impact of this intervention on private household costs for childhood febrile illness. Methods: Households with recent febrile illness in a young child in previous two weeks were selected randomly before and during the intervention and data obtained on household costs for the illness episode. Household costs included consultation fees, registration costs, user fees, diagnosis, bed, drugs, food and transport costs. Private household costs per episode before and during the intervention were compared. The intervention’s impact on household costs per episode was calculated and projected to district-wide impacts on household costs. Results: Use of CHW increased from 35% of illness episodes before the intervention to 50% during the intervention (p&lt;0.0001) and total household costs per episode decreased significantly in each country from 4.36 to 1.54 dollars in Burkina Faso, from 3.90 to 2.04 dollars in Nigeria and from 4.46 to 1.42 in dollars Uganda (all p&lt;0.0001). There was no difference in the time used by the child’s caregiver to care for a sick child (59% before intervention vs. 51% during intervention spent 2 days or less). Using the most recent population figures for each study district, we estimate that the intervention could save households a total of 29,965, 254,268 and 303,467 dollars, respectively in the study districts in Burkina Faso, Nigeria and Uganda. Conclusions: Improving access to malaria diagnostics and treatments in malaria endemic areas substantially reduces private household costs. The key challenge is to develop and strengthen community human resources to deliver the intervention, and ensure adequate supplies of commodities and supervision. We demonstrate feasibility and benefit to populations living in difficult circumstances