Encouraging Adoption of Health Technology: The Case of Rapid Diagnostic Tests in Zambia
Malaria is one of the world’s foremost public health concerns, causing as many as 1 million deaths each year, the majority of which occur in sub-Saharan Africa.1 Malaria is often associated with poverty—the poor are most affected, likely because they have reduced access to medical services and information, and the lowest ability to avoid working in malaria epidemic areas. The disease can also perpetuate poverty, taking a high toll on households and healthcare systems. Rapid diagnostic tests (RDTs), a fast and reliable blood test to detect the malaria parasite, can make the detection and treatment of malaria more efficient. The World Health Organization estimated in 2008 that only 20% of patients with suspected malaria were being subjected to diagnostic tests; the rest were clinically diagnosed based on their symptoms. A mistaken clinical diagnosis can lead to over-prescription of malaria treatment and increased drug resistance among malaria parasites as well as waste of limited drug supplies. This study tests different mechanisms for encouraging the use of and compliance with the results of RDT
In 2008, there were 247 million cases of malaria and nearly one million deaths, primarily among children living in Africa.2 Malaria is the leading cause of mortality in Zambia and is responsible for one quarter of childhood deaths.3 Despite improvements in technology that allow for affordable and simple mechanisms to diagnose malaria and effective regimens to treat malaria, the disease continues to be a significant health challenge in many Sub-Saharan African countries. The development of sensitive and specific RDTspresents an opportunity to improve the targeting of treatment for malaria. RDTs use modern molecular biological technology to allow diagnosis by a health worker with limited training in just fifteen minutes. RDTs can detect with great accuracy the existence of antigens that are produced in the presence of malaria parasites.
This study will identify what barriers prevent health workers from using RDTs, and will test different mechanisms for encouraging the use of and compliance with RDTs. Approximately one thousand health facilities from across Zambia will be randomly to one of three treatment groups or a comparison group, which will see no changes in treatment. The three treatment programs include:
- An intervention to help clinicians update their knowledge on local prevalence rates. If a clinician believes that malaria is endemic in his region, then he may be more likely to over-diagnose malaria or believe that all fevers are caused by malaria. The intervention will involve training health staff on the epidemiology of malaria. Additionally, it will include an interactive component where clinicians are able to generate their own information on prevalence rates in their area through testing.
- An intervention to address doubts about the accuracy of RDTs. If a clinician believes that the RDT is giving a false negative, then he may prescribe anti-malarials to patients who test negative “just in case”. The intervention will involve the clinician following up with patients who test negative several days later so they can see that indeed these individuals were negative for malaria.
- An intervention to train clinicians how to diagnose and treat other causes of fever beyond malaria. If a clinician lacks the tools or knowledge to diagnose other causes of febrile illness, he may prescribe anti-malarials as an alternative to “doing nothing”. The intervention will provide training for clinicians on both the differential diagnosis for fever as well as the risks of not treating other febrile illnesses.
These three interventions will allow the researchers to determine what issues are preventing the use of RDTs, and determine what format of information dissemination is most effective for communicating with healthcare providers.
1 WHO, "10 Facts on Malaria," http://www.who.int/features/factfiles/malaria/en/index.html.
2 WHO, “Malaria,” http://www.who.int/mediacentre/factsheets/fs094/en/.
3 USAID, “Population, Health and Nutritional Issues in Zambia,” http://www.usaid.gov/zm/population/phn.htm.