# Abstract

 The World Health Organization recommends that malaria be confirmed by parasitological diagnosis before treatment using Artemisinin-based Combination Therapy (ACT). Despite this, many health workers in malaria endemic countries continue to diagnose malaria based on symptoms alone. This study evaluates interventions to help bridge this gap between guidelines and provider practice. A stratified cluster-randomized trial in 42 communities in Enugu state compared 3 scenarios: Rapid Diagnostic Tests (RDTs) with basic instruction (control); RDTs with provider training (provider arm); and RDTs with provider training plus a school-based community intervention (provider-school arm). The primary outcome was the proportion of patients treated according to guidelines, a composite indicator requiring patients to be tested for malaria and given treatment consistent with the test result. The primary outcome was evaluated among 4946 (93%) of the 5311 patients invited to participate. A total of 40 communities (12 in control, 14 per intervention arm) were included in the analysis. There was no evidence of differences between the three arms in terms of our composite indicator (p = 0.36): stratified risk difference was 14% (95% CI -8.3%, 35.8%; p = 0.26) in the provider arm and 1% (95% CI -21.1%, 22.9%; p = 0.19) in the provider-school arm, compared with control. The level of testing was low across all arms (34% in control; 48% provider arm; 37% provider-school arm; p = 0.47). Presumptive treatment of uncomplicated malaria remains an ingrained behaviour that is difficult to change. With or without extensive supporting interventions, levels of testing in this study remained critically low. Governments and researchers must continue to explore alternative ways of encouraging providers to deliver appropriate treatment and avoid the misuse of valuable medicines. 

## Trial Registration ClinicalTrials.gov [NCT01350752](#) # Results The trial profile is provided in [Fig 2](#). The study took place between 6^th^ June and 19^th^ December 2011. A total of 42 clusters (14 per arm) were randomised and 40 (12 in control, 14 per intervention arm) were included in the analysis. Two clusters in the control arm were not included in the analysis because no patients visited these health facilities. The primary outcome was evaluated among 4946 (93%) of the 5311 patients invited to participate in the study. <figure> 10.1371/journal.pone.0133832.g002 <p><img src="" /></p> <figcaption>Trial profile.</figcaption> </figure> 

## Process evaluation Of the 137 facilities that were invited and agreed to participate in the trial, 113 (82%; 125 providers) were represented at the RDT demonstration or provider training. Reasons for non-attendance included being too busy, short-staffed, travelling, bereavement, and sickness or death. The training workshops were successfully delivered, with 112/125 (90%) of participants strongly agreeing that they were satisfied with the delivery of the course by the trainers and the relevance of the material to their work. Participants' knowledge of topics covered in the material increased from 59% to 82% (as measured by the pre-post training test). In the intervention arms 71/79 (90%) facilities received support visits, due to closure of some facilities on the visit days. A total of 109 teachers from 59 schools were initially trained on peer health education and holding community events. Teachers from 57 schools subsequently trained 510 children as PHEs. Twenty-seven schools held a malaria event with considerable variation in terms of the range of activities undertaken, attendance (80 to 400 community members) and duration (1 to 4 hours). The evaluation of pre and post tests for training of school teachers showed an increase in knowledge from 12% to 50%. Three facilities in each of the provider (6%) and control (7%) arm reported stock-outs of RDTs in the 4 weeks prior to the provider survey compared to 1 facility (2%) in the provider-school arm. All facilities procured ACT through the usual channels with a third of facilities in the provider (32%) and provider-school (33%) arms reporting stock-outs in the 4 weeks before the provider survey compared with 16% in control. Stock-outs of ACT mainly occurred in public facilities (86%) compared with pharmacies (5%) and drug stores (23%) due to an unexpected break in supply from the Central Medical Stores to public facilities. 

## Characteristics of the study population The stratification and restricted randomisation were shown to have provided study arms that were generally similar in their characteristics with a few exceptions ([Table 1](#)). Patients were more likely to attend pharmacies in the provider-school arm, and drug stores in the other arms. Those in the control arm appear to be of higher socio-economic status and of the highest (tertiary) education. ::::table-wrap

10.1371/journal.pone.0133832.t001

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##

##

## Characteristics of clusters and patients, by study arm.

:::

![](<>)

Characteristics Control Provider arm Provider-school arm

______________________________________________________________________

**CLUSTER LEVEL** **N**~**c**~**= 12** **N**~**c**~**= 14** **N**~**c**~**= 14**
**Number per cluster (median, range)**\
Facilities 1 (1--16) 1 (1--15) 1 (1--10)
Patients 41 (34--593) 43 (15--596) 40 (11--393)
Schools n/a n/a 3.5 (1--13)
**Stratum**\
Enugu 7 (58%) 8 (57%) 8 (57%)
Udi 5 (42%) 6 (43%) 6 (43%)
**PATIENT LEVEL** **N**~**p**~**= 1588**[^**†**^](#) **N**~**p**~**= 1850** **N**~**p**~**= 1508**
**Number of patients (median, range)**\
Per cluster 41 (34--593) 43 (15--596) 40 (11--393)
Per facility 40 (15--46) 40 (15--51) 40 (6--60)
**Stratum**\
Enugu 1386 (87%) 1473 (80%) 1270 (84%)
Udi 202 (13%) 377 (20%) 238 (16%)
**Facility type**\
Public 236 (15%) 340 (18%) 216 (14%)
Pharmacy 534 (34%) 600 (32%) 680 (45%)
PMD 818 (52%) 910 (49%) 612 (41%)
**Gender**\
Male 807 (51%) 927 (50%) 801 (53%)
Female 770 (49%) 913 (50%) 698 (47%)
**Age**\
\<5 years 142 (9%) 166 (9%) 166 (11%)
5--19 years 312 (20%) 292 (16%) 214 (14%)
20--40 years 869 (55%) 910 (49%) 860 (57%)
≥40 years 265 (17%) 482 (26%) 268 (18%)
**Education of respondent**[^**‡**^](#)\
None 73 (5%) 141 (8%) 102 (7%)
Primary 169 (11%) 270 (15%) 170 (11%)
Secondary 617 (39%) 756 (41%) 700 (47%)
Tertiary 711 (45%) 664 (36%) 520 (35%)
**Wealth index**[^**#**^](#)\
Poorest 361 (25%) 612 (30%) 535 (42%)
Less poor 426 (30%) 625 (35%) 453 (35%)
Least poor 647 (45%) 55 (31%) 300 (23%)
**Days of illness**[\*](#)\
Median (range) 2 (0--31) 2 (0--42) 2 (0--90)
**Seeking treatment for first time**[\*](#)\
No 323 (21%) 388 (21%) 238 (16%)
Yes 1242 (79%) 1457 (79%) 1262 (84%)

TABLE NOTES

Numbers and percentages are presented unless stated otherwise.

^†^ N~p~ represents the number of patients who participated in the
patient exit questionnaire (PEQ).

‡ Education level of respondent not known for 18 in control arm, 19 in
provider arm and 16 in provider-school arm

^#^ Generated through principle component analysis and based on
ownership of household possessions (e.g. electricity, radio, mobile
phone, generator, bicycle, and car), access to utilities (toilet type
and source of drinking water), and housing characteristics (floor type,
fuel, persons per sleeping room) in line with DHS Wealth Index
\[[29](#)\] and Vyas et al \[[30](#)\] use of PCA for SES.

- Refers to this illness episode. For those who had previously sought
  treatment for this illness episode 622 (74%) had sought treatment once
  before, while 138 (16%) had sought treatment twice before and 10% more
  than three times.:::: 

## Impact on treatment according to guidelines Although clusters in the provider arm tended to have higher proportions of people treated according to guidelines (36% in provider, 23% control, 24% provider-school) there was no evidence of a statistically significant difference between the arms (p = 0.36) ([Table 2](#)). After adjustment for stratification and covariates of interest the proportion was on average 8% higher than control in the provider arm (95% CI -4.4%, 21.3%; p = 0.15) and 7% higher than control in provider-school arm (95% CI -5.7%, 20.0%; p = 0.17). There was also no evidence of a difference between the two intervention arms; adjusted RD was -12.9% (95% CI -34.0%, 8.3%) ([Table 2](#) --Notes). ::::table-wrap
  10.1371/journal.pone.0133832.t002

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## Effects of the interventions on the primary outcome compared with control, by stratum.

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![](<>)

Outcome Study arm and stratum Clusters Individual-level prevalence Cluster-level prevalence Crude risk difference Stratified risk difference[^†^](#) F test[^†^](#)

______________________________________________________________________

```
                                                                              n                    n/N (%)                       Mean (SD)                  RD (95% CI)               RD (95% CI)                          p-value
```

**Febrile patients tested for malaria** **Control** **12** **432/1536 (28%)** **33.9% (29)** **0** **0** **0.47**
Enugu 7 339/1336 (25%) 24.8% (19)\
Udi 5 93/200 (47%) 46.7% (38)\
**Provider** **14** **416/1832 (23%)** **48.3% (33)** **14.4 (-11.2, 40.0)** **14.2 (-11.0, 39.4)**\
Enugu 8 287/1463 (20%) 50.0% (39)\
Udi 6 129/369 (35%) 46.0% (28)\
**Provider-school** **14** **231/1496 (15%)** **36.5% (33)** **2.5 (-23.0, 28.1)** **2.4 (-22.8, 27.6)**\
Enugu 8 133/1266 (11%) 24.8% (22)\
Udi 6 98/230 (43%) 52.0% (41)\
**Test positive patients receiving ACT** **Control** **12** **238/320 (74%)** **64.2% (28)** **0** **0** **0.76**
Enugu 7 200/265 (75%) 71.2% (25)\
Udi 5 38/55 (69%) 54.3% (32)\
**Provider** **14** **95/142 (67%)** **56.1% (31)** **-8.1 (-33.3, 17.0)** **-6.9 (-29.6, 15.8)**\
Enugu 8 6/87 (79%) 73.8% (19)\
Udi 6 26/55 (47%) 35.3% (31)\
**Provider-school** **12** **59/98 (60%)** **56.4% (33)** **-7.8 (-33.5, 17.9)** **-7.8 (-30.9, 15.4)**\
Enugu 7 46/68 (68%) 67.5% (26)\
Udi 5 13/30 (43%) 41.0% (38)\
**Test negative patients receiving an antimalarial** **Control** **11** **51/112 (46%)** **55.6% (38)** **0** **0** **0.28**
Enugu 6 34/74 (46%) 60.8% (40)\
Udi 5 17/38 (45%) 49.4% (40)\
**Provider** **14** **94/274 (34%)** **30.9% (33)** **-24.7 (-55.5, 6.2)** **-24.9 (-56.0, 6.2)**\
Enugu 8 70/200 (35%) 24.3% (28)\
Udi 6 24/74 (32%) 39.7% (38)\
**Provider-school** **13** **61/133 (46%)** **43.7% (42)** **-12.0 (-43.3, 19.4)** **-12.5 (-44.2, 19.1)**\
Enugu 8 48/65 (74%) 56.1% (48)\
Udi 5 13/68 (19%) 23.7% (22)\
**Treatment according to malaria guidelines**[^‡^](#) **Control** **12** **299/1536 (20%)** **22.6% (23)** **0** **0** **0.36**
Enugu 7 240/1336 (18%) 17.6% (15)\
Udi 5 59/200 (30%) 29.6% (31)\
**Provider**[^§^](#) **14** **275/1832 (15%)** **36.4% (32)** **13.8% (-8.0, 35.7)** **13.8% (-8.3, 35.8)**\
Enugu 8 199/1463 (14%) 43.5% (38)\
Udi 6 76/369 (21%) 27.0% (21)\
**Provider-school**[^§^](#) **14** **131/1496 (9%)** **23.5% (26)** **1.0% (-20.9, 22.9)** **0.9% (-21.1, 22.9)**\
Enugu 8 63/1266 (5%) 13.0% (14)\
Udi 6 68/230 (30%) 37.6% (32)

TABLE NOTES

ACT = Artemisinin-based Combination Therapy. Only those with complete
data for all components of the primary outcome are included. Hence, for
example, 1,079 people are shown as having been tested, 58 fewer than the
1,137 in [Fig 3](#), due to the 11+29+18 missing values noted there.

^**†**^Stratified analysis of cluster-level summary measures, F test of
the null hypothesis of no differences between the three treatment arms,
therefore 2 numerator degrees of freedom.

^‡^The between-cluster coefficient of variation was 0.26 in the Provider
arm, and 0.19 in the Provider-school arm. A further comparison between
arms adjusted for: facility type, stock-out of ACTs in past 4 weeks, age
and sex of patient, tertile of socio-economic status from principal
component analysis, whether the patient had previously sought treatment,
and whether they asked for a blood test. Missing values in these
variables forced the omission of 577 people. Compared to control, this
yielded a benefit of Provider of 8.4% (95% CI: -4.4 to 21.3%) and of
Provider-school of 7.1% (95% CI: -5.7 to 20%).

^§^The stratified analysis of Provider-school arm versus Provider arm
showed a difference of -12.9% (95% CI -34.0 to 8.3%).:::: Less than half of febrile patients attending the facilities were tested for malaria and of those tested, the proportion of patients who tested positive and received (or were prescribed) an ACT was lower in the intervention arms, but these differences were not statistically significant ([Table 2](#); [Fig 3](#)). There was a decrease in the proportion of test negative patients who received (or were prescribed) an antimalarial in the intervention arms but again the differences were not statistically significant ([Table 2](#); [Fig 3](#)). A larger proportion of patients in public facilities were tested compared to the private sector but there was no evidence of differences in testing or treatment according to results between arms in either sector ([Table 3](#)). <figure> 10.1371/journal.pone.0133832.g003 <p><img src="" /></p> <figcaption>Flow chart showing definition of primary outcome.</figcaption> </figure> ::::table-wrap
10.1371/journal.pone.0133832.t003

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##

##

## Effects of the interventions on the primary outcome compared with control, by facility type.

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![](<>)

Outcome Study arm Clusters[^†^](#) Individual-level prevalence Cluster-level prevalence Stratified risk difference[^‡^](#)

______________________________________________________________________

```
                                                                 Public             Private                       Public                     Private                              Public       Private               Public               Private
                                                                 n                  n                             n/N (%)                    n/N (%)                              Mean (SD)    Mean (SD)             RD(95% CI)           RD(95% CI)
```

**Febrile patients tested for malaria** Control 6 6 118/229 (51.5%) 314/1307 (24.0%) 50.0% (32) 17.9% (15) 0 0
Provider 10 7 230/325 (70.8%) 186/1507 (12.3%) 69.2% (21) 16.9% (12) 22.7%(-5.6, 51.0) 0.5%(-15.2, 16.2)\
Provider-school 7 7 122/213 (57.3%) 109/1283 (8.5%) 61.8% (28) 11.1% (12) 13.1%(-16.7, 42.9) -6.1%(-21.5, 9.3)\
**Test positive patients receiving ACT** Control 6 6 45/66 (68%) 193/254 (76%) 61.9% (34) 66.5% (23) 0 0
Provider 10 7 40/73 (55%) 55/69 (80%) 57.3% (36) 51.3% (35) -8.3%(-46.7, 30.0) 3.2%(-33.7, 40.2)\
Provider-school 7 7 16/37 (43%) 43/61 (70%) 48.6% (32) 64.3% (36) -13.4%(-55.2, 28.5) -2.2%(-34.6, 30.3)\
**Test negative patients receiving an antimalarial** Control 6 6 18/52 (35%) 33/60 (55%) 41.1% (41) 73.0% (29) 0 0
Provider 10 7 27/157 (17%) 67/117 (57%) 24.7% (32) 33.0% (33) -14.0%(-54.7, 26.7) -37.6%(-83.3, 8.3)\
Provider-school 7 7 21/85 (25%) 40/48 (83%) 26.5% (38) 63.7% (41) -13.8%(-56.7, 29.1) -9.6%(-56.0, 36.7)\
**Treatment according to malaria guidelines** Control 6 6 79/229 (34%) 220/1307 (17%) 33.3% (27) 11.8% (11) 0 0
Provider 10 7 170/325 (52%) 105/1507 (7%) 52.3% (28) 10.0% (8) 20.1%(-10.5, 50.8) -0.7%(-12.3, 11.0)\
Provider-school 7 7 80/213 (38%) 51/1283 (4%) 40.7% (26) 6.4% (9) 7.8%(-24.6, 40.1) -4.9%(-16.3, 6.5)

TABLE NOTES

^**†**^A cluster contributes to the analysis of public facilities if it
has at least one such facility, and similarly for private. Clusters with
at least one of each type contribute to both analyses.

^‡^The stratified risk differences were calculated as before, but
separately for public and private facilities.:::: Agreement between RDT reporting in registers and the patient exit survey was very high for RDT testing (98% agreement; κ = 0.94) and test results (97% agreement; κ = 0.95). The observed agreement between the readings from the independent testing by the study team and the malaria registers was also excellent (96%; κ = 0.93). 

## Impact on provider and community knowledge There was no evidence of a difference by arm in the proportion of providers who knew the treatment guidelines or reported they would not give an antimalarial for test negative cases ([Table 4](#)). Almost all providers knew that febrile patients should be tested for malaria although a markedly higher proportion of providers in the intervention arms reported that they would give an ACT if a malaria test was positive (83% in control, 98% in provider arm and 99% in provider-school arm). Community knowledge was marginally higher among households in the intervention arms but differences were not statistically significant. ::::table-wrap
10.1371/journal.pone.0133832.t004

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##

##

## Impact on provider and community knowledge of malaria diagnosis and treatment, by study arm.

:::

![](<>)

Arm Clusters Individual-level prevalence[\*N](#) (%) Cluster-level prevalenceMean (SD) Stratified RD (95% CI) F-test (p-value)

______________________________________________________________________

**PROVIDER KNOWLEDGE**\
The treatment guidelines[^†^](#) Control 12 40/74 (54%) 67% (31%) 0 0.72
Provider 14 57/109 (52%) 62% (33%) -5.2% (-33.4, 23.1)\
Provider-school 13 52/74 (70%) 57% (44%) -11.5% (-40.2, 17.3)\
Febrile patients should be tested for malaria Control 12 71/75 (95%) 95% (8%) 0 0.70
Provider 14 105/109 (96%) 98% (5%) 3.1% (-4.5, 10.7)\
Provider-school 13 73/74 (99%) 96% (14%) 1.2% (-6.5 9.0)\
How to use an RDT[^‡^](#)^(mean score, SD)^ Control 12 6.4 (3.1) 6.8 (3.2) 0 0.27
Provider 14 7.9 (3.4) 7.6 (1.3) 0.9 (-0.9, 2.6)\
Provider-school 13 9.1 (2.8) 8.2 (1.8) 1.4 (-0.3, 3.2)\
How to interpret an RDT result[^§^](#) Control 12 28/54 (52%) 57% (38%) 0 0.92
Provider 14 52/90 (58%) 61% (34%) 4.1% (-27.2, 35.5)\
Provider-school 13 44/63 (70%) 63% (44%) 6.5% (-25.5, 38.4)\
First line treatment recommended by the Government Control 12 42/68 (62%) 75% (40%) 0 0.18
Provider 14 85/93 (91%) 86% (21%) 10.5% (-10.5, 31.6)\
Provider-school 13 67/74 (91%) 96% (9%) 20.1% (-1.3, 41.5)\
ACT given if the malaria test is positive Control 12 68/70 (97%) 84% (30%) 0 0.06
Provider 14 104/106 (98%) 98% (5%) 13.9% (0.1, 27.6)\
Provider-school 13 73/73 (100%) 99% (2%) 15.6% (1.6, 29.6)\
Antimalarial not given if the malaria test is negative Control 12 56/71 (79%) 75% (32%) 0 0.60
Provider 14 94/105 (89%) 83% (24%) 8.6% (-13.0, 30.3)\
Provider-school 13 59/65 (91%) 85% (25%) 10.5% (-11.6, 32.5)\
**COMMUNITY KNOWLEDGE**\
Febrile patients should be tested for malaria[^ǁ^](#) Control 12 61/85 (72%) 77% (25%) 0 0.85
Provider 14 94/116 (81%) 75% (25%) -2.1% (-22.4, 18.3)\
Provider-school 14 97/115 (84%) 81% (31%) 3.5% (-17.2, 24.2)\
First line treatment recommended by the Government Control 12 50/64 (78%) 79% (26%) 0 0.53
Provider 13 70/81 (86%) 88% (18%) 8.4% (-9.1, 25.8)\
Provider-school 14 112/126 (89%) 88% (20%) 8.5% (-8.6, 25.6)\
Were aware of a school or local community malaria event[^#^](#) Control 12 64 /320 (20%) 20% (25%) 0 0.002
Provider 14 30 /353 (9%) 9% (9%) -10.7% (-29.3, 7.9)\
Provider-school 14 110/288 (38%) 43% (31%) 22.5% (3.9, 41.1)\
Attended a school or local community malaria event[^#^](#) Control 10 52/64 (81%) 66% (39%) 0 0.17
Provider 10 25/30 (83%) 86% (30%) 21.3% (-5.1, 47.6)\
Provider-school 12 89/108 (82%) 86% (17%) 21.2% (-4.0, 46.5)

TABLE NOTES

- Number of providers -- 75 in control, 110 in provider and 74 in
  provider-school. Number of households -- 382 in control, 423 in
  provider, 413 in provider-school.

† Report that parasitological testing is recommended and that ACTs are
for confirmed cases of malaria.

‡ Data are mean (SD): based on a score (out of 11) derived from correct
identification of several steps taken in the use of an RDT. Steps
include: Wear gloves; Write patient's name; Warm patient's finger;
Clean patient's finger; Use lancet to prick finger; Dispose of lancet;
Use loop to collect blood; Drop blood in well; Dispose of loop; Add
buffer; Read results after 10--15 minutes. Sub-set of those who
correctly identified that an RDT is used to diagnose malaria

^§^ Knows how to identify positive, negative, and invalid malaria RDT
results

# May or may not be a REACT-initiated malaria event at school (some

schools were used to distribute ITNs). Attended an event only asked of
those who were aware of malaria activities in the schools or community
in past year.

ǁ Among those who reported that they had heard about malaria diagnostic
tests or RDTs:::: 

## Costs Public facilities were supplied RDTs free of charge and although providers reported that they did not charge their patients for the RDTs some patients reported paying for them. Across all arms the median charge of RDTs in pharmacies and drug stores was 100 Naira (US$0.6), as reported by the provider. However, there was considerable variation in charges with patients commonly reporting higher costs ([Table 5](#)). The median cost of ACT was similar across all arms. ::::table-wrap
10.1371/journal.pone.0133832.t005

::: caption



##

##

## Financial Costs of Intervention Design and Implementation, and costs of diagnosing and treating suspected malaria (USD 2011 prices).

:::

![](<>)

```
                                                                         Control Arm                      Provider Arm                     Provider-school Arm
```

______________________________________________________________________

**Financial costs of intervention development and implementation**\
**Start-Up Costs**\
Engaging stakeholders 5, 055 5, 055 5, 055
Development of training materials 7, 128 28, 512 56, 516
**Implementation Costs**\
Demonstration on how to use RDTs 1, 384 - -
Provider training workshop - 8, 156 8,156
Support visits to providers[\*](#) - 950 847
Training workshop on school-based intervention - - 9,135
School malaria activities[\*](#) - - 4,788
**TOTAL** **13,567** **42,672** **84,496**
**Cost (median, range) of diagnosis and treatment of suspected malaria**\
**RDT cost to patients (provider reported)**[^**†**^](#) **(Naira)(USD)** **(Naira)(USD)** **(Naira)(USD)**
Public facility 0 0 0
Pharmacy 100 (50--250)0.6 (0.3--1.5) 100 (80--200)0.6 (0.48--1.2) 100 (100--650)0.6 (0.6--3.9)
Drug store 100 (50--200)0.6 (0.3--1.2) 100 (50--1100)0.6 (0.3--6.6) 100 (50--500)0.6 (0.3--3.0)
**RDT cost to patients (patient reported)**\
Public facility 0 (0--350)0 (0--2.1) 0 (0--200)0 (0--1.2) 0 (0--50)0 (0--0.3)
Pharmacy 100 (100--800)0.6 (0.6--4.8) 100 (100--150)0.6 (0.6--0.9) 150 (100--950)0.9 (0.6--5.7)
Drug store 150 (50--1200)0.9 (0.3--7.2) 150 (50--500)0.9 (0.3--3.0) 200 (50--1200)1.2 (0.3--7.2)
**ACT cost (patient reported)**[^**‡**^](#)\
Public facility 50 (0--1500)0.3 (0--9.0) 0 (0--4000)0 (0--24.0) 0 (0--3800)0 (0--22.80)
Pharmacy 500 (130--1100)3.0 (0.8--6.6) 550 (150--4200)3.3 (0.9--25.2) 550 (50--1870)3.3 (0.3--11.22)
Drug store 400 (100--1790)2.4 (0.6--10.7) 400 (150--1200)2.4 (0.9--7.2) 450 (100--1550)2.7 (0.6--9.3)
Overall 420 (0--1790)2.5 (0--10.7) 450 (0--4200)2.7 (0--25.2) 500 (0--3800)3.0 (0--22.8)

TABLE NOTES

- The cost of the support visits and the school malaria events reflects
  the actual number of visits and events held.

† RDTs were supplied free of charge to facilities.

‡ The cost of the ACT medicine that the patient was prescribed or
received.:::: The design and implementation cost of the interventions was $13,567 for RDTs with basic instruction (control) which is approximately one-third the cost of the provider intervention and one-sixth the cost of the provider-school intervention ([Table 5](#)). A full cost-effectiveness analysis was not considered necessary given the higher costs and minimal effect in the provider and provider-school intervention arms.


Extracted trial result:
Outcome: Community knowledge (continuous)
Intervention: provider
Comparator: control
Intervention group size: 14
Comparator group size: 12
Notes: outcome too broad