The need for social group interventions to increase malaria rapid diagnostic test uptake in Nigeria
Authors: Catherine O Falade, Olugbenga A Mokuolu
Journal: The Lancet Global Health (2021)

Correct diagnosis is key to appropriate treatment of any disease, whether infectious or otherwise, and is particularly pertinent for the diagnosis of malaria and, consequently, appropriate treatment. Parasite-based diagnosis of malaria reduces unnecessary use of artemisinin-based combination therapy and the chances of emergence of resistant strains of Plasmodium spp.1Bruxvoort KJ Leurent B Chandler CIR et al.The impact of introducing malaria rapid diagnostic tests on fever case management: a synthesis of ten studies from the ACT consortium.Am J Trop Med Hyg. 2017; 97: 1170-1179Crossref PubMed Scopus (27) Google Scholar Parasite-based diagnosis also enhances surveillance and early diagnosis of non-malaria febrile illnesses such as pneumonia and other viral illnesses in children. This method of diagnosis is becoming increasingly useful because the prevalence of malaria parasitaemia has reduced globally, and especially in sub-Saharan Africa.2WHOWorld malaria report 2019. World Health Organization, Geneva2019Google Scholar Malaria rapid diagnostic tests (MRDTs) have been shown to be the best diagnostic method for programmatic deployment because of their ease of use, sensitivity, and quick turn-around time for results.3Boadu NY Amuasi J Ansong D Einsiedel E Menon D Yanow SK Challenges with implementing malaria rapid diagnostic tests at primary care facilities in a Ghanaian district: a qualitative study.Malar J. 2016; 15: 126Crossref PubMed Scopus (21) Google Scholar, 4Maloney K Ward A Krenz B et al.Expanding access to parasite-based malaria diagnosis through retail drug shops in Tanzania: evidence from a randomized trial and implications for treatment.Malar J. 2017; 16: 6Crossref PubMed Scopus (12) Google Scholar The benefits of using MRDTs have also been specifically validated among the most vulnerable population (febrile children younger than 5 years).5Falade CO Orimadegun AE Michael OS et al.Consequences of restricting antimalarial drugs to rapid diagnostic test-positive febrile children in south-west Nigeria.Trop Med Int Health. 2019; 24: 1291-1300Crossref PubMed Scopus (2) Google Scholar However, the potential of MRDTs will not be fully realised if uptake remains low. Improving the uptake of MRDTs is particularly important during the COVID-19 pandemic because the early symptoms of COVID-19 are similar to those of malaria and other febrile illness, with many patients with COVID-19 being diagnosed with malaria by default.6Ajayi IO Ajumobi OO Falade C Malaria and COVID-19: commonalities, intersections and implications for sustaining malaria control.Pan Afr Med J. 2020; 37: 1PubMed Google Scholar A study by Ugwu Omale and colleagues7Omale UI Azuogu BN Alo C et al.Social group and health-care provider interventions to increase the demand for malaria rapid diagnostic tests among community members in Ebonyi state, Nigeria: a cluster-randomised controlled trial.Lancet Glob Health. 2021; 9: e320-e330Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar in The Lancet Global Health has explored the use of MRDT in an unconventional manner by looking at a way to increase MRDT uptake by increasing end-user demand. This approach differs from the usual approach, in which health-care workers, either formal or informal (in the community), or the staff of drug outlets are usually targeted to increase their use of the tests. Omale and colleagues showed that increasing end-user demand led to an increase in the uptake of MRDTs (with an adjusted risk difference of 25·6% [95% CI 16·8–34·4] in the social group arm vs the control arm). However, it should be noted that this is a simplified look at uptake of MRDTs.3Boadu NY Amuasi J Ansong D Einsiedel E Menon D Yanow SK Challenges with implementing malaria rapid diagnostic tests at primary care facilities in a Ghanaian district: a qualitative study.Malar J. 2016; 15: 126Crossref PubMed Scopus (21) Google Scholar, 8Mokuolu OA Ajumobi OO Ntadom GN et al.Provider and patient perceptions of malaria rapid diagnostic test use in Nigeria: a cross-sectional evaluation.Malar J. 2018; 17: 200Crossref PubMed Scopus (4) Google Scholar The authors did not specify whether MRDTs were provided for free during the study. The additional cost of MRDTs is a known deterrent for uptake, especially among lower socioeconomic groups. Some other reported reasons for low uptake of MRDT are low availability of essential malaria commodities such as gloves,3Boadu NY Amuasi J Ansong D Einsiedel E Menon D Yanow SK Challenges with implementing malaria rapid diagnostic tests at primary care facilities in a Ghanaian district: a qualitative study.Malar J. 2016; 15: 126Crossref PubMed Scopus (21) Google Scholar understaffing of health-care workers, perception of health-care workers about MRDT, and clear articulation of malaria treatment policy in the country.8Mokuolu OA Ajumobi OO Ntadom GN et al.Provider and patient perceptions of malaria rapid diagnostic test use in Nigeria: a cross-sectional evaluation.Malar J. 2018; 17: 200Crossref PubMed Scopus (4) Google ScholarThis assessment needs to go beyond increased uptake of MRDT to include examination of the effect of increased uptake on antimalaria treatment practices and factors affecting both. On the surface, it appears that the increased uptake of MRDTs was as a result of the sensitisation and education of social groups about MRDTs and not a result of training providers. However, there was no positive control arm in the study. There are probably some hidden factors that were not captured. In a 2018 study by Mokuolu and colleagues,8Mokuolu OA Ajumobi OO Ntadom GN et al.Provider and patient perceptions of malaria rapid diagnostic test use in Nigeria: a cross-sectional evaluation.Malar J. 2018; 17: 200Crossref PubMed Scopus (4) Google Scholar uptake of MRDTs in Enugu, Nigeria was poor because health-care workers in Enugu state alone, out of six geopolitical zones in Nigeria, perceived the results of MRDTs to be inaccurate. Furthermore, the same authors in 2016 reported a preference for use of microscopy (61·8%) compared with the use of MRDTs (38·2%) in the diagnosis of malaria among health-care providers from 201 private hospitals.9Mokuolu OA Ntadom GN Ajumobi OO et al.Status of the use and compliance with malaria rapid diagnostic tests in formal private health facilities in Nigeria.Malar J. 2016; 15: 4Crossref PubMed Scopus (15) Google Scholar Therefore, the detrimental preferences and perceptions of health-care workers need to be addressed before scaling up the findings reported by Omale and colleagues. It is noteworthy that most of the increase in MRDT uptake usually occurs among patients treated outside of health facilities,1Bruxvoort KJ Leurent B Chandler CIR et al.The impact of introducing malaria rapid diagnostic tests on fever case management: a synthesis of ten studies from the ACT consortium.Am J Trop Med Hyg. 2017; 97: 1170-1179Crossref PubMed Scopus (27) Google Scholar which was reported by Omale and colleagues who targeted social groups (who are not health-care workers).7Omale UI Azuogu BN Alo C et al.Social group and health-care provider interventions to increase the demand for malaria rapid diagnostic tests among community members in Ebonyi state, Nigeria: a cluster-randomised controlled trial.Lancet Glob Health. 2021; 9: e320-e330Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar Areas needing more research include making sure that the increase in uptake of MRDTs translates to improved malaria management and not just increased sales for the private sector. It would have been desirable to have at least a two-point measurement of outcome, such as extending the study for an additional 3 months, to measure the sustainability of the interventions. Health-care interventions that involve only mothers are likely to lead to poor uptake because fathers make decisions on the treatment of their ill child more often than mothers, even though mothers are likely to be the ones who detect the illness and might actually end up funding the care. A positive control group consisting of sensitisation and education for health-care providers only, without the social group intervention, would have been useful in validating the main findings of this study and to provide further insight into associated factors. Omale and colleagues7Omale UI Azuogu BN Alo C et al.Social group and health-care provider interventions to increase the demand for malaria rapid diagnostic tests among community members in Ebonyi state, Nigeria: a cluster-randomised controlled trial.Lancet Glob Health. 2021; 9: e320-e330Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar rightly suggest application of their findings to other malaria-endemic areas in Nigeria. Scaled-up research findings are notoriously difficult to implement into regular routine in health-care facilities.10Jegede A Willey B Hamade P et al.Evaluation of a capacity building intervention on malaria treatment for under-fives in rural health facilities in Niger State, Nigeria.Malar J. 2020; 19: 90Crossref PubMed Scopus (1) Google Scholar Training of trainers is usually the first step, and this training is then usually cascaded down to others. The failure to reach all staff who need to be trained is a major issue, and sometimes half or less than half of those who need to be trained are. Another issue is the loss of quality in the training process. These two main causes of implementation failures must be guided against. The key message from this study by Omale and colleagues is that it is important to educate the end users about MRDTs. The Article provided evidence that social group intervention in the form of education and sensitisation led to significant increase in uptake, and that focusing on health-care providers only (formal and community) will not provide maximal uptake of MRDTs. These findings have implications for the scale-up of MRDT in a country like Nigeria where the uptake in the non-government health sector has been low. Future research should focus on sustainability of this model and the interrelationship with the health-care providers to better inform the scale-up efforts of the National Malaria Elimination Programme. We declare no competing interests. Social group and health-care provider interventions to increase the demand for malaria rapid diagnostic tests among community members in Ebonyi state, Nigeria: a cluster-randomised controlled trialThe sensitisation and education of social groups about MRDTs can significantly increase the demand for MRDTs. This intervention is pragmatic and could be applied within malaria control or elimination programmes, in Nigeria and in other high-burden countries, to enhance diagnostic testing for patients suspected of having malaria. Full-Text PDF Open AccessClarification on social group interventions and malaria rapid diagnostic test uptake in NigeriaI thank Catherine Falade and Olugbenga Mokuolu1 for their Comment on our recent Article.2 The authors rightly highlighted some of the factors that influence malaria rapid diagnostic test (MRDT) uptake in Nigeria. However, some of Falade and Mokuolus' statements might mislead readers with regards to our study. Thus, I need to make some clarifications to avoid any misunderstandings. Full-Text PDF Open Access