Technical Session for Health Workers

TECHNICAL SESSION FOR HEALTH WORKERS

Introduction

We are here today to provide technical support to you and your team who are responsible for diagnosing and treating malaria patients. We would like to learn about and address some of your questions and concerns, particularly in using Rapid Diagnostic Tests (or RDTs)to diagnose malaria, and to share with you recent Ministry of Health (MOH) recommendations on malaria diagnosis and treatments.

In the next few months MOH will carry out a campaign to strongly promote malariatestingbefore getting treatment. In the past, here in Uganda all fevers have been treated as malaria, but as you well know, all fevers are certainly not malaria. There are many other illnesses you see in your clinics that cause fevers.

Our practice of treating all fevers as malaria, has meant that in some cases we have prescribed anti-malarial drugs even when patients did not have malaria. This practice has allowed malaria parasites to develop resistance to the antimalarial drugs. Now we can no longer use Fansidar and Chloroquine as they are not effective because we have overused them, so we have had to switch to new anti-malarial drugs. It is expensive and takes a long time to develop new drugs, and it is not easy.

Also, if we continue providing anti-malarials to patients with a fever who do not have malaria, not only will we wasting expensive medicines and creating more resistance, but patients will likely suffer more by not receiving the correct treatment needed for their illnesses.

I.Activity: Understanding Health Workers Beliefs and Attitudes

To get started, may we ask you to share your views and opinions on a few issues about malaria testing. There are no right or wrong answers. We only want to better understand your own views and beliefs about testing.

Note to SMP team: This exercise can be done orally (more like a game) where participants stand up and move across a line (a simple rope or other object is placed in the middle of the room) based on whether they agree of disagree with the statement. The key is to allow individuals to debate or try to convince their colleagues to be on their ‘side’ by defending their response.

Or if you are meeting with only two or three health workers, you could ask them to individually note down whether they agree or disagree with the following statements and then after to explain why. Make sure they understand you are not asking them to state whether the statement is correct or incorrect, but to state what they BELIEVE and whythey agree or disagree with the statement.

As the health workers defend their positions or state why they agreed or disagreed with the statements, we need to document the reasons they provide, as this information will help us to gain a better understanding of their beliefs.

‘I agree’or‘I disagree.’

1.I believe that malaria can be diagnosed without a blood test.

Why:

2.I do not trust RDT results.

Why:

3.I do not think that misdiagnosis of malaria is a serious problem in Uganda.

Why:

4.I believe that diagnostic tests are a waste of time and money when a very

sick child appears in my clinic.

Why:

5.I do not know where to get RDTs in my district.

Why:

6.I experience lots of patient pressure to treat for malaria without diagnosis.

Why:

7.If the RDT is negative, I am usually not sure what alternative diagnoses

and treatments to offer patients.

Why:

8.It is necessary to wait exactly X minutes before reading the results of a

RDT test.

Why:

9.Examining the blood on a slide under a microscope is a better, more

accurate, test for malaria than using the RDT.

Why:

10.Many of my patients do not trust the RDTs.

Why:

II.Discussion: Soliciting information about RDTs

Now, we would like to talk with you more specifically about RDTS. We want to better understand any challenges you face using RDTs, and your thoughts about this method of testing for malaria.

1. Opinions of the test

1. Have you ever used an RDT test before?
2. What do you think of the test?

Elicit positive and negative opinions – some of this information will have already emerged in the first activity, but it is good to ask again, to see if any additional opinions about the test come out.

Probe if necessary:Do you consider it helpful? In what ways? Do you consider it un-helpful? Why?

1. What additional information or support do you usually need when you are looking at the results of the test?

1. Current behaviors when using the test (Use pictures)

Show picture: sick child + positive test result.

1. What do you do when you have this situation?

Show picture: sick child + negative test result.

2.What do you do when you have this situation?

If still prescribe when result is negative, probe:

1. What usually makes you decide to prescribe anyway?

Elicit as many reasons and see if there is a main reason that most agree on.

5.Doesprescribing an antimalarial when the results are negative happen a

lot in your clinic or area? If so, why?

Try to get at the most frequent or common reasons.

If not prescribe when result is negative:

6.What made you decide not to prescribe? OrWhat made you decide that

that was the right decision.

7.What if your co-worker said to you: “You should repeat the test to see if

the results are still negative.” How would you respond to that? What

made you decide to respond that way?

1. Experience with counseling caregivers

1.How do caregivers usually react when you do an RDT test? (positive,

negative). Do they understand the test? Do they confuse it with other

tests that look similar (e.g. pregnancy or HIV tests?)

2.Do caregivers usually accept negative test results? What

do you do when they do not accept the results and insist that their child

has malaria? How do they respond to that?

(Elicit the various responses and strategies used by the health workers.)

3. What kind of support or information do you think would help you to

convince caretakers to accept negative results?

(Probe for specific answers. For example if they say ‘more training’ – then ask training on what? e.g. how to diagnose other fever related illnesses, etc.)

1. Sources of information

I would like you to think of a recent case you have had of a very sick child with a high fever. If you were not sure of the child’s diagnosis…

1.Who or what source would you go to for advice on how to handle this

patient?

(Probe on facility, community, district, regional and national level opinion leaders)

Do you trust the quality of any advice they would give? What makes you think they are trustworthy? (e.g.: it is useful, accurate, actionable/within our scope, etc.)

2.Would you like to learn more about how to handle malaria cases?

If yes: What sort of information do you need to make it easier for you to successfully handle malaria cases?

(Probe for specific answers… ‘training’ – is not specific and does not give us much useful information. Also, try to get at how they would need to receive this information.)

1. Feedback on current Job Aids and Messages

End the session by briefly reviewing the key messages MOH will promote in their campaign, highlighting the emphasis now being on testing before treating, versus the message to date (which has been ‘to treat within 24 hours’).

Insert Key Messages:

Use the finalized Key Messages from the Radio Scripts….

• All patients should be tested before treated.

Uganda updated its national malaria policy in 2012. The new policy now states that all cases suspected of malaria (which includes all fevers) should receive a test for malaria and receive the appropriate treatment. This is in line with the updated WHO guidelines for malaria case management from 2010 and WHO’s new initiative Test, Treat and Track which launched in 2012.

• ……

1.What information and support do you and your colleagues in order to

promote and adhere to these messages?

(Probe for specific information and focus more on the use of Job Aids as a source of information and support.Use some of the existing Job Aids and find out if health workers need to know how to administer the RDT properly (show the Job Aid on that), or is it that more clients needs to know that the services are available (show the posters on that), or is it that health workers need to know how to counsel clients when the tests are negative, etc.)

2.What, in your view, do caretakers need to know and understand in order

to follow these messages?

(Try to get at the question of whether patients understand RDTs – fear them? Confused by them? If fear, why and what can we do to help patients overcome fears? If confused, what sort of simple information will help them not be confused? etc. )