Completeness of malaria indicator data reporting via the District Health Information Software 2 in Kenya, 2011-2015.

BACKGROUND: Health facility-based data reported through routine health information systems form the primary data source for programmatic monitoring and evaluation in most developing countries. The adoption of District Health Information Software (DHIS2) has contributed to improved availability of routine health facility-based data in many low-income countries. An assessment of malaria indicators data reported by health facilities in Kenya during the first 5 years of implementation of DHIS2, from January 2011 to December 2015, was conducted. METHODS: Data on 19 malaria indicators reported monthly by health facilities were extracted from the online Kenya DHIS2 database. Completeness of reporting was analysed for each of the 19 malaria indicators and expressed as the percentage of data values actually reported over the expected number; all health facilities were expected to report data for each indicator for all 12 months in a year. RESULTS: Malaria indicators data were analysed for 6235 public and 3143 private health facilities. Between 2011 and 2015, completeness of reporting in the public sector increased significantly for confirmed malaria cases across all age categories (26.5-41.9%, p < 0.0001, in children aged <5 years; 30.6-51.4%, p < 0.0001, in persons aged ≥5 years). Completeness of reporting of new antenatal care (ANC) clients increased from 53.7 to 70.5%, p < 0.0001). Completeness of reporting of intermittent preventive treatment in pregnancy (IPTp) decreased from 64.8 to 53.7%, p < 0.0001 for dose 1 and from 64.6 to 53.4%, p < 0.0001 for dose 2. Data on malaria tests performed and test results were not available in DHIS2 from 2011 to 2014. In 2015, sparse data on microscopy (11.5% for children aged <5 years; 11.8% for persons aged ≥5 years) and malaria rapid diagnostic tests (RDTs) (8.1% for all ages) were reported. In the private sector, completeness of reporting increased significantly for confirmed malaria cases across all age categories (16.7-23.1%, p < 0.0001, in children aged <5 years; 19.4-28.6%, p < 0.0001, in persons aged ≥5 years). Completeness of reporting also improved for new ANC clients (16.2-23.6%, p < 0.0001), and for IPTp doses 1 and 2 (16.6-20.2%, p < 0.0001 and 15.5-20.5%, p < 0.0001, respectively). In 2015, less than 3% of data values for malaria tests performed were reported in DHIS2 from the private sector. CONCLUSIONS: There have been sustained improvements in the completeness of data reported for most key malaria indicators since the adoption of DHIS2 in Kenya in 2011. However, major data gaps were identified for the malaria-test indicator and overall low reporting across all indicators from private health facilities. A package of proven DHIS2 implementation interventions and performance-based incentives should be considered to improve private-sector data reporting.

Efficacy of text-message reminders on paediatric malaria treatment adherence and their post-treatment return to health facilities in Kenya: a randomized controlled trial.

BACKGROUND: Short Message Service (SMS) reminders have been suggested as a potential intervention for improving adherence to medications and health facility attendance. METHODS: An open-label, randomized, controlled trial to test the efficacy of automated SMS reminders in improving adherence to artemether-lumefantrine (AL) and post-treatment attendance in comparison with standard care was conducted at four health facilities in western Kenya. Children below five years of age with uncomplicated malaria were randomized to intervention (SMS reminders) or control groups. Within each study group they were further randomized to three categories, which determined the timing of home visits to measure adherence to complete AL course and to individual AL doses. A sub-set of caregivers was advised to return to the facility on day 3 and all were advised to return after 28 days. The primary outcomes were adherence to medication and return on day 3. The primary analysis was by intention-to-treat. RESULTS: Between 9 June, 2014 and 26 February, 2016, 1677 children were enrolled. Of 562 children visited at home on day 3, all AL doses were completed for 97.6% (282/289) of children in the control and 97.8% (267/273) in the intervention group (OR = 1.10; 95% CI = 0.37-3.33; p = 0.860). When correct timing in taking each dose was considered a criteria for adherence, 72.3% (209/289) were adherent in the control and 69.2% (189/273) in the intervention group (OR = 0.82; 95% CI = 0.56-1.19; p = 0.302). Sending SMS reminders significantly increased odds of children returning to the facility on day 3 (81.4 vs 74.0%; OR = 1.55; 95% CI = 1.15-2.08; p = 0.004) and on day 28 (63.4 vs 52.5%; OR = 1.58; 95% CI = 1.30-1.92; p < 0.001). CONCLUSIONS: In this efficacy trial, SMS reminders increased post-treatment return to the health facility, but had no effect on AL adherence which was high in both control and intervention groups. Further effectiveness studies under the real world conditions are needed to determine the optimum role of SMS reminders. Trial registration ISRCTN39512726.

A national health facility survey of malaria infection among febrile patients in Kenya, 2014.

BACKGROUND: The use of malaria infection prevalence among febrile patients at clinics has a potential to be a valuable epidemiological surveillance tool. However, routine data are incomplete and not all fevers are tested. This study was designed to screen all fevers for malaria infection in Kenya to explore the epidemiology of fever test positivity rates. METHODS: Random sampling was used within five malaria epidemiological zones of Kenya (i.e., high lake endemic, moderate coast endemic, highland epidemic, seasonal low transmission and low risk zones). The selected sample was representative of the number of hospitals, health centres and dispensaries within each zone. Fifty patients with fever presenting to each sampled health facility during the short rainy season were screened for malaria infection using a rapid diagnostic test (RDT). Details of age, pregnancy status and basic demographics were recorded for each patient screened. RESULTS: 10,557 febrile patients presenting to out-patient clinics at 234 health facilities were screened for malaria infection. 1633 (15.5%) of the patients surveyed were RDT positive for malaria at 124 (53.0%) facilities. Infection prevalence among non-pregnant patients varied between malaria risk zones, ranging from 0.6% in the low risk zone to 41.6% in the high lake endemic zone. Test positivity rates (TPR) by age group reflected the differences in the intensity of transmission between epidemiological zones. In the lake endemic zone, 6% of all infections were among children aged less than 1 year, compared to 3% in the coast endemic, 1% in the highland epidemic zone, less than 1% in the seasonal low transmission zone and 0% in the low risk zone. Test positivity rate was 31% among febrile pregnant women in the high lake endemic zone compared to 9% in the coast endemic and highland epidemic zones, 3.2% in the seasonal low transmission zone and zero in the low risk zone. CONCLUSION: Malaria infection rates among febrile patients, with supporting data on age and pregnancy status presenting to clinics in Kenya can provide invaluable epidemiological data on spatial heterogeneity of malaria and serve as replacements to more expensive community-based infection rates to plan and monitor malaria control.

Development of a text-messaging intervention to improve treatment adherence and post-treatment review of children with uncomplicated malaria in western Kenya.

BACKGROUND: Patients' low adherence to artemisinin-based combination therapy has been reported in areas of Kenya bordering the Lake Victoria region, where the burden of malaria remains high. A randomized controlled trial is underway to determine the efficacy of short message service (SMS) text reminders on adherence to artemether-lumefantrine and post-treatment review of children under the age of five. This paper reports on the iterative process of intervention and delivery system development. METHODS: An intervention development workshop involving the research team and other stakeholders was held to determine the content of the text messages. Three focus group discussions were conducted to test caregivers' understanding of the messages developed during the workshop. The tested messages were refined and incorporated into an automated SMS distribution system and piloted with 20 caregivers drawn from facilities neighbouring the study sites. The automated SMS distribution system was repeatedly refined following the pilot and implemented at the start of the trial. RESULTS: The content of SMS messages underwent major revisions following the focus group discussions. Technical terms and abbreviations were replaced with simplified general terms. Message sign-off was modified to reflect the name of health facility, removing references to health workers. Day 3 post-treatment review visit reminder was modified to state the purpose of the visit while wording 'day 28' was added to the last post-treatment review visit reminder to help the caregiver recall the appointment date. The unscheduled visit prompt was modified to reflect flexibility and practicality of taking the child back to the facility if unwell. Reception of SMS reminders during the pilot was low with only 169/240 (70%) of scheduled messages delivered to the caregivers. The automated distribution system underwent major refinement and repeated testing following the pilot until effective delivery of all scheduled messages was achieved and sustained over a period of 3 months. CONCLUSIONS: Text message interventions should be carefully developed, tested and refined before implementation to ensure they are written in the most appropriate way for their target population. SMS distribution systems should be rigorously tested to ensure efficient delivery of the messages before they are deployed.

The feasibility, patterns of use and acceptability of using mobile phone text-messaging to improve treatment adherence and post-treatment review of children with uncomplicated malaria in western Kenya.

BACKGROUND: Trials evaluating the impact of mobile phone text-messaging to support management of acute diseases, such as malaria, are urgently needed in Africa. There has been however a concern about the feasibility of interventions that rely on access to mobile phones among caregivers in rural areas. To assess the feasibility and inform development of an intervention to improve adherence to malaria medications and post-treatment review, mobile phone network, access, ownership and use among caregivers in western Kenya was assessed. METHODS: A cross-sectional survey based on outpatient exit interviews was undertaken among caregivers of children with malaria at four trial facilities. The main outcomes were proportions of caregivers that have mobile signal at home; have access to mobile phones; are able to read; and use text-messaging. Willingness to receive text-message reminders was also explored. Descriptive analyses were performed. RESULTS: Of 400 interviewed caregivers, the majority were female (93.5%), mothers of the sick children (87.8%) and able to read (97.3%). Only 1.7% of caregivers were without any education. Nearly all (99.8%) reported access to a mobile signal at home. 93.0% (site range: 89-98%) had access to a mobile phone within their household while 73.8% (site range: 66-78%) possessed a personal phone. Among caregivers with mobile phone access, 93.6% (site range: 85-99%) used the phone to receive text-messages. Despite only 19% having electricity at home nearly all (99.7%) caregivers reported that they would be able to have permanent phone access to receive text-messages in the next 28 days. Willingness to receive text-message reminders was nearly universal (99.7%) with 41.7% of caregivers preferring texts in English, 32.3% in Kiswahili and 26.1% in Dholuo. CONCLUSIONS: Despite concerns that the feasibility of text-messaging interventions targeting caregivers may be compromised in rural high malaria risk areas in Kenya, very favourable conditions were found with respect to mobile network, access and ownership of phones, use of text-messaging and minimum literacy levels required for successful intervention delivery. Moreover, there was a high willingness of caregivers to receive text-message reminders. Impact evaluations of carefully tailored text-messaging interventions targeting caregivers of children with malaria are timely and justified.

Using mobile phone text messaging for malaria surveillance in rural Kenya.

BACKGROUND: Effective surveillance systems are required to track malaria testing and treatment practices. A 26-week study "SMS for Life" was piloted in five rural districts of Kenya to examine whether SMS reported surveillance data could ensure real-time visibility of accurate data and their use by district managers to impact on malaria case-management. METHODS: Health workers from 87 public health facilities used their personal mobile phones to send a weekly structured SMS text message reporting the counts of four basic surveillance data elements to a web-based system accessed by district managers. Longitudinal monitoring of SMS reported data through the web-based system and two rounds of cross-sectional health facility surveys were done to validate accuracy of data. RESULTS: Mean response rates were 96% with 87% of facilities reporting on time. Fifty-eight per cent of surveillance data parameters were accurately reported. Overall mean testing rates were 37% with minor weekly variations ranging from 32 to 45%. Overall test positivity rate was 24% (weekly range: 17-37%). Ratio of anti-malarial treatments to test positive cases was 1.7:1 (weekly range: 1.3:1-2.2:1). District specific trends showed fluctuating patterns in testing rates without notable improvement over time but the ratio of anti-malarial treatments to test positive cases improved over short periods of time in three out of five districts. CONCLUSIONS: The study demonstrated the feasibility of using simple mobile phone text messages to transmit timely surveillance data from peripheral health facilities to higher levels. However, accuracy of data reported was suboptimal. Future work should focus on improving quality of SMS reported surveillance data.

The magnitude and trend of artemether-lumefantrine stock-outs at public health facilities in Kenya.

BACKGROUND: Health facility stock-outs of artemether-lumefantrine (AL), the common first-line therapy for uncomplicated malaria across Africa, adversely affect effective malaria case-management. They have been previously reported on various scales in time and space, however the magnitude of the problem and trends over time are less clear. Here, 2010-2011 data are reported from public facilities in Kenya where alarming stock-outs were revealed in 2008. METHODS: Data were collected between January 2010 and June 2011 as part of 18 monthly cross-sectional surveys undertaken at nationally representative samples of public health facilities. The primary monitoring indicator was total stock-out of all four weight-specific AL packs. The secondary indicators were stock-outs of at least one AL pack and individual stock-outs for each AL pack. Monthly proportions and summary means of the proportions over the monitoring period were measured for each indicator. Stock-out trends were assessed using linear regression. RESULTS: The number of surveyed facilities across 18 time points ranged between 162 and 176 facilities. The stock-out means of the proportion of health facilities were 11.6% for total AL stock-out, 40.6% for stock-out of at least one AL pack, and between 20.5% and 27.4% for stock-outs of individual AL packs. Monthly decrease of the total AL stock-out was 0.005% (95% CI: -0.5 to +0.5; p = 0.983). Monthly decrease in the stock-out of at least one AL pack was 0.7% (95% CI: -1.5 to +0.3; p = 0.058) while stock-outs of individual AL packs decreased monthly between 0.2% for AL 24-pack and 0.7% for AL six-pack without statistical significance for any of the weight-specific packs. CONCLUSIONS: Despite lower levels of AL stock-outs compared to the reports in 2008, the stock-outs at Kenyan facilities during 2010-2011 are still substantial and of particular worry for the most detrimental:- simultaneous absence of any AL pack. Only minor decrease was observed in the stock-outs of individual AL packs. Recently launched interventions to eliminate AL stock-outs in Kenya are fully justified.

Progress towards implementation of ACT malaria case-management in public health facilities in the Republic of Sudan: a cluster-sample survey.

BACKGROUND: Effective malaria case-management based on artemisinin-based combination therapy (ACT) and parasitological diagnosis is a major pillar within the 2007-2012 National Malaria Strategic Plan in the Sudan. Three years after the launch of the strategy a health facility survey was undertaken to evaluate case-management practices and readiness of the health facilities and health workers to implement a new malaria case-management strategy. METHODS: A cross-sectional, cluster sample survey was undertaken at public health facilities in 15 states of Sudan. Data were collected using quality-of-care assessment methods. The main outcomes were the proportions of facilities with ACTs and malaria diagnostics; proportions of health workers exposed to malaria related health systems support activities; and composite and individual indicators of case-management practices for febrile outpatients stratified by age, availability of ACTs and diagnostics, use of malaria diagnostics, and test result. RESULTS: We evaluated 244 facilities, 294 health workers and 1,643 consultations for febrile outpatients (425 < 5 years and 1,218 ≥ 5 years). Health facility and health worker readiness was variable: chloroquine was available at only 5% of facilities, 73% stocked recommended artesunate and sulfadoxine/pyrimethamine (AS+SP), 51% had the capacity to perform parasitological diagnosis, 53% of health workers had received in-service training on ACTs, 24% were trained in the use of malaria Rapid Diagnostic Tests, and 19% had received a supervisory visit including malaria case-management. At all health facilities 46% of febrile patients were parasitologically tested and 35% of patients were both, tested and treated according to test result. At facilities where AS+SP and malaria diagnostics were available 66% of febrile patients were tested and 51% were both, tested and treated according to test result. Among test positive patients 64% were treated with AS+SP but 24% were treated with artemether monotherapy. Among test negative patients only 17% of patients were treated for malaria. The majority of ACT dispensing and counseling practices were suboptimal. CONCLUSIONS: Five years following change of the policy from chloroquine to ACTs and 3 years before the end of the new malaria strategic plan chloroquine was successfully phased out from public facilities in Sudan, however, an important gap remained in the availability of ACTs, diagnostic capacities and coverage with malaria case-management activities. The national scale-up of diagnostics, using the findings of this survey as well as future qualitative research, should present an opportunity not only to expand existing testing capacities but also to implement effective support interventions to bridge the health systems gaps and support corrective case-management measures, including the discontinuation of artemether monotherapy treatment.

Self-reported fever, treatment actions and malaria infection prevalence in the northern states of Sudan.

BACKGROUND: The epidemiology of fevers and their management in areas of low malaria transmission in Africa is not well understood. The characteristics of fever, its treatment and association with infection prevalence from a national household sample survey in the northern states of Sudan, an area that represents historically low parasite prevalence, are examined in this study. METHODS: In October-November 2009, a cluster sample cross-sectional household malaria indicator survey was undertaken in the 15 northern states of the Sudan. Data on household assets and individual level information on age, sex, whether the individual had a fever in the last 14 days and on the day of survey, actions taken to treat the fever including diagnostic services and drugs used and their sources were collected. Consenting household members were asked to provide a finger-prick blood sample and examined for malaria parasitaemia using a rapid diagnostic test (RDT). All proportions and odds ratios were weighted and adjusted for clustering. RESULTS: Of 26,471 respondents 19% (n = 5,299) reported a history of fever within the last two weeks prior to the survey and 8% had fever on the day of the survey. Only 39% (n = 2,035) of individuals with fever in last two weeks took any action, of which 43% (n = 875) were treated with anti-malarials. About 44% (n = 382) of malaria treatments were done using the nationally recommended first-line therapy artesunate+sulphadoxine-pryrimethamine (AS+SP) and 13% (n = 122) with non-recommended chloroquine or SP. Importantly 33.9% (n = 296) of all malaria treatments included artemether monotherapy, which is internationally banned for the treatment of uncomplicated malaria. About 53% of fevers had some form of parasitological diagnosis before treatment. On the day of survey, 21,988 individuals provided a finger-prick blood sample and only 1.8% were found positive for Plasmodium falciparum. Infection prevalence was higher among individuals who had fever in the last two weeks (OR = 3.4; 95%CI = 2.6 - 4.4, p < 0.001) or reported fever on the day of survey (OR = 6.2; 95%CI = 4.4 - 8.7, p < 0.001) compared to those without a history of fever. CONCLUSION: Across the northern states of the Sudan, the period prevalence of fever is low. The proportion of fevers that are likely to be malaria is very low. Consequently, parasitological diagnosis of all fevers before treatment is an appropriate strategy for malaria case-management. Improved regulation and supervision of health workers is required to increase the use of diagnostics and remove the practice of prescribing artemisinin monotherapy.

Kenyan school book knowledge for water, sanitation, hygiene and health education interventions: Disconnect, integration or opportunities?

BACKGROUND: Schools, depending on their access to and quality of water, sanitation and hygiene (WASH) and the implementation of healthy behaviours, can be critical for the control and spread of many infectious diseases, including COVID-19. Schools provide opportunities for pupils to learn about the importance of hygiene and WASH-related practice, and build healthy habits and skills, with beneficial medium- and long-term consequences particularly in low- and middle-income countries: reducing pupils' absenteeism due to diseases, promoting physical, mental and social health, and improving learning outcomes. WASH services alone are often not sufficient and need to be combined with educational programmes. As pupils disseminate their acquired health-promoting knowledge to their (extended) families, improved WASH provisions and education in schools have beneficial effects also on the community. International organisations frequently roll out interventions in schools to improve WASH services and, in some cases, train pupils and teachers on safe WASH behaviours. How such interventions relate to local school education on WASH, health promotion and disease prevention knowledge, whether and how such knowledge and school books are integrated into WASH education interventions in schools, are knowledge gaps we fill. METHODS: We analyzed how Kenyan primary school science text book content supports WASH and health education by a book review including books used from class 1 through class 8, covering the age range from 6 to 13 years. We then conducted a rapid literature review of combined WASH interventions that included a behaviour change or educational component, and a rapid review of international policy guidance documents to contextualise the results and understand the relevance of books and school education for WASH interventions implemented by international organisations. We conducted a content analysis based on five identified thematic categories, including drinking water, sanitation, hygiene, environmental hygiene & health promotion and disease risks, and mapped over time the knowledge about WASH and disease prevention. RESULTS: The books comprehensively address drinking water issues, including sources, quality, treatment, safe storage and water conservation; risks and transmission pathways of various waterborne (Cholera, Typhoid fever), water-based (Bilharzia), vector-related (Malaria) and other communicable diseases (Tuberculosis); and the importance of environmental hygiene and health promotion. The content is broadly in line with internationally recommended WASH topics and learning objectives. Gaps remain on personal hygiene and handwashing, including menstrual hygiene, sanitation education, and related health risks and disease exposures. The depth of content varies greatly over time and across the different classes. Such locally available education materials already used in schools were considered by none of the WASH education interventions in the considered intervention studies. CONCLUSIONS: The thematic gaps/under-representations in books that we identified, namely sanitation, hygiene and menstrual hygiene education, are all high on the international WASH agenda, and need to be filled especially now, in the context of the current COVID-19 pandemic. Disconnects exist between school book knowledge and WASH education interventions, between policy and implementation, and between theory and practice, revealing missed opportunities for effective and sustainable behaviour change, and underlining the need for better integration. Considering existing local educational materials and knowledge may facilitate the buy-in and involvement of teachers and school managers in strengthening education and implementing improvements. We suggest opportunities for future research, behaviour change interventions and decision-making to improve WASH in schools.

Efficacy of Mobile Phone Short Message Service (SMS) Reminders on Malaria Treatment Adherence and Day 3 Post-Treatment Reviews (SMS-RES-MAL) in Kenya: A Study Protocol.

BACKGROUND: Mobile phone short messaging services (SMS) have been investigated in health information reporting, provider performance, drug and diagnostic stock management and patient adherence to treatment for chronic diseases. However, their potential role in improving patients' adherence to malaria treatment and day 3 post treatment reviews remains unclear. METHODS/DESIGN: A "proof of concept" open label randomised controlled trial will be conducted at four sites in Western Kenya. Principal research questions are: 1) Can mobile phone SMS reminders improve patient adherence to malaria treatment? 2) Can mobile phone SMS reminders improve day 3 post treatment reviews? Eligible caregivers (n=1000 per arm) of children under five years old with uncomplicated malaria will be randomly assigned (one to one) to: a) the current standard of care (provider counselling and health education); and b) the current standard of care plus SMS reminders. Within each arm, caregivers will be further randomized to three different categories. In categories 1 and 2, 300 caregivers per arm per category will be visited at home on day 1 and 2 of follow up respectively, to measure appropriate timing and adherence of the second Artemether-Lumefantrine (AL) dose and doses 3 and 4. Further, caregivers in categories 1 and 2 will be required to come to the health facility for the day 3 post treatment reviews. Finally, in category 3, 400 caregivers per arm will be visited at home on day 3 to measure adherence for the full AL course. Each category will be visited at home only once to avoid biases in the measures of adherence as a result of home consultations. Primary outcomes will be adherence to the full AL course (category 3), as well as, the proportion of patients reporting back for day 3 post treatment reviews (categories 1 and 2). The primary analysis will be intention-to-treat. Costs of the intervention will be measured over the period of the intervention, and a cost-effectiveness ratio will be estimated. DISCUSSION: If successful, evidence from this trial could improve malaria treatment adherence and offer pragmatic approaches for antimalarial drug resistance surveillance and risk mitigation in Africa. CURRENT CONTROLLED TRIALS: ISRCTN39512726.

The impact of water on health and ill-health in a sub-Saharan African wetland: Exploring both sides of the coin.

Wetlands are a source of water out of which humans derive their livelihoods in Sub-Saharan Africa. They are often over-utilized and expose humans to disease-causing infectious agents. This calls for an evaluation of the role of water, sanitation and hygiene (WASH) and their effects in disease prevention and transmission in wetlands. A health risk assessment based on syndromic surveillance of self-reported abdominal complaints and fever gathered from a rural wetland in semiarid Kenya is presented with symptoms serving as proxies for real health threats in wetlands. The incidence of abdominal complaints was significantly higher for those using unimproved water sources compared to improved water users (odds ratio 7.5; 95% CI 2.59-26.9; p=0.001). Drainage of stagnant water near the house (odds ratio 0.2; 95% CI 0.08-0.54; p=0.002) and sanitary hygiene (odds ratio 0.4; 95% CI 0.71-0.97; p=0.056) were associated with reduced risk of abdominal complaints. Drainage of water was also associated with reduced risk of fever (odds ratio 0.3; 95% CI 0.02-0.59; p=0.002) and so was the use of mosquito nets (odds ratio 0.6; 95% CI 0.39-0.02; p=0.063). Usage of wetlands in the afternoon, e.g. for irrigated agriculture, increased the incidence of fever (odds ratio 1.5; 95% CI 0.91-2.33; p=0.040). Overall, there appears a greater likelihood of reducing pathogen exposure in the domestic than in the occupational domain or in the proximity to the wetland. We show that WASH, environmental hygiene and human behaviour are risk factors associated with the contraction of diseases characterized by abdominal complaints (e.g. diarrhoea) and fever (e.g. malaria) in wetlands. The same factors also have the potential to promote human health in the context of wetlands. We demonstrate the applicability of syndromic approaches in surveillance-scarce areas and emphasize the importance of adopting an integrated health-based wetland management that considers WASH and incorporates strategies based on grassroots level risk assessments.

Major improvements in the quality of malaria case-management under the "test and treat" policy in Kenya.

BACKGROUND: Monitoring implementation of the "test and treat" case-management policy for malaria is an important component of all malaria control programmes in Africa. Unfortunately, routine information systems are commonly deficient to provide necessary information. Using health facility surveys we monitored health systems readiness and malaria case-management practices prior to and following implementation of the 2010 "test and treat" policy in Kenya. METHODS/FINDINGS: Between 2010 and 2013 six national, cross-sectional, health facility surveys were undertaken. The number of facilities assessed ranged between 172 and 176, health workers interviewed between 216 and 237 and outpatient consultations for febrile patients evaluated between 1,208 and 2,408 across six surveys. Comparing baseline and the last survey results, all readiness indicators showed significant (p<0.005) improvements: availability of parasitological diagnosis (55.2% to 90.7%); RDT availability (7.5% to 69.8%); total artemether-lumefantrine (AL) stock-out (27.2% to 7.0%); stock-out of one or more AL packs (59.5% to 21.6%); training coverage (0 to 50.2%); guidelines access (0 to 58.1%) and supervision (17.9% to 30.8%). Testing increased by 34.0% (23.9% to 57.9%; p<0.001) while testing and treatment according to test result increased by 34.2% (15.7% to 49.9%; p<0.001). Treatment adherence for test positive patients improved from 83.3% to 90.3% (p = 0.138) and for test negative patients from 47.9% to 83.4% (p<0.001). Significant testing and treatment improvements were observed in children and adults. There was no difference in practices with respect to the type and result of malaria test (RDT vs microscopy). Of eight dosing, dispensing and counseling tasks, improvements were observed for four tasks. Overall AL use for febrile patients decreased from 63.5% to 35.6% (p<0.001). CONCLUSIONS: Major improvements in the implementation of "test and treat" policy were observed in Kenya. Some gaps towards universal targets still remained. Other countries facing similar needs and challenges may consider health facility surveys to monitor malaria case-management.

Reducing stock-outs of life saving malaria commodities using mobile phone text-messaging: SMS for life study in Kenya.

BACKGROUND: Health facility stock-outs of life saving malaria medicines are common across Africa. Innovative ways of addressing this problem are urgently required. We evaluated whether SMS based reporting of stocks of artemether-lumefantrine (AL) and rapid diagnostic tests (RDT) can result in reduction of stock-outs at peripheral facilities in Kenya. METHODS/FINDINGS: All 87 public health facilities in five Kenyan districts were included in a 26 week project. Weekly facility stock counts of four AL packs and RDTs were sent via structured incentivized SMS communication process from health workers' personal mobile phones to a web-based system accessed by district managers. The mean health facility response rate was 97% with a mean formatting error rate of 3%. Accuracy of stock count reports was 79% while accuracy of stock-out reports was 93%. District managers accessed the system 1,037 times at an average of eight times per week. The system was accessed in 82% of the study weeks. Comparing weeks 1 and 26, stock-out of one or more AL packs declined by 38 percentage-points. Total AL stock-out declined by 5 percentage-points and was eliminated by the end of the project. Stock-out declines of individual AL packs ranged from 14 to 32 percentage-points while decline in RDT stock-outs was 24 percentage-points. District managers responded to 44% of AL and 73% of RDT stock-out signals by redistributing commodities between facilities. In comparison with national trends, stock-out declines in study areas were greater, sharper and more sustained. CONCLUSIONS: Use of simple SMS technology ensured high reporting rates of reasonably accurate, real-time facility stock data that were used by district managers to undertake corrective actions to reduce stock-outs. Future work on stock monitoring via SMS should focus on assessing response rates without use of incentives and demonstrating effectiveness of such interventions on a larger scale.

"Even if you know everything you can forget": health worker perceptions of mobile phone text-messaging to improve malaria case-management in Kenya.

This paper presents the results of a qualitative study to investigate the perceptions and experiences of health workers involved in a a cluster-randomized controlled trial of a novel intervention to improve health worker malaria case-management in 107 government health facilities in Kenya. The intervention involved sending text-messages about paediatric outpatient malaria case-management accompanied by "motivating" quotes to health workers' mobile phones. Ten malaria messages were developed reflecting recommendations from the Kenyan national guidelines. Two messages were delivered per day for 5 working days and the process was repeated for 26 weeks (May to October 2009). The accompanying quotes were unique to each message. The intervention was delivered to 119 health workers and there were significant improvements in correct artemether-lumefantrine (AL) management both immediately after the intervention (November 2009) and 6 months later (May 2010). In-depth interviews with 24 health workers were undertaken to investigate the possible drivers of this change. The results suggest high acceptance of all components of the intervention, with the active delivery of information in an on the job setting, the ready availability of new and stored text messages and the perception of being kept 'up to date' as important factors influencing practice. Applying the construct of stages of change we infer that in this intervention the SMS messages were operating primarily at the action and maintenance stages of behaviour change achieving their effect by creating an enabling environment and providing a prompt to action for the implementation of case management practices that had already been accepted as the clinical norm by the health workers. Future trials testing the effectiveness of SMS reminders in creating an enabling environment for the establishment of new norms in clinical practice as well as in providing a prompt to action for the implementation of the new case-management guidelines are justified.

Malaria case-management following change of policy to universal parasitological diagnosis and targeted artemisinin-based combination therapy in Kenya.

BACKGROUND: The change of malaria case-management policy in Kenya to recommend universal parasitological diagnosis and targeted treatment with artemether-lumefantrine (AL) is supported with activities aiming by 2013 at universal coverage and adherence to the recommendations. We evaluated changes in health systems and case-management indicators between the baseline survey undertaken before implementation of the policy and the follow-up survey following the first year of the implementation activities. METHODS/FINDINGS: National, cross-sectional surveys using quality-of-care methods were undertaken at public facilities. Baseline and follow-up surveys respectively included 174 and 176 facilities, 224 and 237 health workers, and 2,405 and 1,456 febrile patients. Health systems indicators showed variable changes between surveys: AL stock-out (27% to 21%; p = 0.152); availability of diagnostics (55% to 58%; p = 0.600); training on the new policy (0 to 22%; p = 0.001); exposure to supervision (18% to 13%; p = 0.156) and access to guidelines (0 to 6%; p = 0.001). At all facilities, there was an increase among patients tested for malaria (24% vs 31%; p = 0.090) and those who were both tested and treated according to test result (16% to 22%; p = 0.048). At facilities with AL and malaria diagnostics, testing increased from 43% to 50% (p = 0.196) while patients who were both, tested and treated according to test result, increased from 28% to 36% (p = 0.114). Treatment adherence improved for test positive patients from 83% to 90% (p = 0.150) and for test negative patients from 47% to 56% (p = 0.227). No association was found between testing and exposure to training, supervision and guidelines, however, testing was significantly associated with facility ownership, type of testing, and patients' caseload, age and clinical presentation. CONCLUSIONS: Most of the case-management indicators have shown some improvement trends; however differences were smaller than expected, rarely statistically significant and still leaving a substantial gap towards optimistic targets. The quantitative and qualitative improvement of interventions will ultimately determine the success of the new policy.