Why do some health workers prescribe malaria drugs even when a rapid test is negative?

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Malaria rapid diagnostic tests (RDTs) were at an early stage of introduction across malaria-endemic countries. Their introduction was central to efforts to reduce malaria overdiagnosis, the consequent overuse of valuable anti-malarials, and underdiagnosis of other causes of fever. Evidence on whether introducing RDTs reduced anti-malarial overprescribing was mixed. A recent trial in rural health facilities in Ghana reduced overprescribing, but 45.5% of patients with negative RDT results were still prescribed an anti-malarial.

Researchers conducted a qualitative study of that trial using in-depth interviews with a purposive sample of participating health workers. The sample ranged from workers who continued prescribing anti-malarials to most patients with negative RDT results to those who largely restricted these medicines to patients with positive results. Interviews explored trial participants’ experiences of using RDTs and their results.

Health workers constructed their understanding of RDTs through using the tests themselves and through interactions with colleagues, patients and the research team. These different ways of engaging with the tests and their results changed practice for some workers but reinforced existing practice for others. Many characteristics of RDTs were found to be inherently conducive to change. However, the analysis also identified limited support from those supplying the tests, a lack of pre-existing system conditions conducive to change, and limited system readiness for change.

The researchers concluded that, when introduced with a limited supporting package, RDTs were interpreted and used in different ways, reflecting how health workers had learned to use the results through participation. To build health workers’ confidence when faced with negative results, they recommended a supporting package that includes local preparation for the innovation; unambiguous guidelines; training in alternative causes of disease; regular support for workers to meet as communities of practice; interventions addressing negotiation within health worker–patient relationships and encouraging reflection on their own practice; feedback systems for RDT quality-control results; feedback systems for the results of workers’ practice with RDTs; and additional RDT support, such as a technical and/or clinical troubleshooting resource.