Zurovac D, Rowe A K, Ochola S A, Noor A M, Midia B, English M, Snow R W
Médecins Sans Frontières-France, P.O. Box 39719, Nairobi, Kenya.
Int J Epidemiol. 2004 Oct;33(5):1080-91. doi: 10.1093/ije/dyh253. Epub 2004 Jul 15.
BACKGROUND: When replacing failing drugs for malaria with more effective drugs, an important step towards reducing the malaria burden is that health workers (HW) prescribe drugs according to evidence-based guidelines. Past studies have shown that HW commonly do not follow guidelines, yet few studies have explored with appropriate methods why such practices occur. METHODS: We analysed data from a survey of government health facilities in four Kenyan districts in which HW consultations were observed, caretakers and HW were interviewed, and health facility assessments were performed. The analysis was limited to children 2-59 months old with uncomplicated malaria. Treatment was defined as recommended (antimalarial recommended by national guidelines), a minor error (effective, but non-recommended antimalarial), or inappropriate (no effective antimalarial). RESULTS: We evaluated 1006 consultations performed by 135 HW at 81 facilities: 567 children received recommended treatment, 314 had minor errors, and 125 received inappropriate treatment (weighted percentages: 56.9%, 30.4%, and 12.7%). Multivariate logistic regression analysis revealed that programmatic interventions such as in-service malaria training, provision of guidelines and wall charts, and more frequent supervision were significantly associated with better treatment quality. However, neither in-service training nor possession of the guideline document showed an effect by itself. More qualified HW made more errors: both major and minor errors (but generally more minor errors) when second-line drugs were in stock, and more major errors when second-line drugs were not in stock. Child factors such as age and a main complaint of fever were also associated with treatment quality. CONCLUSIONS: Our results support the use of several programmatic strategies that can redress HW deficiencies in malaria treatment. Targeted cost-effectiveness trials would help refine these strategies and provide more precise guidance on affordable and effective ways to strengthen and maintain HW practices.
背景：在用更有效的药物替代治疗疟疾效果不佳的药物时，减少疟疾负担的重要一步是卫生工作者（HW）根据循证指南开药。过去的研究表明，卫生工作者通常不遵循指南，但很少有研究采用适当方法探究为何会出现这种情况。 方法：我们分析了对肯尼亚四个地区政府卫生设施进行调查的数据，在这些设施中观察了卫生工作者的诊疗过程，采访了看护人员和卫生工作者，并对卫生设施进行了评估。分析仅限于2至59个月患有非复杂性疟疾的儿童。治疗被定义为推荐治疗（国家指南推荐的抗疟药）、轻微错误（有效但非推荐的抗疟药）或不适当治疗（无有效抗疟药）。 结果：我们评估了81个设施中135名卫生工作者进行的1006次诊疗：567名儿童接受了推荐治疗，314名有轻微错误，125名接受了不适当治疗（加权百分比：56.9%、30.4%和12.7%）。多变量逻辑回归分析显示，在职疟疾培训、提供指南和挂图以及更频繁的监督等项目干预措施与更好的治疗质量显著相关。然而，在职培训和拥有指南文件本身均未显示出效果。资质更高的卫生工作者犯错更多：二线药物有库存时，重大和轻微错误（但通常轻微错误更多）都更多，二线药物无库存时，重大错误更多。年龄和主要发热症状等儿童因素也与治疗质量相关。 结论：我们的结果支持采用多种项目策略来纠正卫生工作者在疟疾治疗方面的不足。有针对性的成本效益试验将有助于完善这些策略，并就加强和维持卫生工作者行为的经济有效方式提供更精确的指导。
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