Wasunna Beatrice, Zurovac Dejan, Goodman Catherine A, Snow Robert W
Eastern and Southern Africa Centre of International Parasite Control (ESACIPAC)/KEMRI, P.O. Box 54840-00200, Nairobi, Kenya.
Malar J. 2008 Feb 5;7:29. doi: 10.1186/1475-2875-7-29.
Kenya recently changed its antimalarial drug policy to a specific artemisinin-based combination therapy (ACT), artemether-lumefantrine (AL). New national guidelines on the diagnosis, treatment and prevention were developed and disseminated to health workers together with in-service training.
Between January and March 2007, 36 in-depth interviews were conducted in five rural districts with health workers who attended in-service training and were non-adherent to the new guidelines. A further 20 interviews were undertaken with training facilitators and members of District Health Management Teams (DHMTs) to explore reasons underlying health workers' non-adherence.
Health workers generally perceived AL as being tolerable and efficacious as compared to amodiaquine and sulphadoxine-pyremethamine. However, a number of key reasons for non-adherence were identified. Insufficient supply of AL was a major issue and hence fears of stock outs and concern about AL costs was an impediment to AL prescription. Training messages that contradicted the recommended guidelines also led to health worker non-adherence, compounded by a lack of follow-up supervision. In addition, the availability of non-recommended antimalarials such as amodiaquine caused prescription confusion. Some health workers and DHMT members maintained that shortage of staff had resulted in increased patient caseload affecting the delivery of the desirable quality of care and adherence to guidelines.
The introduction of free efficacious ACTs in the public health sector in Kenya and other countries has major potential public health benefits for Africa. These may not be realized if provider prescription practices do not conform to the recommended treatment guidelines. It is essential that high quality training, drug supply and supervision work synergistically to ensure appropriate case management.
肯尼亚最近将其抗疟药物政策改为采用一种特定的青蒿素联合疗法（ACT），即蒿甲醚-本芴醇（AL）。制定了关于诊断、治疗和预防的新国家指南，并与在职培训一起分发给卫生工作者。
2007年1月至3月期间，在五个农村地区对参加了在职培训但未遵守新指南的卫生工作者进行了36次深入访谈。还与培训促进者和地区卫生管理团队（DHMT）成员进行了另外20次访谈，以探究卫生工作者不遵守规定的潜在原因。
与阿莫地喹和磺胺多辛-乙胺嘧啶相比，卫生工作者普遍认为AL耐受性良好且疗效显著。然而，确定了一些不遵守规定的关键原因。AL供应不足是一个主要问题，因此担心缺货和对AL成本的担忧成为开具AL处方的障碍。与推荐指南相矛盾的培训信息也导致卫生工作者不遵守规定，而缺乏后续监督则使问题更加严重。此外，如阿莫地喹等未被推荐的抗疟药物的供应导致了处方混乱。一些卫生工作者和DHMT成员坚持认为，工作人员短缺导致患者病例数量增加，影响了提供理想质量的护理以及遵守指南的情况。
在肯尼亚和其他国家的公共卫生部门引入免费有效的ACTs对非洲具有重大的潜在公共卫生益处。如果提供者的处方做法不符合推荐的治疗指南，这些益处可能无法实现。高质量培训、药品供应和监督必须协同工作，以确保适当的病例管理。
