Abstract：
BACKGROUND: Health workers\' compliance with outpatient malaria \'test and treat\' guidelines has improved since 2010 but plateaued from 2014 at suboptimal levels in Kenya. This study examined the factors associated with high but suboptimal compliance levels at facilities with available malaria tests and drugs.
METHODS: Data from four national, cross-sectional health facility surveys undertaken between 2014 and 2016 in Kenya were analysed. Association between 31 factors and compliance with malaria testing (survey range (SR): 65-69%) and no anti-malarial treatment for test negative patients (SR: 90-92%) were examined using multilevel logistic regression models.
RESULTS: A total of 2,752 febrile patients seen by 594 health workers at 486 health facilities were analysed. Higher odds of malaria testing were associated with lake endemic (aOR = 12.12; 95% CI: 5.3-27.6), highland epidemic (aOR = 5.06; 95% CI: 2.7-9.5) and semi-arid seasonal (aOR = 2.07; 95% CI: 1.2-3.6) compared to low risk areas; faith-based (FBO)/ non-governmental organization (NGO)-owned compared to government-owned facilities (aOR = 5.80; 95% CI: 3.2-10.6); health workers\' perception of malaria endemicity as high-risk (aOR = 3.05; 95% CI: 1.8-5.2); supervision with feedback (aOR = 1.84; 95% CI: 1.2-2.9); access to guidelines (aOR = 1.96; 95% CI: 1.1-3.4); older patients compared to infants, higher temperature measurements and main complaints of fever, diarrhoea, headache, vomiting and chills. Lower odds of testing were associated with febrile patients having main complaints of a cough (aOR = 0.65; 95% CI: 0.5-0.9), a rash (aOR = 0.32; 95% CI: 0.2-0.7) or a running nose (aOR = 0.59; 95% CI: 0.4-0.9). Other factors associated with compliance with test negative results included the type of diagnostic test available at the facility, in-service training, health workers\' age, and correct knowledge of the targeted treatment policy.
CONCLUSIONS: To optimize outpatient malaria case-management, reduce testing compliance gaps and eliminate overtreatment of test negative patients, there is a need to focus on compliance within low malaria risk areas in addition to ensuring the universal and continuous availability of \'test and treat\' commodities. Targeting of older and government health workers; dissemination of updated guidelines; and continuing with in-service training and supportive supervision with feedback is essential. Lastly, there is a need to improve health workers\' knowledge about malaria testing criteria considering their perceptions of endemicity.
METHODS: Data from four national, cross-sectional health facility surveys undertaken between 2014 and 2016 in Kenya were analysed. Association between 31 factors and compliance with malaria testing (survey range (SR): 65-69%) and no anti-malarial treatment for test negative patients (SR: 90-92%) were examined using multilevel logistic regression models.
RESULTS: A total of 2,752 febrile patients seen by 594 health workers at 486 health facilities were analysed. Higher odds of malaria testing were associated with lake endemic (aOR = 12.12; 95% CI: 5.3-27.6), highland epidemic (aOR = 5.06; 95% CI: 2.7-9.5) and semi-arid seasonal (aOR = 2.07; 95% CI: 1.2-3.6) compared to low risk areas; faith-based (FBO)/ non-governmental organization (NGO)-owned compared to government-owned facilities (aOR = 5.80; 95% CI: 3.2-10.6); health workers\' perception of malaria endemicity as high-risk (aOR = 3.05; 95% CI: 1.8-5.2); supervision with feedback (aOR = 1.84; 95% CI: 1.2-2.9); access to guidelines (aOR = 1.96; 95% CI: 1.1-3.4); older patients compared to infants, higher temperature measurements and main complaints of fever, diarrhoea, headache, vomiting and chills. Lower odds of testing were associated with febrile patients having main complaints of a cough (aOR = 0.65; 95% CI: 0.5-0.9), a rash (aOR = 0.32; 95% CI: 0.2-0.7) or a running nose (aOR = 0.59; 95% CI: 0.4-0.9). Other factors associated with compliance with test negative results included the type of diagnostic test available at the facility, in-service training, health workers\' age, and correct knowledge of the targeted treatment policy.
CONCLUSIONS: To optimize outpatient malaria case-management, reduce testing compliance gaps and eliminate overtreatment of test negative patients, there is a need to focus on compliance within low malaria risk areas in addition to ensuring the universal and continuous availability of \'test and treat\' commodities. Targeting of older and government health workers; dissemination of updated guidelines; and continuing with in-service training and supportive supervision with feedback is essential. Lastly, there is a need to improve health workers\' knowledge about malaria testing criteria considering their perceptions of endemicity.
摘要：
背景：肯尼亚卫生工作者“门诊疟疾测试和治疗”指南的依从性自2010年以来有所改善，但从2014年开始稳定在次优水平。这项研究检查了在具有可用疟疾测试和药物的设施中与高但次优的依从性水平相关的因素。
方法：数据来自四个国家，我们分析了2014年至2016年在肯尼亚开展的卫生机构横断面调查.使用多水平逻辑回归模型检查了31个因素与疟疾测试依从性（调查范围（SR）：65-69％）和测试阴性患者没有抗疟疾治疗（SR：90-92％）之间的关联。
结果：分析了486个医疗机构的594名卫生工作者看到的2,752例发热患者。较高的疟疾检测几率与湖泊地方病相关（aOR=12.12；95％CI：5.3-27.6），与低风险地区相比，高地流行（aOR=5.06；95％CI：2.7-9.5）和半干旱季节性（aOR=2.07；95％CI：1.2-3.6）；基于信仰的（FBO）/非政府组织（NGO）拥有的与政府拥有的设施相比（aOR=5.80；95％CI：3.2-10.6）；卫生工作者对疟疾的感知率（95％至95％CI=1.84％较高的温度测量值和发烧的主要投诉，腹泻,头痛,呕吐和寒战。较低的检测几率与有咳嗽主诉的发热患者相关(aOR=0.65;95%CI:0.5-0.9),皮疹(aOR=0.32;95%CI:0.2-0.7)或流鼻涕(aOR=0.59;95%CI:0.4-0.9)。与符合测试阴性结果相关的其他因素包括设施可用的诊断测试类型，在职培训,卫生工作者的年龄，以及对针对性治疗政策的正确认识。
结论：优化门诊疟疾病例管理，减少测试依从性差距，消除测试阴性患者的过度治疗，除了确保普遍和持续提供“测试和治疗”商品外，还需要关注低疟疾风险地区的合规性。针对老年人和政府卫生工作者；传播最新指南；继续进行在职培训和支持性监督并提供反馈至关重要。最后,考虑到卫生工作者对地方性疾病的看法，有必要提高卫生工作者对疟疾检测标准的认识。
方法：数据来自四个国家，我们分析了2014年至2016年在肯尼亚开展的卫生机构横断面调查.使用多水平逻辑回归模型检查了31个因素与疟疾测试依从性（调查范围（SR）：65-69％）和测试阴性患者没有抗疟疾治疗（SR：90-92％）之间的关联。
结果：分析了486个医疗机构的594名卫生工作者看到的2,752例发热患者。较高的疟疾检测几率与湖泊地方病相关（aOR=12.12；95％CI：5.3-27.6），与低风险地区相比，高地流行（aOR=5.06；95％CI：2.7-9.5）和半干旱季节性（aOR=2.07；95％CI：1.2-3.6）；基于信仰的（FBO）/非政府组织（NGO）拥有的与政府拥有的设施相比（aOR=5.80；95％CI：3.2-10.6）；卫生工作者对疟疾的感知率（95％至95％CI=1.84％较高的温度测量值和发烧的主要投诉，腹泻,头痛,呕吐和寒战。较低的检测几率与有咳嗽主诉的发热患者相关(aOR=0.65;95%CI:0.5-0.9),皮疹(aOR=0.32;95%CI:0.2-0.7)或流鼻涕(aOR=0.59;95%CI:0.4-0.9)。与符合测试阴性结果相关的其他因素包括设施可用的诊断测试类型，在职培训,卫生工作者的年龄，以及对针对性治疗政策的正确认识。
结论：优化门诊疟疾病例管理，减少测试依从性差距，消除测试阴性患者的过度治疗，除了确保普遍和持续提供“测试和治疗”商品外，还需要关注低疟疾风险地区的合规性。针对老年人和政府卫生工作者；传播最新指南；继续进行在职培训和支持性监督并提供反馈至关重要。最后,考虑到卫生工作者对地方性疾病的看法，有必要提高卫生工作者对疟疾检测标准的认识。
