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Abstract：
BACKGROUND: Nonadherence to national standards for malaria diagnosis and treatment has been reported in Sudan. In this study, qualitative research examined the clinical domains of nonadherence, factors influencing nonadherent practices and health workers\' views on how to improve adherence.
METHODS: In September 2023, five Focus Group Discussions (FGDs) were undertaken with 104 health workers from 42 health facilities in Sudan\'s Northern State. The participants included medical assistants, doctors, nurses, laboratory personnel, pharmacists and public health officers. The FGDs followed a semi-structured guide reflecting the national malaria case management protocol. Qualitative thematic analysis was performed.
RESULTS: Nonadherent practices included disregarding parasitological test results, suboptimal paediatric artemether-lumefantrine (AL) dosing, lack of counselling, use of prohibited artemether injections for uncomplicated and severe malaria, artesunate dose approximations and suboptimal preparations, lack of AL follow on treatment for severe malaria; and rare use of primaquine for radical Plasmodium vivax treatment and dihydroartemisinin-piperaquine as the second-line treatment for uncomplicated malaria. Factors influencing nonadherence included stock-outs of anti-malarials and RDTs; staff shortages; lack of training, job aids and supervision; malpractice by specialists; distrust of malaria microscopy and RDTs; and patient pressure for diagnosis and treatment. Health workers recommended strengthening the supply chain; hiring personnel; providing in-service protocol training including specialists; establishing external quality assurance for malaria diagnosis; and providing onsite supportive supervision and public health campaigns.
CONCLUSIONS: This study revealed a broad spectrum of behavioural and systemic challenges in malaria management among frontline health workers in Northern Sudan, including nonadherence to protocols due to resource shortages, training gaps, a lack of supportive supervision and patient pressure. These insights, including health workers\' views about improvements, will inform evidence-based interventions by Sudan\'s National Malaria Control Programme to improve health systems readiness and the quality of malaria case management.
METHODS: In September 2023, five Focus Group Discussions (FGDs) were undertaken with 104 health workers from 42 health facilities in Sudan\'s Northern State. The participants included medical assistants, doctors, nurses, laboratory personnel, pharmacists and public health officers. The FGDs followed a semi-structured guide reflecting the national malaria case management protocol. Qualitative thematic analysis was performed.
RESULTS: Nonadherent practices included disregarding parasitological test results, suboptimal paediatric artemether-lumefantrine (AL) dosing, lack of counselling, use of prohibited artemether injections for uncomplicated and severe malaria, artesunate dose approximations and suboptimal preparations, lack of AL follow on treatment for severe malaria; and rare use of primaquine for radical Plasmodium vivax treatment and dihydroartemisinin-piperaquine as the second-line treatment for uncomplicated malaria. Factors influencing nonadherence included stock-outs of anti-malarials and RDTs; staff shortages; lack of training, job aids and supervision; malpractice by specialists; distrust of malaria microscopy and RDTs; and patient pressure for diagnosis and treatment. Health workers recommended strengthening the supply chain; hiring personnel; providing in-service protocol training including specialists; establishing external quality assurance for malaria diagnosis; and providing onsite supportive supervision and public health campaigns.
CONCLUSIONS: This study revealed a broad spectrum of behavioural and systemic challenges in malaria management among frontline health workers in Northern Sudan, including nonadherence to protocols due to resource shortages, training gaps, a lack of supportive supervision and patient pressure. These insights, including health workers\' views about improvements, will inform evidence-based interventions by Sudan\'s National Malaria Control Programme to improve health systems readiness and the quality of malaria case management.
摘要：
背景：苏丹有报道不遵守疟疾诊断和治疗的国家标准。在这项研究中,定性研究检查了不依从性的临床领域，影响非依从性实践的因素和卫生工作者对如何提高依从性的看法。
方法：2023年9月，与来自苏丹北部州42个医疗机构的104名卫生工作者进行了5次焦点小组讨论（FGD）。参与者包括医疗助理，医生,护士,实验室人员,药剂师和公共卫生官员。FGD遵循了反映国家疟疾病例管理协议的半结构化指南。进行了定性主题分析。
结果：不遵守的做法包括无视寄生虫学测试结果，儿童蒿甲醚-本莫特林(AL)次优剂量，缺乏咨询,使用违禁的蒿甲醚注射剂治疗简单和严重的疟疾，青蒿琥酯剂量近似值和次优制剂，严重疟疾治疗缺乏AL随访；罕见地使用伯氨喹治疗间日疟原虫，并使用双氢青蒿素-哌喹作为单纯性疟疾的二线治疗。影响不依从性的因素包括抗疟药和RDT的缺货；人员短缺；缺乏培训，工作辅助和监督；专家的不当行为；对疟疾显微镜和RDT的不信任；以及患者诊断和治疗的压力。卫生工作者建议加强供应链；雇用人员；提供包括专家在内的在职协议培训；为疟疾诊断建立外部质量保证；并提供现场支持性监督和公共卫生运动。
结论：这项研究揭示了苏丹北部一线卫生工作者在疟疾管理方面的广泛行为和系统性挑战，包括由于资源短缺而不遵守协议，培训差距，缺乏支持性监督和患者压力。这些见解,包括卫生工作者对改善的看法，将为苏丹的国家疟疾控制计划提供基于证据的干预措施，以改善卫生系统的准备情况和疟疾病例管理的质量。
方法：2023年9月，与来自苏丹北部州42个医疗机构的104名卫生工作者进行了5次焦点小组讨论（FGD）。参与者包括医疗助理，医生,护士,实验室人员,药剂师和公共卫生官员。FGD遵循了反映国家疟疾病例管理协议的半结构化指南。进行了定性主题分析。
结果：不遵守的做法包括无视寄生虫学测试结果，儿童蒿甲醚-本莫特林(AL)次优剂量，缺乏咨询,使用违禁的蒿甲醚注射剂治疗简单和严重的疟疾，青蒿琥酯剂量近似值和次优制剂，严重疟疾治疗缺乏AL随访；罕见地使用伯氨喹治疗间日疟原虫，并使用双氢青蒿素-哌喹作为单纯性疟疾的二线治疗。影响不依从性的因素包括抗疟药和RDT的缺货；人员短缺；缺乏培训，工作辅助和监督；专家的不当行为；对疟疾显微镜和RDT的不信任；以及患者诊断和治疗的压力。卫生工作者建议加强供应链；雇用人员；提供包括专家在内的在职协议培训；为疟疾诊断建立外部质量保证；并提供现场支持性监督和公共卫生运动。
结论：这项研究揭示了苏丹北部一线卫生工作者在疟疾管理方面的广泛行为和系统性挑战，包括由于资源短缺而不遵守协议，培训差距，缺乏支持性监督和患者压力。这些见解,包括卫生工作者对改善的看法，将为苏丹的国家疟疾控制计划提供基于证据的干预措施，以改善卫生系统的准备情况和疟疾病例管理的质量。
