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Does test-based prescription of evidence-based treatment for malaria improve treatment seeking and satisfaction? Findings of repeated cross-sectional surveys in Papua New Guinea
  1. Justin Pulford1,
  2. Olga P M Saweri2,
  3. Caroline Jeffery1,
  4. Peter M Siba2,
  5. Ivo Mueller3,4,5,
  6. Manuel W Hetzel6,7
  1. 1 International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
  2. 2 Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
  3. 3 Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
  4. 4 University of Melbourne, Melbourne, Australia
  5. 5 Institut Pasteur, Paris, France
  6. 6 Swiss Tropical and Public Health Institute, Basel, Switzerland
  7. 7 University of Basel, Basel, Switzerland
  1. Correspondence to Dr Justin Pulford; Justin.Pulford{at}


Introduction The presumptive treatment of febrile illness with antimalarial medication is becoming less common in low-income and middle-income countries as access to reliable diagnostic tests improves. We explore whether the shift towards test-based antimalarial prescription, and the introduction of highly efficacious artemisinin combination therapies (ACTs), reduces critical delays in seeking treatment for febrile illness or increases patient satisfaction.

Methods We conducted countrywide repeat, cross-sectional surveys in 118 randomly selected primary healthcare services in Papua New Guinea. The clinical case management of 1765 consecutively presenting febrile patients was observed and exit interviews were completed at discharge. This was done prior to implementation of test-based ACT prescription (2011) and at 12 (2012) and 60  months (2016) postimplementation. We conducted multiple logistic regressions. Treatment response time was dichotomised as <24  hours from symptom onset vs 24+ hours. Satisfaction was dichotomised as a ‘high’ vs ‘low’ rating based on participant response to a visual, 7-point Likert-type scale.

Results 62% (322/517) of febrile patients reported seeking treatment within 24  hours of symptom onset in 2011 compared with 53% (230/434) in 2012 and 42% (339/814) in 2016. Adjusted ORs for reporting a treatment response time <24  hours in the postimplementation surveys were 0.77 (95% CI 0.48 to 1.26) and 0.45 (95% CI 0.31 to 0.65), respectively when compared with the preimplementation period. 53% (230/533) of febrile patients reported ‘high’ satisfaction with the service received in 2011 compared with 32% (143/449) in 2012 and 35% (278/803) in 2016. Adjusted ORs for reporting high satisfaction in the postimplementation surveys were 0.52 (95% CI 0.32 to 0.85) and 0.65 (95% CI 0.39 to 1.10), respectively when compared with the preimplementation period.

Conclusion Nationwide implementation of test-based ACT prescription in Papua New Guinea has increased the likelihood of critical treatment seeking delays and decreased patient satisfaction with the service received.

  • malaria
  • febrile disease
  • treatment delay
  • satisfaction
  • ACT
  • papua new guinea
  • LMIC

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  • Handling editor Valery Ridde

  • Contributors JP contributed to study design, coordinated the study, conducted the analysis and drafted the final manuscript. OPMS supervised data collection, contributed to data analysis and critically revised the manuscript. CJ contributed to data analysis and critical revision of the manuscript. PMS, IM and MWH contributed to study design and critical revision of the manuscript. All authors read and approved the final manuscript.

  • Funding This study was financially supported by successive Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) country grants.

  • Disclaimer GFATM played no role in study design, data collection, analysis and interpretation nor did they contribute to the drafting or reviewing of this published article in any way.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The study was approved and granted ethical clearance by the Medical Research Advisory Committee of Papua New Guinea (MRAC No. 10.12, 26 February 2010 and No. 15.21, 26 October 2015).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The datasets used during the current study are available from the corresponding author on reasonable request.

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