Study population
Response rate was 97% (685/707): northern (93%, 129/139), eastern (97%, 125/129), western (94%, 127/135) and central (95%, 290/305). Mean age of HCPs was 30 (SD = 7.4) years with equal proportions of males (51%, 349/685) and females (49%, 336/685). Median professional experience was 3 years (interquartile range, IQR of 2 to 6 years), see Table 1.
Reporting of ACT-failure in the past 6-months
One in five [20%, 137/685; 95% confidence intervals (CI) 17% to 23%] HCPs had reported ACT-failure to any authority in the previous 6-months, see Table 1; a third (34%, 47/137; 95% CI 26% to 43%) of whom received feedback.
The most frequently cited authority to whom HCPs reported ACT-failure was the immediate supervisor (72%, 106/147), followed by the Health Management Information System (7%, 11/147), colleague/workmate (7%, 11/147), District Health Officer (3%, 5/147), NPC (1%, 1/147) and others (9%, 13/147). Some of the 137 HCPs reported to more than one authority, thus the 147 responses.
Most HCPs reported ACT-failure verbally only (80%, 109/137), followed by written report only (10%, 14/137), verbal & written report(s) (9%, 12/137) and other (1%, 2/137). The singular respondent HCP who reported ACT-failure to NPC did so verbally: She was a 31-year-old pharmacist with 4-years of professional experience and based at a private for-profit community pharmacy in northern Uganda.
In the previous 4-weeks, see Table 2, 42% (285/685) of HCPs received 1147 patient-complaints of ACT-failure which represents 1.67 (1147/685) patient-complaints per HCP per month. Also, 33% (228/685) of HCPs suspected 920 ACT-failures which represents 1.34 (920/685) HCP-suspected ACT-failures per HCP per month, implying a HCP-suspected ACT-failure rate of 0.80 (1.34/1.67) per patient-complaint of ACT-failure.
Motivation to report ACT-failure
Increased morbidity and mortality from malaria complications (42%, 53/126) was the most frequently cited reason for the motivation to report ACT-failure followed by the need for advice/solutions for better treatment options (26%, 33/126), self-drive (11%, 14/126), fear of drug resistance (6%, 7/126), patient-complaints (5%, 6/126) and others (10%, 13/126). The 126 reasons for the motivation to report were provided by 117 of the 137 HCPs who had reported ACT-failure in the past 6-months.
Circumstances that make it difficult to report ACT-failure
The most frequently cited reason for the difficulty to report ACT-failure was unavailability of reporting procedures (31%, 129/421) followed by poor feedback from and/or no follow-up of treated patients (22%, 93/421), absence of reporting tools such as forms and registers which results in poor documentation of ACT-failure (16%, 68/421), and patient overload (9%, 38/421), among others, see Table 3.
Suggestions to improve the reporting of ACT-failure
The most frequent suggestion to improve the reporting of ACT-failure was to provide report forms, journals, books, registers and other tools to document ACT-failure (25%, 121/490), followed by sensitizing patients and availing a toll-free line for reporting ACT-failure (22%, 110/490), providing clear reporting procedures and systems (16%, 76/490), sensitizing and training HCPs to report ACT-failure (13%, 66/490) and providing contact persons/office in charge of reporting ACT-failure (10%, 47/490), among others, see Table 4.
Factors associated with the reporting of ACT-failure
Factors associated with a higher likelihood to report ACT-failure in the past 6-months were: hospital-status (vs other; OR = 2.4, 95% CI, 1.41 to 4.21), HCPs aged under 25 years (OR = 2.2, 95% CI, 1.29 to 3.76), suspicion of ACT-failure in the past 4-weeks (OR = 2.3, 95% CI, 1.29 to 3.92) and having received at least one patient-complaint of ACT-failure in the past 4-weeks (OR = 2.9, 95% CI, 1.62 to 5.12). HCPs from the northern (vs central; OR = 0.5, 95% CI, 0.28 to 0.93) and western parts of the country (vs central; OR = 0.4, 95% CI, 0.17 to 0.77) were less likely to have reported ACT-failure in the past 6-months, see Table 5.