The median age of study participant was 35 (ranging from 27–46) years. Providers had on average, had six years of experience providing health care and had worked in the study area for at least three years. Among the three clinicians, two were males and one female. All clinicians had the academic qualification level of medical assistant, referred to as clinical officers in Tanzania. All the nurses were females with the professional title of Enrolled Nurses. At the time of the interview, each facility had already treated at least 150 patients with SLD primaquine co-administered with AL.
The age of the FGD participants ranged from 19 to 44 years, and their education level ranged from no school to ordinary secondary school level. All participants were residents of the study area and had a prior experience of treated for malaria with AL only.
Patient screening experience
All participating HCP supported the importance of screening patients for the recommended treatment eligibility criteria, starting with a detailed patient medical history and conducting a physical examination and laboratory tests. This is also part of their medical training to screen all patients before treatment and not only for suspected malaria cases. More than two-thirds of the providers mentioned that screening patient for SLD primaquine as outlined in the PROMPT is clear to follow and guides them better towards the appropriate management, particularly to some criteria that can easily be overlooked and missed.
“The screening information in the guide helps me to make sure I have assessed all patient’s eligibility criteria for this new malaria treatment otherwise, you can easily miss important medical conditions such as an allergy to other malaria drugs or even pregnancy”. IDI, Nurse aged 46
“Routine screening for anaemia has helped us a lot to diagnosed malaria patients with severe anaemia because previously, we did not often measure Hb when we see a child is stable. Now we are surprised to see a child with Hb below 4 g/dl and is stable and walking”. IDI, Clinical Officer aged 35
HCP mentioned some challenges regarding patients screening. About half of the providers said that they spend more time attending a patient because of going through the eligibility criteria and screening for anaemia even though they were using a rapid anaemia screening machine (Hemocue® machine). Some providers were also concerned about the sustainability of routine screening for anaemia because of limited supplies to support such an exercise beyond the programme funding period.
One provider mentioned that the workload at public health was already too much:
“Explaining to the patient about this new treatment and anaemia screening to all before treatment is somehow demanding in our facility because I am the only clinician here together with two nurses who spend most of the time in reproductive and child health (RCH) clinic and labour room, and no laboratory officer…., so you can imagine the workload I have, measuring Hb to all patients receiving primaquine and at the same time managing other cases as well as facility administrative duties”. IDI, Clinical Officer aged 35
In reference to the stockout challenge, one provider expressed her skepticism in the following:
“…… I’m not sure about how this be sustained considering the stock out of supplies, particularly the trips used in the Hemocue machine for measuring Hb is a chronic problem in our district. A facility may take up to two months or more without measuring Hb, forcing us to refer patients to other facilities only to check Hb. IDI, Nurse aged 34
Majority of the patients mentioned the providers took more time exploring their medical history when comparing with their previous experience in the same facility. They felt more valued by the clinician by showing more concern about the presenting illness and even taking blood for anaemia screening whenever they are found to have malaria.
“…… in the past, doctors appeared to be rushing in order to clear the number of patients waiting for his service … he may just ask you few questions about how you feel and immediately tells you to go and check for malaria At times you even hesitate to ask him all your questions assuming that you might waste his time….. This time is different; he asks you different questions and even wants to know whether you are pregnant while you just came for malaria treatment”. FGD, female patients
Patient treatment information
HCP provided the information on primaquine treatment, possible adverse events and insisted on returning to the clinic on day seven to follow up with all patients. They also reported having given all patients a PROMPT patient information card, a sheet of paper with about 70 words that mention the treatment received, possible primaquine side effects, the date for day seven follow visit and the provider’s cellphone number. Nearly all providers mentioned patients are happy with the information card provided, especially by including the provider's phone number.
"Patients are happy with the sheet we are providing to them because it has our phone numbers so as they can call and ask questions when they are at home or even sometimes when the facility is closed”. IDI, Clinical Officer aged 38
HCP reported that they frequently received regular calls from patients and responded to their questions, including matters unrelated to malaria.
“Our phone numbers provided in the card makes it easier for the patients to reach us whenever they see something is wrong with them….. I remember the last call came from a patient complaining of having dark urine, and I told him to come back immediately in the morning for a checkup”. IDI, Clinical Officer aged 35
Patients are happy with the information card because apart from the providers’ phone number provided, they also mentioned that the information card reminds them of the adverse events related to the primaquine use. However, the information card was not as useful to illiterate patients, and most depended on literate family members to read for them.
I was provided with a sheet explaining the treatment, which I think is something good, but I couldn't read it, and no one at home could help me”. FGD, female patients
Many patients also attested to the good service from the HCP. They reported that the information provided was clear and useful even for those who could not read or write.
“…… as you can see most of us can’t read this information sheet at home due to different reasons but I think the information explained by the doctor in the facility was clear and the good thing in this sheet there is doctor’s phone number, and she said to call her at any time when we see something is going wrong”. FGD, male patients
HCPs also mentioned that despite being aware of most of their patients being illiterate, they still provided information card to all treated patients as per the PROMPT protocol.
“Many people in our community don't know how to read and write but we still give them the form and advise to ask someone at home to read for them for more understanding”. HCP in IDI 03
Contrary to the broader positive view regarding providing treatment information to the patients as indicated in the PROMPT, there were other opinions whereby providers found it challenging. They feel some patients don’t understand the message clearly when explaining to them in the clinic. Some take mixed messages to the community about the treatment leading to misperception of the treatment.
“Level of understanding of patients is very low. Some don't understand and at some point, they send different message messages to the community about primaquine prescribed”. IDI, Nurse aged 34
Limited time to explain to each patient clearly about the treatment and responding to patients queries was mentioned by nearly half of the providers as a key challenge.
“Sometimes it is hard to explain in detail everything to the patient about primaquine due to a big number of patients who are waiting to be attended, and some are in critical condition hence, forces us to summarise the information on the key safety issues”. IDI, Clinical Officer aged 32
Primaquine prescription and administration
All the providers mentioned the primaquine dosage chart from PROMPT defined therapeutic dose range is constructive as it guides them to choose the appropriate dose based on the patient’s weight. The challenge mentioned was when there is a need to crush a tablet and come with the proper amount, particularly for patients with the age range of 10-15 kg (require 0.5 tablet of primaquine 7.5 mg) and 31-24 kg (require 1.5 tablets of primaquine 7.5 mg). All providers talked about the challenge related to the administration of primaquine by dissolving first the tablet of 7.5 mg in a small glass tube with 7.5 ml clean water. After that, draw with a syringe to get the required patient dose as instructed in study training for treating malaria with SLD+ACT. Nearly all providers were also concerned about the bitter taste of dissolved primaquine and thus were administering it to the patient together with a sweet beverage to mask the bitterness. This was thought to subject a patient to unnecessary cost in the absence of support from the study. All the providers recommended the need to have a new primaquine formulation that requires no crushing or dissolving the tablet.
“It is very challenging for us to dissolve first the tablet in water to estimate the recommended patient dose. This is something that is new to us and very difficult in the actual practice of our environment….. we think it is an unnecessary additional cost to the patient by taking soda together with dissolved primaquine tablet so as not to feel the bitterness”. IDI, Nurse aged 34
“….good to have dose-specific tablets for patients according to their age and weight like other treatment and not to crush the tablet that is very small than piriton (chlorphenamine tablet which is considered to be the smallest tablet by many providers)”. IDI, Nurse aged 27
However, patients including parents and guardians with young children, mentioned that it was not a problem taking a tablet dissolved in water. The sweet beverage provided for swallowing primaquine made the experience of swallowing the medicine desirable among children. .
“The medicine was ok and my child was fine with the taste, I think it was because of the soda used to diluting the medicine….. sometimes at home, they are asking if we can go again to the hospital and take the malaria medicine”. FGD, parents/guardian
Patient follow-up experience
Most of the patients supported the importance of follow up in the facility after treatment to ensure that they were progressing in good health. However, they were concerned about the transportation challenges when coming to the facility for the scheduled follow up visit. Reflecting on access barriers and transport costs for a return visit a patient reported:
“The challenge of coming back on day seven after a treatment has transportation challenges to some of us who are staying far from this facility…… we use a lot of money in the commuter bus and bodaboda (motorbike taxi) to reach to this facility”. FGD, female patients
A second patient talked about access in the following:
“Many of us are staying far from the facility and the road is poorly accessible especially during the rainy season that’s why some of our friends failed to come back… but I assure you if you want all of us to come back as scheduled, then you should consider reimbursing our transportation expenses”. FGD, male patients
All HCP supported the importance of patients returning on day seven for the follow-up. Determining the haemoglobin status post-treatment was the main reason for the latter. A big drop in haemoglobin level was observed among most patients, albeit no one mentioned the incidence of significant haemoglobin drop, leading to severe anaemia.
“….this is very important to follow patients so as to be sure of their Hb (haemoglobin) status after treatment because of what we observed….. I can say most patients presented with Hb drop of about 1 to 3 unit from the original value”. IDI, Clinical Officer aged 38
HCPs were also concerned with patients transportation challenges which were responsible for some of the patients failing to follow up. Failure to return was perceived to be attributed to patient behaviour. When the patient felt better after completing the medication, they were least motivated to see a clinician:
“Some patients don’t come on day 7 as scheduled and instead may come on day 10 or not at all simply because of transportation challenges to access the health facility which is contributed by long distance to the facility and poor road condition, having mud and flood”. IDI, Clinical Officer aged 32
Data collection form
More than two-thirds of the providers found the PROMPT data collection form useful as it helped them ensure that they had noted down all the necessary information required in making a treatment decision. They were not used to only one person completing a similar form in a specific fixed order. They mentioned the later as one of the reasons for a prolonged time in attending to malaria patient. They suggested that the form should be shortened and that this should be incorporated with the existing medical information system.
“We are not used to documenting patients information in detail, covering all issues about the treatment by following a specific order, step by step, and then provide our phone numbers to all patients attended. Initially, it was a big burden in terms of time to make sure we are not making mistakes but as time goes on we improved the speed and accuracy” [IDI, Nurse aged 34]
Perceived primaquine safety and outcome
All HCP reported no cases of severe adverse events such as death, severe anaemia or case referred for blood transfusion or any reason for using SLD primaquine in the management of uncomplicated malaria. The treatment safety concern mentioned by nearly all providers was the drop of haemoglobin level in many patients observed on day 7 of follow up but not to the level that may require a blood transfusion. Two providers each mentioned to have seen the patient coming back complaining of dark urine, and after two days, the urine was clear. HCPs mentioned managing this condition by prescribing oral rehydration therapy (ORS) and was used at home for two days. None of the providers received a patient with serious complaints linked to primaquine, such as stomachache, nausea or vomiting.
“I only have experience of one patient presented with dark urine after using the treatment, we told him to come back on the following day and confirmed his urine was dark, but we did not check his Hb because day 0 Hb was around 12 points and something (12 mg/dl). We then gave him 4 sachets of ORS (for 4 litres) and encouraged him to use them at home; after two days, he called us again and was happily informing us he is doing ok”. IDI, Nurse aged 46
Nearly half of the providers mentioned the treatment has helped reduce the turn-up of patients to the facility due to recurrence of malaria. This was observed since they started including SLD primaquine in treating patients with ACT.
“The treatment has reduced a big number of patients returning to our facility with malaria in a few days after completing malaria treatment. Now it can take several months for patients to return to the facility for malaria treatment…. I can say this new medicine has also reduced the number of malaria attended cases”.[ IDI, Clinical Officer aged 35]
A similar experience was also mentioned in one FGD with parents and guardians:
…… every month, my children were suffering from malaria, but since they started getting this treatment, at least a month has now passed without having malaria in my family”. FGD, parents/guardian.