Sociodemographic characteristics of the study participants
A total of 384 patients’ medical records were assessed. Nearly half of the malaria cases were aged 6–18 years 187/384 (48.7%), followed by those aged ≤ 5 years 93/384 (24.22%). The sex distribution was nearly equal, with females accounting for 51.56% (n = 198/384). Table 2 provides the details.
Table 2 Sociodemographic characteristics of participants
For the key informants’ interviews, the age range was 29 to 50 years, and years of experience ranged from 4 to 20 years. Academic qualifications varied from diplomas to a bachelor’s degree. More details are reported in Table 3.
Table 3 Sociodemographic characteristics of qualitative key informantsLevel of HCWs’ adherence to severe malaria treatment guidelines
The overall level of adherence to severe malaria treatment guidelines was 33.07% (n = 127/384). Among the 384 patients that participated in the study, less than half, 180/384 (46.88%) had had a detailed history taking and medical examination performed, and 330/384 (85.94%) were tested for malaria. Majority 298/330 (90.3%) tested positive, of whom 237/298 (79.53%) were given a right treatment of IV drugs followed by oral medicines on stabilization. A total 24/32 (75%) patients tested negative and were not given antimalarial drugs while others were treated despite a negative test. Table 4 provides more details.
Table 4 Adherence to severe malaria treatment guidelinesFactors influencing adherence to the severe malaria treatment guidelines among HCWs in public hospitals in Acholi sub region
On bivariate and multivariable analysis, medical officers were more likely to adhere to severe malaria treatment guidelines [aIRR = 1.7 (95% CI 1.03–2.794), P = 0.035] as compared to clinical officers (reference category) and nurses [aIRR 0.2 (95% CI 0.0332–1.851), P = 0.174].
Table 5 indicated that adherence to the severe malaria treatment guidelines was more likely among HCWs from general hospitals [aIRR = 2.9 (95% CI 1.782–4.817), P = 0.001] for Anaka general hospital and [aIRR 1.4 (95% CI 0.780–2.442), P = 0.268] for Kitgum general hospital as compared to those treated from Gulu regional referral hospital.
Table 5 Bivariate and multivariable analysis of factors associated with adherence to the severe malaria treatment guidelines among HCW in Public hospitals in Acholi subregionFacilitators of adherence to the severe malaria treatment guidelines among healthcare workers in public hospitals in the Acholi subregion
Factors facilitating adherence to the severe malaria treatment guidelines were further explored qualitatively with key informants. These facilitators are categorized into four themes: knowledge and training support, institutional and policy support, guidelines accessibility and ease of use, and positive attitudes and motivation as shown below.
Theme 1: knowledge and training support
Two key sub-themes concerning continuous medical education and training at the academic level emerged and are explained in details.
Sub-theme: continuous medical education and training
Participants emphasized that ongoing education, such as on-the-job training, mentorship programmes, refresher courses, continuous medical education sessions (CMEs), and seminars, plays a vital role in improving compliance with severe malaria treatment guidelines by keeping healthcare workers informed and current with best practices.
On-job training: Participants noted that on-job training programmes, such as refresher courses, CMEs, and workshops/seminars on malaria guidelines, can enhance adherence to severe malaria treatment guidelines. These courses provided opportunities to refresh knowledge and ensure healthcare workers were up-to-date with the latest protocols.
Health workers should be given refresher training, you know, medicine can evaporate with time. We have to train them to cope with the new guidelines. (Participant 4 Medical officer)
Mentorship programmes: Mentorship programmes were seen as an essential support structure, with senior healthcare workers offering guidance on how to manage complex malaria cases in line with the guidelines. Participants noted that mentorship provided a platform for ongoing learning in a practical and hands-on setting.
Mentors, yes. They train the fresh workers and students on what to do and how to deal with the guidelines. (Participant 1, Nurse)
Sub-theme: training at the academic level
Participants also noted the role of academic training in medical education institutions in enhancing adherence to malaria guidelines. Facilitators such as curriculum content and level of education were noted as quoted below;
Level of qualification: Participants indicated that the level of qualification of the HCW significantly influences their ability to adhere to severe malaria treatment guidelines. Participants observed that individuals with higher qualifications, such as medical doctors or specialist nurses, displayed greater confidence in applying the guidelines accurately. However, some participants with lower qualifications, such as clinical officers or nursing assistants, mentioned that they occasionally felt more prepared than their colleagues.
“I think qualification matters. I expect a doctor to be good at treating malaria than maybe a nurse”. (Participant 8, Pharmacist)
Curriculum content: The content of healthcare training curricula was also identified as a key factor in guideline adherence. Participants felt that while severe malaria treatment was well-covered in most programmes, the focus on practical application and updates on new treatments was often insufficient. Some participants suggested that curricula should be continuously revised to include newer treatment regimens.
The curriculum content during my training was solid, but it was heavily theoretical. I wish there had been more practical training on how to apply the malaria guidelines in real-world cases, especially when patients have complications. (Participant 6, Clinical officer)
Theme 2: guideline accessibility and ease of use
One sub-theme emerged concerning the guideline accessibility and ease of use as a major facilitator to adherence to severe malaria treatment guidelines.
Sub-theme: availability of clear and simplified guidelines
It was noted that the availability of clear and simplified guidelines is a major facilitator to adherence to severe malaria treatment guidelines, as several components that make guidelines simplified and easy to implement were noted as shown below;
Job aids: Participants also noted the presence of job aids such as malaria treatment leaflets as one of the facilitators of adherence to severe malaria treatment guidelines.
“Here we have sections of guidelines given out as leaflets, printed out, for people who are lazy. Secondly, we can have screens that show these guidelines or educational series. These help even patients.” (Participant 4, Medical officer)
Wall chart: As one of the facilitators, wall charts were widely regarded as a useful tool in improving adherence to severe malaria treatment guidelines. Participants noted that having simplified treatment wall charts helped them make timely and accurate treatment decisions, especially in busy settings.
Do you see this chart, it saves a lot. When you forget the dose, you just look at the wall and you treat the child. (Participant 6, Clinical officer)
Mobile apps for quick reference: The availability of clear and simplified guidelines on mobile apps for quick reference was reported to improve access to malaria guidelines and hence promote adherence to these guidelines. Participants appreciated the accessibility and convenience of apps that provided real-time access to the latest guidelines and drug doses.
“These days, life is easy. We have phones with some apps or books, you even check on the phone when you forget. It’s just your problem if you don’t follow the guidelines.” (Participant 1, Nurse)
Theme 3: institutional and policy support
Institutional and policy support emerged as a crucial factor influencing adherence to severe malaria treatment guidelines. Participants highlighted the role of strong supervision and monitoring as the sub-theme under this theme as follows;
Sub-theme: strong supervision and monitoring
The majority of the participants noted the role of support supervision and monitoring in promoting adherence to severe malaria treatment guidelines. This supervision takes various forms as shown below;
Regular audits: Participants highlighted that regular audit were an important mechanism for ensuring adherence to severe malaria treatment guidelines. These audits allow healthcare workers to assess their own practices and identify areas of improvement.
“Regular audits help us identify where we might be going wrong and areas where we can improve. It’s not just about the numbers; it’s about making sure we’re actually applying the guidelines correctly in practice”. (Participant 8, Pharmacist)
Supportive supervision: Supportive supervision was mentioned as a critical factor in guiding healthcare workers to adhere to malaria guidelines. Participants felt that supportive supervision went beyond simple oversight but promoted a conducive environment for learning.
“Everyone has to be supervised, even the boss is supervised. Having supervisors can help clarify things you may be unsure about, and it is easier to follow the guidelines”. (Participant 6, Clinical officer)
Facility recommendations: Recommendations by the health facility to their staff were also noted as a facilitator to adherence to severe malaria treatment guidelines. Participants noted that health facilities that have strict policies on the use of guidelines
“I think when a hospital has a policy that for them, they want treatment based on only guidelines, the staff will adhere. It’s different when the policies are lousy”. (Participant 8, Pharmacist)
Theme 4: positive attitudes and motivation
This theme identified attitude related facilitators for adherence to severe malaria treatment guidelines. Having a positive attitude facilitated the use of the guidelines.
Sub-theme: HCW commitment to best practices
It was also noted that commitment to best clinical practices by HCWs can enhance adherence to severe malaria treatment guidelines. Factors such as the need to maintain a strong professional ethics, patient-centred care, and evidence-based medicine were noted to promote adherence as shown below.
Strong professional ethics: It was reported that healthcare workers who adhered to strong professional ethics were more likely to follow severe malaria treatment guidelines as compared to those who did not. Participants indicated that maintaining high ethical standards, such as prioritizing patient care and respecting professional duties, helped ensure consistent and guideline-compliant practices.
“Strong professional ethics keep us focused on what’s best for our patients. When we stay true to our ethical responsibilities, it naturally aligns with following the treatment guidelines”. (Participant 4, Medical officer)
Patient-centred care: Likewise, the need to provide patient-centreed care was seen as an essential factor in adhering to severe malaria treatment guidelines. Participants emphasized that when healthcare workers focused on individual patient needs and preferences, it led to better communication, and it made them practice what is recommended.
“Also, patient-centred care. Patient-centred care is important because when we engage with patients, listen to their concerns, and personalize treatment plans, we are more likely to adhere to the guidelines”. (Participant 4, Medical officer)
Evidence-based medicine: The use of evidence-based medicine was frequently mentioned as a key factor in ensuring that severe malaria treatment was done according to the guidelines. This is because HCWs know that malaria guidelines are evidence based, and hence have a responsibility to practice them.
“As a healthcare provider, I always ensure that I follow the guidelines because it is my responsibility to provide evidence-based care to my patients. These guidelines promote proper decision making” (Participant 6, clinical officer)
Sub-theme: Supportive team culture and collaboration
The majority of the participants noted the importance of teamwork and health care worker collaborations as a facilitator to adherence to severe malaria treatment guidelines, as shown below;
Teamwork: A culture of teamwork and collaboration among healthcare workers was identified as a significant facilitator of adherence to severe malaria treatment guidelines. Participants noted that working collaboratively with other healthcare workers, such as laboratory staff, doctors, and nurses, facilitated the proper implementation of the guidelines and improved patient care.
“We work together as a team to cross-check each other’s decisions. If the lab person is not sure, he can call us, and then we see what is the best thing to do” (Participant 4, Medical Officer)
Proper reporting of lab results: Participants however noted that proper communication and reporting of lab results were crucial in ensuring accurate diagnosis and treatment.
“Sometimes even us (nurses) advise the doctors. A child can be very sick and the doctor just gives tablets. It’s my role to assess the patient and then tell the doctor to give injections” (Participant 9, Nurse).
Barriers to adherence to the severe malaria treatment guidelines
Barriers to adherence to the severe malaria treatment guidelines were explored. Overall, these barriers were categorized into two themes that emerged from the transcripts: (1) knowledge and awareness gaps, (2) resource availability constraints, and socio-cultural and patient factors.
Theme 1: knowledge and awareness gaps
The theme knowledge and awareness gaps of severe malaria treatment guidelines were noted as major barriers to adherence to severe malaria treatment guidelines, with two sub-themes emerging as described below.
Sub-theme: limited training on updated guidelines
Participants highlighted a lack of regular training on updated severe malaria treatment guidelines as a major barrier to the implementation of severe malaria treatment guidelines. The codes generated under this subtheme are described below.
Lack of continuous medical education and outdated knowledge: Many healthcare workers reported limited access to continuous medical education, leading to outdated knowledge on malaria management. The absence of regular training and refresher courses contributed to knowledge gaps, reducing adherence to updated treatment guidelines.
“The ministry normally updates the guidelines, but for us, they don’t give us training on the new guidelines. I think we need some continuous medical education so that we can have good knowledge on the guidelines whenever they are changed.” (Participant 6, clinical officer)
Participants noted a lack of updated knowledge on severe malaria treatment guidelines, which limits their ability to effectively apply these guidelines. It was observed that these guidelines are regularly updated, yet efforts are rarely made to educate health workers on the current guidelines, causing some to have outdated knowledge. One of the participants stated:
“Some health workers have outdated knowledge, maybe because we don’t give them continuous medical education. This may affect the application of these guidelines.” (Participant 4, Medical officer)
Inadequate refresher courses: the majority of the participants noted that refresher courses were infrequent or completely absent in some facilities, making it difficult to stay updated on proper malaria management protocols.
“This government, we don’t get refresher trainings. Without refresher courses, we rely on old practices, which may not align with the current treatment guidelines”. (Participant 9, Nurse)
Sub-theme: misinterpretation of malaria guidelines
Some HCWs interviewed expressed difficulties in interpreting the malaria guidelines as one of the major barriers to the implementation of malaria guidelines. Major points of confusion were noted on interpreting drug dosages and diagnostic protocols as shown below.
Confusion about drug dosages: It was noted that HCWs often misinterpret malaria guidelines mainly drug dosages. This confusion was most reported on the use of quinine, artesunate or artemether. One participant explained:
“Some doctors don’t know the right prescription. They for example, don’t know when we should use quinine or artesunate. They are just used to prescribing artesunate even when we have to use quinine.” (Participant 1, Nurse)
Misapplication of diagnostic protocols: It was also noted that health workers often misinterpret diagnostic protocols and results, an act that affects what treatment they give.
“Sometimes it can be confusing. Now, when you use the RDTs, you cannot tell whether the malaria is severe or not, and normally we have no microscope to use, especially at night.” (Participant 4, medical officer)
“The lab results can tell you 3+, but the patient looks like he has a simple malaria. Here you get confused and sometimes you just decide on whether to consider it severe or mild malaria. This obviously, effects the treatment that you are going to give.” (Participant 4, medical officer)
Theme 2: resource availability constraints
This theme identified that the lack of key resources for use in severe malaria treatment is one of the reasons why HCWs may not adhere to severe malaria treatment guidelines. Three sub-themes emerged as follows;
Sub-theme: frequent stock-outs of essential drugs
Participants noted that even when they know what the guidelines say, they find themselves in a difficult situation adhering to them when the drugs recommended are not available. Therefore, they provide what is available. One participant explained:
“The guidelines, for example, say artesunate for severe malaria, but when you check, it’s not in the store. Here you just have to use whatever is available, maybe quinine or artemether.” (Participant 8, pharmacist)
Sub-theme: inadequate diagnostic tools and supplies
Limited availability of diagnostic tools, particularly rapid diagnostic tests (RDTs) and functional laboratory equipment, emerged as a major challenge to the implementation of severe malaria treatment guidelines.
Shortage of Rapid Diagnostic Test (RDT) kits: The limited availability of RDT kits, forced HCWs to rely on clinical diagnosis rather than confirmed laboratory results. Due to frequent stockouts of diagnostic tools, many HCWs resorted to clinical diagnosis, which is less accurate and may result in the overuse or underuse of antimalarial drugs.
You know we have a challenge, when RDT kits are unavailable, we have to diagnose based on symptoms, which sometimes leads to misdiagnosis. (Participant 2, lab technician).
Malfunctioning microscopes: Also, in some facilities, the microscopes were noted to be faulty and could compromise the results. This made HCWs instead rely on clinical judgment, which is not in accordance with the treatment guidelines.
“Here, our lab closes at night. When you have a patient, you have to use the RDT and you know it cannot quantify the malaria. But even our microscope is faulty” (Participant 6, clinical officer)
Sub-theme: high patient load and staff shortages
Participants also noted heavy workload at their work stations as one of the barriers to adherence to severe malaria treatment guidelines.
Work overload: Participants also noted high patient load as one of the barriers to adherence to severe malaria treatment guidelines. The high number of patients limits HCWs from effectively diagnosing and following up with patients.
“Sometimes I have very many samples, and results are needed urgently. Here, I cannot be sure if I have done the right thing or not, and maybe the treatment can be different if I had taken my time to quantify the malaria.” (Participant 2, lab technician)
Limited time for consultations. Because of high patient volumes, participants noted that patients are often given little time at the OPD. The limited time for patient consultation meant that HCWs sometimes skipped diagnostic steps or defaulted to presumptive treatment.
The patient load is overwhelming. Sometimes, we don’t have the luxury of following the full history to make a full diagnosis because there are so many people waiting. (Participant 1, Nurse)
Theme 3: socio-cultural and patient factors
Under this theme, two themes emerged denoting the social-cultural barriers and patient-related factors that hinder adherence to severe malaria treatment guidelines.
Sub-theme: patient preference for alternative treatments
Participants reported that some patients come to the health facilities when they already have some preferred treatment options, which are sometimes contrary to the guidelines and which sometimes make it hard for the HCWs, as quoted below.
Reluctance to accept ACT: Participants reported that patients often come for severe malaria treatment when they already have preferences for treatment, which sometimes deviates from the treatment guidelines.
“Some patients, when you prescribe for them Artesunate, Coartem or D-artepp as recommended by the treatment guideline, they refuse, saying that quinine works better for them.” (Participant 5, Clinical officer).
Demand for injections over oral medication: Participants also reported that some patients try to influence them into prescribing the parenteral medications when their medical conditions do not warrant them to be given. This was highlighted by some participants as quoted;
“Also it is noted that many patients insist on injections even when oral ACTs are the recommended treatment. They think tablets are ineffective” (Participant 1, Nurse)
Sub-theme: poor health-seeking behaviours among patients
Poor healthcare-seeking behaviour was another commonly reported challenge to many HCWs, as most patients often presented at health facilities when their condition had worsened, or they first bought medications, which made their conditions complex, making recommended treatment guidelines less effective, as described in detail below.
Late presentation to hospital: it was reported that many patients with malaria symptoms delay seeking medical care, often arriving at health facilities when the disease has progressed to severe or even life-threatening stages. Such delays not only increase the risk of complications and mortality but also limit the effectiveness of first-line antimalarial therapies that are most appropriate for uncomplicated malaria. In these situations, HCWs are frequently compelled to manage emergency symptoms and complications rather than follow standard treatment protocols designed for early-stage malaria. As a result, adherence to national severe malaria treatment guidelines is compromised, with clinical decisions being shaped more by the severity of the condition than by recommended guidelines.
“Patients often come late for treatment and you just have to assume its severe malaria and use IV drugs no matter the symptoms.” (Participant 4, medical officer)
Self-medication: Self-medication was reported as a common practice among patients, often leading to inappropriate use of antimalarial drugs before they seek professional care. Many individuals purchase over-the-counter medications without proper diagnosis or rely on traditional remedies, which can mask symptoms or lead to drug resistance. This behaviour complicates clinical decision-making for HCWs as patients often present at health facilities in advanced stages of the disease sometimes with unclear treatment histories. Thus, this undermines strict adherence to severe malaria treatment guidelines as HCWs may be forces to deviate from recommended protocols to manage complex or atypical cases.
“Our patients first buy drugs from the clinics, and when they come here with symptoms, you can’t just give them the same medications again, but have to start on IVs, which I think is against the guidelines.” (Participant 3, medical officer).