Co-design of a routine clinical review to improve the safety of high dose radical cure treatment for Plasmodium vivax malaria: findings from Cambodia and Ethiopia

Abstract

Background: Low dose primaquine regimens are widely used to treat Plasmodium vivax malaria, but they have limited efficacy and effectiveness. Short courses with higher daily doses as well as single dose tafenoquine have the potential to improve effectiveness but can increase the risk of adverse events. A clinical review visit on day 3 post-treatment initiation could facilitate adherence and improve safety, but it is unclear how it could be integrated into routine malaria care. Methods: Between March and September 2023, focus group discussions (FGDs) with P. vivax malaria patients and healthcare providers were conducted in Cambodia and Ethiopia. In the FGDs participants co-designed a day 3 review suitable for their setting based on material infrastructure ‘building blocks’ (location, implementer, procedures, and support mechanisms). Nine FGDs were completed in three health facility catchment areas in Cambodia and six FGDs in four facilities in Ethiopia. Data were analysed using an inductive-deductive analytical process allowing the development of themes. Results: Participants in Cambodia and Ethiopia had different preferences for the material infrastructure of the day 3 review, from which a model for each country was developed. In Cambodia, proximity to patients was prioritized, maintaining the existing referral mechanism in which the initial day 3 review is conducted in the community, focusing on an enhanced symptom assessment. In Ethiopia, continuity of care was prioritized, resulting in the day 3 review occurring at the location of initial diagnosis, with a tiered approach to procedures conducted during the visit. In addition, the dynamics and relationships between people (relational infrastructure), specifically collaboration, were identified as key facilitators for the review’s implementation in both study countries. Collaboration across levels of the health system and among healthcare providers was found to be a process influenced and necessitated by the environment (e.g., the infrastructural and epidemiological contexts), contributing to quality of care, continuity of care, safety, and effective treatment. Conclusion: Identifying how clinical review visits could be adapted to local settings is important and can be achieved through co-creation. Collaboration has the potential to enable quality of care and patient safety. Suitable ways of reinforcing this relational infrastructure are required to optimize case management of patients.