Characteristics of healthcare workers and health facilities associated with inaccurate recording of malaria rapid diagnostic test results: a multi-country study

Background: Malaria rapid diagnostic tests (RDTs) have improved case management and surveillance across sub-Saharan Africa by reducing presumptive treatment and enhancing diagnostic specificity. However, healthcare workers’ (HCWs) concerns about limitations of RDTs, the lack of other diagnostic tools and patient expectations may result in non-adherence to RDT outcomes in treatment decisions. This study aimed to determine associations between HCW characteristics and the accuracy of recording malaria RDT results. 

Methods: A multi-country, mixed-methods observational study was conducted in 64 public health facilities across Benin, Côte d’Ivoire, Nigeria, and Uganda between June and December 2023. HCW demographic characteristics, attitudes and perceptions of RDTs, and proficiency performing RDTs were collected via surveys and structured observations. Completed RDTs were photographed, interpreted by a trained panel, and compared with health facility registers. Multivariable logistic regression models were used to identify factors associated with misrecording. 

Results: Among more than 100,000 RDTs performed by 499 HCWs, 5.1–7.3% of results were misrecorded as positive, and 0.7–3.7% were misrecorded as negative. The test positivity rate (TPR) was highest in Côte d’Ivoire (59.7%) and lowest in Nigeria (45.3%). Overall agreement on RDT results between the external panel and the result recorded by HCWs in the health facility register ranged from 90.2% in Nigeria to 94.3% in Benin. Misrecording of negative or invalid results as positive varied by country. In Benin, older HCWs and those with stronger malaria knowledge were less likely to misrecord, but HCWs who believed patients should still be treated after a negative test were more likely to do so. In Côte d’Ivoire, community health workers had higher odds of misrecording, while higher education reduced the risk. In Nigeria, medical auxiliary staff were less likely to misrecord than other cadres. In Uganda, misrecording was more common in high-volume, high-positivity facilities and among HCWs recently observed by a supervisor. 

Conclusion: Misrecording of RDT results is influenced by a combination of individual, contextual, and systemic factors, with differing patterns for results misrecorded as positive and negative. Improving malaria surveillance will require interventions that address both HCW behaviour and broader facility- and system-level influences.