Assessing the accuracy of the recording and reporting of malaria rapid diagnostic test results in four African countries: Methods and key results

Background Rapid diagnostic test (RDT) results are the foundation of both case management and malaria surveillance across sub-Saharan Africa. However, RDT results may be misrecorded in health facility registers, either unintentionally or deliberately, for example, to justify treatment based on clinical judgment. We conducted a multi-country evaluation to quantify the extent of RDT misrecording and identify factors associated with recording and reporting accuracy. This report summarizes the study’s methods, key findings, and implications for improving malaria RDT data quality. Methods We conducted a mixed-methods observational study in Benin, Côte d'Ivoire, Nigeria, and Uganda in 2023. At participating health facilities, images of RDTs were captured at the point of care and later reviewed by a trained, independent panel. Agreement between the panel’s interpretation and the result recorded in the register was assessed using weighted mean Cohen’s kappa (κ). Secondary objectives included identifying factors associated with inaccurate recording, assessing the durability of RDT results after one month of storage, evaluating data accuracy in national health management information systems (HMIS), and measuring the observer effect on test positivity rates (TPR) reported to HMIS. Results We analyzed agreement on 102,091 RDT results. Agreement between register-recorded results and the external panel was high, ranging from κ = 0.81 (95% confidence interval [CI] 0.76, 0.85) in Nigeria to κ = 0.88 (95% CI 0.84, 0.92) in Benin. HCWs were more likely to misrecord results as positive (range: 5.0, 7.1%) than negative (range: 0.7, 3.5%). After the study began, TPRs reported from the HMIS declined more in study than control facilities in all countries except Benin. Decreases in study facilities ranged from 6.4 to 20.4 percentage points more than in control facilities, although only Côte d’Ivoire showed a statistically significant difference-in-difference (rate ratio: 0.80, 95% CI 0.76, 0.84). Conclusions Although HCWs generally recorded RDT results accurately, the disproportionately higher number misrecorded as positive raises concern about possible intentional misreporting. The observed TPR decrease after study onset in three of four countries suggests HCWs can be motivated to reduce misrecording and improve the quality of malaria case management and surveillance data.