Characteristics of healthcare workers 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. To align antimalarial prescriptions with RDT results, outcomes may be mis-recorded in health facility registers. Prior studies assessing adherence and recording accuracy have faced limitations such as reliance on record reviews or unobserved re-testing, potentially underestimating the prevalence and drivers of misrecording. Methods We conducted a multi-country, mixed-methods observational study 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 observation. Completed RDTs were photographed and independently interpreted by a trained panel. These interpretations served as the reference standard against which results recorded in facility registers were compared. 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% of results were misrecorded as negative. Misrecording negative or invalid results as positive was associated with HCW characteristics, notably lower educational attainment and belief that antimalarials should be given even after a negative result. Additionally, both higher local malaria prevalence and patients aged 5 to 14 years were consistently associated with increased odds of this error. Conversely, misrecording positive or invalid results as negative was less frequent and more strongly associated with poor RDT proficiency and patients aged 15 years and older. Conclusion This study highlights that misrecording of RDT results is influenced by a combination of individual, contextual, and systemic factors, with differing patterns for results mis-recorded as positive and negative. Interventions to improve the quality of malaria surveillance data may need to address both HCW behavior and broader facility- and system-level influences.