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Albarqouni L, Palagama S, Chai J, Sivananthajothy P, Pathirana T, Bakhit M, Arab-Zozani M, Ranakusuma R, Cardona M, Scott A, Clark J, Smith CF, Effa E, Ochodo E, Moynihan R. Overuse of medications in low- and middle-income countries: a scoping review. Bull World Health Organ 2023; 101:36-61D. [PMID: 36593777 PMCID: PMC9795388 DOI: 10.2471/blt.22.288293] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 01/04/2023] Open
Abstract
Objective To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions. Methods We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions. Findings We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives. Conclusion Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.
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Affiliation(s)
- Loai Albarqouni
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Sujeewa Palagama
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Julia Chai
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Thanya Pathirana
- School of Medicine and Dentistry, Griffith University, Sunshine Coast, Australia
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Respati Ranakusuma
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Magnolia Cardona
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Anna Scott
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | | | - Emmanuel Effa
- Department of Internal Medicine, University of Calabar, Calabar, Nigeria
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ray Moynihan
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
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Abstract
BACKGROUND The World Health Organization (WHO) recommends parasitological testing of all suspected malaria cases using malaria rapid diagnostic tests (mRDTs) or microscopy prior to treatment. Some governments have extended this responsibility to community health workers (CHWs) to reduce malaria morbidity and mortality through prompt and appropriate treatment. This is an update of a Cochrane Review first published in 2013. OBJECTIVES To evaluate community-based management strategies for treating malaria or fever that incorporate both a definitive diagnosis with an mRDT and appropriate antimalarial treatment. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases, and three trials registers up to 14 September 2021. SELECTION CRITERIA We included individually randomized trials and cluster-randomized controlled trials (cRCTs), controlled before-after studies, and controlled interrupted time series studies in people living in malaria-endemic areas, comparing programmes that train CHWs and drug shop vendors to perform mRDTs and provide appropriate treatment versus similar programmes that do not use mRDTs, and versus routine health facility care. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. For each dichotomous outcome, we extracted the number of participants with the event and the total number of participants in each group, unless studies presented results at a population level only. Primary outcomes were all-cause mortality, hospitalizations, and number of people receiving an antimalarial within 24 hours. Secondary outcomes were malaria-specific mortality, severe malaria, outcomes related to antimalarial treatments, antibiotic prescribing to people with a negative microscopy or polymerase chain reaction (PCR) result, parasitaemia, anaemia, and all adverse events. MAIN RESULTS We included eight studies from several African countries, Afghanistan, and Myanmar. Staff included CHWs and drug shop vendors. Community use of malaria rapid diagnostic tests compared to clinical diagnosis Compared to clinical diagnosis, mRDT diagnosis results in reduced prescribing of antimalarials to people who are found to be malaria parasite-negative by microscopy or PCR testing (71 fewer per 100 people, 95% confidence interval (CI) 79 to 51 fewer; risk ratio (RR) 0.17, 95% CI 0.07 to 0.40; 3 cRCTs, 7877 participants; moderate-certainty evidence). This reduction may be greater among CHWs compared to drug shop vendors. People diagnosed by mRDT are more likely to receive appropriate treatment; that is, an antimalarial if they are microscopy- or PCR-positive and no antimalarial if they are microscopy- or PCR-negative (RR 3.04, 95% CI 2.46 to 3.74, 3 cRCTs, 9332 participants; high-certainty evidence). Three studies found that a small percentage of people with a negative mRDT result (as read by the CHW or drug shop vendors at the time of treatment) were nevertheless given an antimalarial: 38/1368 (2.8%), 44/724 (6.1%) and 124/950 (13.1%). Conversely, in two studies, a few mRDT-positive people did not receive an antimalarial (0.5% and 0.3%), and one small cross-over study found that 6/57 (10.5%) people classified as non-malaria in the clinical diagnosis arm received an antimalarial. Use of mRDTs probably increases antibiotic use compared to clinical diagnosis (13 more per 100 people, 95% CI 3 to 29 more; RR 2.02, 95% CI 1.21 to 3.37; 2 cRCTs, 5179 participants; moderate-certainty evidence). We were unable to demonstrate any effect on mortality. Community use of malaria rapid diagnostic tests compared to health facility care Results were insufficient to reach any conclusion. AUTHORS' CONCLUSIONS Use of mRDTs by CHWs and drug shop vendors compared to clinical diagnosis reduces prescribing of antimalarials to people without malaria. Deaths were uncommon in both groups. Antibiotic prescribing was higher in those with a negative mRDT than in those with a negative clinical diagnosis.
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Affiliation(s)
- Elizabeth N Allen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Alison Beriliy Wiyeh
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Michael McCaul
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Biemba G, Chiluba B, Yeboah-Antwi K, Silavwe V, Lunze K, Mwale RK, Hamer DH, MacLeod WB. Impact of mobile health-enhanced supportive supervision and supply chain management on appropriate integrated community case management of malaria, diarrhoea, and pneumonia in children 2-59 months: A cluster randomised trial in Eastern Province, Zambia. J Glob Health 2021; 10:010425. [PMID: 32509293 PMCID: PMC7243069 DOI: 10.7189/jogh.10.010425] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Despite progress made over the past twenty years, child mortality remains high, with 5.3 million children under five years having died in 2018 globally. Pneumonia, diarrhoea, and malaria remain among the commonest causes of under-five mortality; contributing 15%, 8%, and 5% of global mortality respectively. Recent evidence shows that integrated community case management (iCCM) of pneumonia, diarrhoea, and malaria can reduce under-five mortality. However, despite growing evidence of the effectiveness of iCCM, there are implementation challenges, especially stock out of iCCM commodities and inadequate supportive supervision of community health workers (CHWs). This study aimed to address these two key challenges to successful iCCM implementation by using mobile health (mHealth) technology. Methods This cluster randomised controlled trial compared health centre catchment areas (clusters) where CHWs and their supervisors implemented mHealth-enhanced iCCM supportive supervision and supply chain management vs clusters implementing iCCM as per current Zambian guidelines. CHWs in intervention clusters used community DHIS2 platform on mobile phones to report on a weekly basis children with iCCM conditions and make requisitions for iCCM commodities. Their supervisors received electronic reports on disease caseloads and monthly automated supervision reminders. The supervisors on receipt of requisitions, organized the medical supplies and notified CHWs for collection. Intention-to-treat analysis on the primary outcome, the percentage of children aged 2-59 months receiving appropriate treatment for malaria, pneumonia, or diarrhoea from an iCCM trained CHW, was performed using a generalized linear model. Prevalence ratios and 95% confidence intervals comparing the prevalence of appropriate treatment in the intervention and control groups were calculated using log binomial regression with an exchangeable correlation matrix, adjusted for clustering by health facility. Results In the intervention clusters, 61.3% (98/160) of expected monthly supervision visits took place vs 52.0% (78/150) in the controls. A total of 3690 children 2-59 months old presented with malaria, diarrhoea, or pneumonia. In the intervention group, 65.9% (1,252/1,899) of children received appropriate care for iCCM conditions, compared to 63.3% (1,134/1,791) in the control group. The mHealth intervention was associated with 18.0% improvement in supportive supervision and 21.0% increase in appropriate treatment for pneumonia; these changes were not statistically significant. There was a 2-3-fold increase in the proportion of CHWs receiving supplies ordered: prevalence ratios ranged from 2.82 (confidence interval (CI) = 1.50, 5.30) to 3.01 (95% CI = 1.29, 7.00) depending on the particular commodity. Conclusion This study was unable to determine whether using mHealth technology would strengthen supervision and supply chain management of iCCM commodities for community-level workers. There was no statistically significant effect of mHealth enhanced iCCM on appropriate diagnosis and treatment for children with malaria, pneumonia, and diarrhoea in rural Zambia. Longer term longitudinal studies are required to determine the impact of mHealth enhanced iCCM on health outputs and outcomes. Trial registration ClinicalTrials.gov, NCT02866097
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Affiliation(s)
- Godfrey Biemba
- National Health Research Authority, Lusaka, Zambia.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA.,Zambian Center for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia
| | - Boniface Chiluba
- Zambian Center for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia
| | - Kojo Yeboah-Antwi
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Karsten Lunze
- Division of Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Centre, Massachusetts, USA
| | | | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA.,Zambian Center for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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In-vitro diagnostic point-of-care tests in paediatric ambulatory care: A systematic review and meta-analysis. PLoS One 2020; 15:e0235605. [PMID: 32628707 PMCID: PMC7337322 DOI: 10.1371/journal.pone.0235605] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 06/19/2020] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Paediatric consultations form a significant proportion of all consultations in ambulatory care. Point-of-care tests (POCTs) may offer a potential solution to improve clinical outcomes for children by reducing diagnostic uncertainty in acute illness, and streamlining management of chronic diseases. However, their clinical impact in paediatric ambulatory care is unknown. We aimed to describe the clinical impact of all in-vitro diagnostic POCTs on patient outcomes and healthcare processes in paediatric ambulatory care. METHODS We searched MEDLINE, EMBASE, Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science from inception to 29 January 2020 without language restrictions. We included studies of children presenting to ambulatory care settings (general practice, hospital outpatient clinics, or emergency departments, walk-in centres, registered drug shops delivering healthcare) where in-vitro diagnostic POCTs were compared to usual care. We included all quantitative clinical outcome data across all conditions or infection syndromes reporting on the impact of POCTs on clinical care and healthcare processes. Where feasible, we calculated risk ratios (RR) with 95% confidence intervals (CI) by performing meta-analysis using random effects models. RESULTS We included 35 studies. Data relating to at least one outcome were available for 89,439 children of whom 45,283 had a POCT across six conditions or infection syndromes: malaria (n = 14); non-specific acute fever 'illness' (n = 7); sore throat (n = 5); acute respiratory tract infections (n = 5); HIV (n = 3); and diabetes (n = 1). Outcomes centred around decision-making such as prescription of medications or hospital referral. Pooled estimates showed that malarial-POCTs (Plasmodium falciparum) better targeted antimalarial treatment by reducing over-treatment by a third compared to usual care (RR 0.67; 95% CI [0.58 to 0.77], n = 36,949). HIV-POCTs improved initiating earlier antiretroviral therapy compared to usual care (RR, 3.11; 95% CI [1.55 to 6.25], n = 912). Across the other four conditions, there was limited evidence for the benefit of POCTs in paediatric ambulatory care except for acute respiratory tract infections (RTI) in low-and-middle-income countries (LMICs), where POCT C-Reactive Protein (CRP) may reduce immediate antibiotic prescribing by a third (risk difference, -0.29 [-0.47, -0.11], n = 2,747). This difference was shown in randomised controlled trials in LMICs which included guidance on interpretation of POCT-CRP, specific training or employed a diagnostic algorithm prior to POC testing. CONCLUSION Overall, there is a paucity of evidence for the use of POCTs in paediatric ambulatory care. POCTs help to target prescribing for children with malaria and HIV. There is emerging evidence that POCT-CRP may better target antibiotic prescribing for children with acute RTIs in LMIC, but not in high-income countries. Research is urgently needed to understand where POCTs are likely to improve clinical outcomes in paediatric settings worldwide.
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O'Boyle S, Bruxvoort KJ, Ansah EK, Burchett HED, Chandler CIR, Clarke SE, Goodman C, Mbacham W, Mbonye AK, Onwujekwe OE, Staedke SG, Wiseman VL, Whitty CJM, Hopkins H. Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa. BMC Med 2020; 18:17. [PMID: 31996199 PMCID: PMC6990477 DOI: 10.1186/s12916-019-1483-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/17/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given. METHODS Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007-2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones. RESULTS Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of < 5-year-olds not prescribed ACT ranged up to 41.8% across sites. The odds of not being prescribed an ACT were 2-32 times higher for patients in settings with lower-transmission intensity (using test positivity as a proxy) compared to areas of higher transmission. mRDT-positive children in low-transmission settings were especially likely not to be prescribed ACT, with proportions untreated up to 70%. Of the 7426 mRDT-positive patients not prescribed an ACT, 4121 (55.5%) were prescribed other, non-recommended non-ACT antimalarial medications, and the remainder (44.5%) were prescribed no antimalarial. CONCLUSIONS In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children < 5 years and those in low-transmission settings, were most likely to not be prescribed antimalarials, and young children in low-transmission settings were least likely to be treated for malaria. This major public health risk must be addressed in training and practice. TRIAL REGISTRATION Reported in individual primary studies.
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Affiliation(s)
| | - Katia J Bruxvoort
- London School of Hygiene and Tropical Medicine, London, UK.,Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Evelyn K Ansah
- Centre for Malaria Research, University of Health and Allied Sciences, Accra, Ghana
| | | | | | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Wilfred Mbacham
- Public Health Biotechnology, University of Yaoundé I, Yaoundé, Cameroon
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | | | - Virginia L Wiseman
- London School of Hygiene and Tropical Medicine, London, UK.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | | | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, UK
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Prudhomme O’Meara W, Menya D, Laktabai J, Platt A, Saran I, Maffioli E, Kipkoech J, Mohanan M, Turner EL. Improving rational use of ACTs through diagnosis-dependent subsidies: Evidence from a cluster-randomized controlled trial in western Kenya. PLoS Med 2018; 15:e1002607. [PMID: 30016316 PMCID: PMC6049880 DOI: 10.1371/journal.pmed.1002607] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/08/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND More than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector, where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over the counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for nonmalaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy. METHODS AND FINDINGS We conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population approximately 160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests (RDTs) on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT-positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention, and referral services. We conducted 4 population-based surveys-at baseline, 6 months, 12 months, and 18 months-of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations (GEEs) to account for clustering with prespecified adjustment for gender, age, education, and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria, and 10,870 vouchers were issued. A total of 7,416 randomly selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, n = 4,653). The gender of enrolled participants was balanced in children (49.8%, n = 2,318 boys versus 50.2%, n = 2,335 girls), but more adult women were enrolled than men (78.0%, n = 2,139 versus 22.0%, n = 604). At baseline, 67.6% (n = 1,362) of participants took an ACT for their illness, and 40.3% (n = 810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (n = 454) in the intervention arm and 43.4% (n = 389) in the control arm had a malaria diagnostic test for their recent fever (adjusted risk difference [RD] = 9 percentage points [pp]; 95% CI 2-15 pp; p = 0.015; adjusted risk ratio [RR] = 1.20; 95% CI 1.05-1.38; p = 0.015). By 18 months, the ARR had increased to 1.25 (95% CI 1.09-1.44; p = 0.005). Rational use of ACTs in the intervention area increased from 41.7% (n = 279) at baseline to 59.6% (n = 403) and was 40% higher in the intervention arm at 18 months (ARR 1.40; 95% CI 1.19-1.64; p < 0.001). While intervention effects increased between 12 and 18 months, we were not able to estimate longer-term impact of the intervention and could not independently evaluate the effects of the free testing and the voucher on uptake of testing. CONCLUSIONS Diagnosis-dependent ACT subsidies and community-based interventions that include the private sector can have an important impact on diagnostic testing and population-wide rational use of ACTs. Targeting of the ACT subsidy itself to those with a positive malaria diagnostic test may also improve sustainability and reduce the cost of retail-sector ACT subsidies. TRIAL REGISTRATION ClinicalTrials.gov NCT02461628.
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Affiliation(s)
- Wendy Prudhomme O’Meara
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
| | - Diana Menya
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
| | - Jeremiah Laktabai
- Moi University School of Medicine, College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Alyssa Platt
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
| | - Indrani Saran
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Elisa Maffioli
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Economics, Duke University, Durham, North Carolina, United States of America
| | - Joseph Kipkoech
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Manoj Mohanan
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Economics, Duke University, Durham, North Carolina, United States of America
- Sanford School of Public Policy, Duke University, Durham, North Carolina, United States of America
| | - Elizabeth L. Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
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Gallay J, Mosha D, Lutahakana E, Mazuguni F, Zuakulu M, Decosterd LA, Genton B, Pothin E. Appropriateness of malaria diagnosis and treatment for fever episodes according to patient history and anti-malarial blood measurement: a cross-sectional survey from Tanzania. Malar J 2018; 17:209. [PMID: 29784001 PMCID: PMC5963060 DOI: 10.1186/s12936-018-2357-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 05/14/2018] [Indexed: 12/28/2022] Open
Abstract
Background Monitoring the impact of case management strategies at large scale is essential to evaluate the public health benefit they confer. The use of methodologies relying on objective and standardized endpoints, such as drug levels in the blood, should be encouraged. Population drug use, diagnosis and treatment appropriateness in case of fever according to patient history and anti-malarials blood concentration was evaluated. Methods A cross-sectional survey took place between May and August 2015 in three regions of Tanzania with different levels of malaria endemicity. Interviews were conducted and blood samples were collected by dried blood spots through household surveys for further anti-malarial measurements. Appropriate testing when individuals attended care was defined as a patient with history of fever being tested for malaria and appropriate treatment as (i) having anti-malarial in the blood if the test result was positive (ii) having anti-malarial in the blood if the person was not tested, and (iii) no anti-malarial in the blood when the test result was negative. Results Amongst 6391 participants included in the anti-malarial analysis, 20.8% (1330/6391) had anti-malarial drug detected in the blood. Only 28.0% (372/1330) of the individuals with anti-malarials in their blood reported the use of anti-malarials within the previous month. Amongst all participants, 16.0% (1021/6391) reported having had a fever in the previous 2 weeks and 37.5% of them (383/1021) had detectable levels of anti-malarials in the blood. Of the individuals who sought care in health facilities, 69.4% (172/248) were tested and 52.0% (129/248) appropriately treated. When other providers were sought, 6% (23/382) of the persons were appropriately tested and 44.2% (169/382) appropriately treated. Overall, the proportion of individuals treated was larger than that being tested [47.3% (298/630) treated, 31.0% (195/630) tested]. Conclusion This study showed high prevalence of circulating anti-malarial drug in the sampled population. Efforts should be made to increase rapid diagnostic tests use at all levels of health care and improve compliance to test result in order to target febrile patients that are sick with malaria and reduce drug pressure. Objective drug measurements collected at community level represent a reliable tool to evaluate overall impact of case management strategies on population drug pressure.
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Affiliation(s)
- Joanna Gallay
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box 4002, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Service and Laboratory of Clinical Pharmacology, University Hospital, Lausanne, Switzerland.
| | | | | | | | | | | | - Blaise Genton
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Division of Infectious Diseases and Department of Community Health, University Hospital, Lausanne, Switzerland
| | - Emilie Pothin
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Lal S, Ndyomugenyi R, Paintain L, Alexander ND, Hansen KS, Magnussen P, Chandramohan D, Clarke SE. Caregivers' compliance with referral advice: evidence from two studies introducing mRDTs into community case management of malaria in Uganda. BMC Health Serv Res 2018; 18:317. [PMID: 29720163 PMCID: PMC5932808 DOI: 10.1186/s12913-018-3124-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 04/15/2018] [Indexed: 11/16/2022] Open
Abstract
Background Several malaria endemic countries have implemented community health worker (CHW) programmes to increase access to populations underserved by health care. There is considerable evidence on CHW adherence to case management guidelines, however, there is limited evidence on the compliance to referral advice and the outcomes of children under-5 referred by CHWs. This analysis examined whether caregivers complied with CHWs referral advice. Methods Data from two cluster (village) randomised trials, one in a moderate-to-high malaria transmission setting, another in a low-transmission setting conducted between January 2010–July 2011 were analysed. CHW were trained to recognise signs and symptoms that required referral to a health centre. CHW in the intervention arm also had training on; malaria rapid diagnostic tests (mRDT) and administering artemisinin based combination therapy (ACT); CHW in the control arm were trained to treat malaria with ACTs based on fever symptoms. Caregivers’ referral forms were linked with CHW treatment forms to determine whether caregivers complied with the referral advice. Factors associated with compliance were examined with logistic regression. Results CHW saw 18,497 child visits in the moderate-to-high transmission setting and referred 15.2% (2815/18,497) of all visits; in the low-transmission setting, 35.0% (1135/3223) of all visits were referred. Compliance to referral was low, in both settings < 10% of caregivers complied with referral advice. In the moderate-to-high transmission setting compliance was higher if children were tested with mRDT compared to children who were not tested with mRDT. In both settings, nearly all children treated with pre-referral rectal artesunate failed to comply with referral and compliance was independently associated with factors such as health centre distance and day of referral by a CHW. In the moderate-to-high transmission setting, time of presentation, severity of referral were also associated with compliance, whilst in the low-transmission setting, compliance was low if an ACT was prescribed. Conclusions This analysis suggests there are several barriers to comply with CHWs referral advice by caregivers. This is concerning for children who received rectal artesunate. As CHW programmes continue scale-up, barriers to referral compliance need to be addressed to ensure a continuum of care from the community to the health centre. Trial registration The study was registered with ClinicalTrials.gov. Identifier NCT01048801, 13th January 2010. Electronic supplementary material The online version of this article (10.1186/s12913-018-3124-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sham Lal
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
| | | | - Lucy Paintain
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Neal D Alexander
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian S Hansen
- Section of Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Pascal Magnussen
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark.,Department of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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9
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Bruxvoort KJ, Leurent B, Chandler CIR, Ansah EK, Baiden F, Björkman A, Burchett HED, Clarke SE, Cundill B, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Mangham-Jefferies L, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Rowland MW, Shakely D, Staedke SG, Vestergaard LS, Webster J, Whitty CJM, Wiseman VL, Yeung S, Schellenberg D, Hopkins H. The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium. Am J Trop Med Hyg 2017; 97:1170-1179. [PMID: 28820705 PMCID: PMC5637593 DOI: 10.4269/ajtmh.16-0955] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400-432,513). mRDTs were associated with significantly lower ACT prescription (range 8-69% versus 20-100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs.
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Affiliation(s)
- Katia J Bruxvoort
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Baptiste Leurent
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bonnie Cundill
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | | | | | - Catherine Goodman
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kristian S Hansen
- University of Copenhagen, Copenhagen, Denmark.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Sham Lal
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Toby Leslie
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pascal Magnussen
- Department for Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Makerere University School of Public Health, Kampala, Uganda.,Ministry of Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | | | - Mark W Rowland
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden.,Karolinska Institutet, Stockholm, Sweden.,Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sarah G Staedke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Virginia L Wiseman
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Shunmay Yeung
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Heidi Hopkins
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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10
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Leslie T, Rowland M, Mikhail A, Cundill B, Willey B, Alokozai A, Mayan I, Hasanzai A, Baktash SH, Mohammed N, Wood M, Rahimi HUR, Laurent B, Buhler C, Whitty CJM. Use of malaria rapid diagnostic tests by community health workers in Afghanistan: cluster randomised trial. BMC Med 2017; 15:124. [PMID: 28683750 PMCID: PMC5501368 DOI: 10.1186/s12916-017-0891-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 06/12/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The World Health Organisation (WHO) recommends parasitological diagnosis of malaria before treatment, but use of malaria rapid diagnostic tests (mRDTs) by community health workers (CHWs) has not been fully tested within health services in south and central Asia. mRDTs could allow CHWs to diagnose malaria accurately, improving treatment of febrile illness. METHODS A cluster randomised trial in community health services was undertaken in Afghanistan. The primary outcome was the proportion of suspected malaria cases correctly treated for polymerase chain reaction (PCR)-confirmed malaria and PCR negative cases receiving no antimalarial drugs measured at the level of the patient. CHWs from 22 clusters (clinics) received standard training on clinical diagnosis and treatment of malaria; 11 clusters randomised to the intervention arm received additional training and were provided with mRDTs. CHWs enrolled cases of suspected malaria, and the mRDT results and treatments were compared to blind-read PCR diagnosis. RESULTS In total, 256 CHWs enrolled 2400 patients with 2154 (89.8%) evaluated. In the intervention arm, 75.3% (828/1099) were treated appropriately vs. 17.5% (185/1055) in the control arm (cluster adjusted risk ratio: 3.72, 95% confidence interval 2.40-5.77; p < 0.001). In the control arm, 85.9% (164/191) with confirmed Plasmodium vivax received chloroquine compared to 45.1% (70/155) in the intervention arm (p < 0.001). Overuse of chloroquine in the control arm resulted in 87.6% (813/928) of those with no malaria (PCR negative) being treated vs. 10.0% (95/947) in the intervention arm, p < 0.001. In the intervention arm, 71.4% (30/42) of patients with P. falciparum did not receive artemisinin-based combination therapy, partly because operational sensitivity of the RDTs was low (53.2%, 38.1-67.9). There was high concordance between recorded RDT result and CHW prescription decisions: 826/950 (87.0%) with a negative test were not prescribed an antimalarial. Co-trimoxazole was prescribed to 62.7% of malaria negative patients in the intervention arm and 15.0% in the control arm. CONCLUSIONS While introducing mRDT reduced overuse of antimalarials, this action came with risks that need to be considered before use at scale: an appreciable proportion of malaria cases will be missed by those using current mRDTs. Higher sensitivity tests could be used to detect all cases. Overtreatment with antimalarial drugs in the control arm was replaced with increased antibiotic prescription in the intervention arm, resulting in a probable overuse of antibiotics. TRIAL REGISTRATION ClinicalTrials.gov, NCT01403350 . Prospectively registered.
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Affiliation(s)
- Toby Leslie
- London School of Hygiene & Tropical Medicine, London, WC1H 7HT, UK. .,Health Protection and Research Organisation, Kabul, Afghanistan.
| | - Mark Rowland
- London School of Hygiene & Tropical Medicine, London, WC1H 7HT, UK
| | - Amy Mikhail
- London School of Hygiene & Tropical Medicine, London, WC1H 7HT, UK.,Health Protection and Research Organisation, Kabul, Afghanistan
| | - Bonnie Cundill
- London School of Hygiene & Tropical Medicine, London, WC1H 7HT, UK
| | - Barbara Willey
- London School of Hygiene & Tropical Medicine, London, WC1H 7HT, UK
| | - Asif Alokozai
- Health Protection and Research Organisation, Kabul, Afghanistan
| | - Ismail Mayan
- Health Protection and Research Organisation, Kabul, Afghanistan
| | | | | | - Nader Mohammed
- Health Protection and Research Organisation, Kabul, Afghanistan
| | - Molly Wood
- Health Protection and Research Organisation, Kabul, Afghanistan
| | | | - Baptiste Laurent
- London School of Hygiene & Tropical Medicine, London, WC1H 7HT, UK
| | - Cyril Buhler
- Health Protection and Research Organisation, Kabul, Afghanistan.,OR Diagnostics, Paris, France
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11
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Hansen KS, Ndyomugyenyi R, Magnussen P, Lal S, Clarke SE. Cost-effectiveness analysis of malaria rapid diagnostic tests for appropriate treatment of malaria at the community level in Uganda. Health Policy Plan 2017; 32:676-689. [PMID: 28453718 PMCID: PMC5406761 DOI: 10.1093/heapol/czw171] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2016] [Indexed: 11/21/2022] Open
Abstract
In Sub-Saharan Africa, malaria remains a major cause of morbidity and mortality among children under 5, due to lack of access to prompt and appropriate diagnosis and treatment. Many countries have scaled-up community health workers (CHWs) as a strategy towards improving access. The present study was a cost-effectiveness analysis of the introduction of malaria rapid diagnostic tests (mRDTs) performed by CHWs in two areas of moderate-to-high and low malaria transmission in rural Uganda. CHWs were trained to perform mRDTs and treat children with artemisinin-based combination therapy (ACT) in the intervention arm while CHWs offered treatment based on presumptive diagnosis in the control arm. Data on the proportion of children with fever 'appropriately treated for malaria with ACT' were captured from a randomised trial. Health sector costs included: training of CHWs, community sensitisation, supervision, allowances for CHWs and provision of mRDTs and ACTs. The opportunity costs of time utilised by CHWs were estimated based on self-reporting. Household costs of subsequent treatment-seeking at public health centres and private health providers were captured in a sample of households. mRDTs performed by CHWs was associated with large improvements in appropriate treatment of malaria in both transmission settings. This resulted in low incremental costs for the health sector at US$3.0 per appropriately treated child in the moderate-to-high transmission area. Higher incremental costs at US$13.3 were found in the low transmission area due to lower utilisation of CHW services and higher programme costs. Incremental costs from a societal perspective were marginally higher. The use of mRDTs by CHWs improved the targeting of ACTs to children with malaria and was likely to be considered a cost-effective intervention compared to a presumptive diagnosis in the moderate-to-high transmission area. In contrast to this, in the low transmission area with low attendance, RDT use by CHWs was not a low cost intervention.
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Affiliation(s)
- Kristian S Hansen
- Department of Public Health, Section for Health Services Research, University of Copenhagen, Denmark
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
| | | | - Pascal Magnussen
- Centre for Medical Parasitology and Microbiology & Institute of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Sham Lal
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
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12
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Kaula H, Buyungo P, Opigo J. Private sector role, readiness and performance for malaria case management in Uganda, 2015. Malar J 2017; 16:219. [PMID: 28545583 PMCID: PMC5445348 DOI: 10.1186/s12936-017-1824-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/18/2017] [Indexed: 12/04/2022] Open
Abstract
Background Several interventions have been put in place to promote access to quality malaria case management services in Uganda’s private sector, where most people seek treatment. This paper describes evidence using a mixed-method approach to examine the role, readiness and performance of private providers at a national level in Uganda. These data will be useful to inform strategies and policies for improving malaria case management in the private sector. Methods The ACTwatch national anti-malarial outlet survey was conducted concurrently with a fever case management study. The ACTwatch nationally representative anti-malarial outlet survey was conducted in Uganda between May 18th 2015 and July 2nd 2015. A representative sample of sub-counties was selected in 14 urban and 13 rural clusters with probability proportional to size and a census approach was used to identify outlets. Outlets eligible for the survey met at least one of three criteria: (1) one or more anti-malarials were in stock on the day of the survey; (2) one or more anti-malarials were in stock in the 3 months preceding the survey; and/or (3) malaria blood testing (microscopy or RDT) was available. The fever case management study included observations of provider-patient interactions and patient exit interviews. Data were collected between May 20th and August 3rd, 2015. The fever case management study was implemented in the private sector. Potential outlets were identified during the main outlet survey and included in this sub-sample if they had both artemisinin-based combination therapy (ACT) [artemether–lumefantrine (AL)], in stock on the day of survey as well as diagnostic testing available. Results A total of 9438 outlets were screened for eligibility in the ACTwatch outlet survey and 4328 outlets were found to be stocking anti-malarials and were interviewed. A total of 9330 patients were screened for the fever case management study and 1273 had a complete patient observation and exit interview. Results from the outlet survey illustrate that the majority of anti-malarials were distributed through the private sector (54.3%), with 31.4% of all anti-malarials distributed through drug stores and 14.4% through private for-profit health facilities. Availability of different anti-malarials and diagnostic testing in the private sector was: ACT (80.7%), quality-assured (QA) ACT (72.0%), sulfadoxine–pyrimethamine (SP) (47.1%), quinine (73.2%) and any malaria blood testing (32.9%). Adult QAACT ($1.62) was three times more expensive than SP ($0.48). The results from the fever case management study found 44.4% of respondents received a malaria test, and among those who tested positive for malaria, 60.0% received an ACT, 48.5% received QAACT; 14.4% a non-artemisinin therapy; 14.9% artemether injection, and 42.5% received an antibiotic. Conclusion The private sector plays an important role in malaria case management in Uganda. While several private sector initiatives have improved availability of QAACT, there are gaps in malaria diagnosis and distribution of non-artemisinin monotherapies persists. Further private sector strategies, including those focusing on drug stores, are needed to increase coverage of parasitological testing and removal of non-artemisinin therapies from the marketplace. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1824-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Henry Kaula
- Programme for Accessible Communication and Education (PACE) Uganda, Plot # 2, Ibis Vale, Kololo-off Prince Charles Drive, Kampala, Uganda.
| | - Peter Buyungo
- Programme for Accessible Communication and Education (PACE) Uganda, Plot # 2, Ibis Vale, Kololo-off Prince Charles Drive, Kampala, Uganda
| | - Jimmy Opigo
- National Malaria Control Programme, Ministry of Health, Kampala, Uganda
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13
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Boyce MR, O'Meara WP. Use of malaria RDTs in various health contexts across sub-Saharan Africa: a systematic review. BMC Public Health 2017; 17:470. [PMID: 28521798 PMCID: PMC5437623 DOI: 10.1186/s12889-017-4398-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 05/08/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The World Health Organization recommends parasitological confirmation of malaria prior to treatment. Malaria rapid diagnostic tests (RDTs) represent one diagnostic method that is used in a variety of contexts to overcome limitations of other diagnostic techniques. Malaria RDTs increase the availability and feasibility of accurate diagnosis and may result in improved quality of care. Though RDTs are used in a variety of contexts, no studies have compared how well or effectively RDTs are used across these contexts. This review assesses the diagnostic use of RDTs in four different contexts: health facilities, the community, drug shops and schools. METHODS A comprehensive search of the Pubmed database was conducted to evaluate RDT execution, test accuracy, or adherence to test results in sub-Saharan Africa. Original RDT and Plasmodium falciparum focused studies conducted in formal health care facilities, drug shops, schools, or by CHWs between the year 2000 and December 2016 were included. Studies were excluded if they were conducted exclusively in a research laboratory setting, where staff from the study team conducted RDTs, or in settings outside of sub-Saharan Africa. RESULTS The literature search identified 757 reports. A total of 52 studies were included in the analysis. Overall, RDTs were performed safely and effectively by community health workers provided they receive proper training. Analogous information was largely absent for formal health care workers. Tests were generally accurate across contexts, except for in drug shops where lower specificities were observed. Adherence to RDT results was higher among drug shop vendors and community health workers, while adherence was more variable among formal health care workers, most notably with negative test results. CONCLUSIONS Malaria RDTs are generally used well, though compliance with test results is variable - especially in the formal health care sector. If low adherence rates are extrapolated, thousands of patients may be incorrectly diagnosed and receive inappropriate treatment resulting in a low quality of care and unnecessary drug use. Multidisciplinary research should continue to explore determinants of good RDT use, and seek to better understand how to support and sustain the correct use of this diagnostic tool.
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Affiliation(s)
| | - Wendy P O'Meara
- Duke Global Health Institute, Durham, NC, USA.,School of Public Health, Moi University College of Health Sciences, Eldoret, Kenya
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14
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Burchett HED, Leurent B, Baiden F, Baltzell K, Björkman A, Bruxvoort K, Clarke S, DiLiberto D, Elfving K, Goodman C, Hopkins H, Lal S, Liverani M, Magnussen P, Mårtensson A, Mbacham W, Mbonye A, Onwujekwe O, Roth Allen D, Shakely D, Staedke S, Vestergaard LS, Whitty CJM, Wiseman V, Chandler CIR. Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence. BMJ Open 2017; 7:e012973. [PMID: 28274962 PMCID: PMC5353269 DOI: 10.1136/bmjopen-2016-012973] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts. DESIGN A comparative case study approach, analysing variation in outcomes across different settings. SETTING Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case. PARTICIPANTS 28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria. INTERVENTIONS The interventions included different mRDT training packages, supervision, supplies and community sensitisation. OUTCOME MEASURES Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (% Plasmodium falciparum positive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (% P. falciparum negative not prescribed/given antimalarial). RESULTS Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs. CONCLUSIONS Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.
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Affiliation(s)
- Helen E D Burchett
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Baptiste Leurent
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Frank Baiden
- Epidemiology Unit, Ensign College of Public Health, Kpong, Ghana
| | - Kimberly Baltzell
- Department of Family Health Care Nursing, and Global Health Science, University of California, Berkeley, California, USA
| | - Anders Björkman
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Siân Clarke
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Deborah DiLiberto
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristina Elfving
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Heidi Hopkins
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Sham Lal
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Mårtensson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Wilfred Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé, Yaoundé, Cameroon
| | - Anthony Mbonye
- School of Public Health- Makerere University and Commissioner Health Services, Ministry of Health, Uganda
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria Enugu-Campus, Nigeria
| | | | - Delér Shakely
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
- Department of Medicine, Kungälv Hospital, Sweden
| | - Sarah Staedke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Lasse S Vestergaard
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Denmark
| | - Christopher J M Whitty
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health and Community Medicine, Australia
| | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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15
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Thwing J, Ba F, Diaby A, Diedhiou Y, Sylla A, Sall G, Diouf MB, Gueye AB, Gaye S, Ndiop M, Cisse M, Ndiaye D, Ba M. Assessment of the utility of a symptom-based algorithm for identifying febrile patients for malaria diagnostic testing in Senegal. Malar J 2017; 16:95. [PMID: 28249580 PMCID: PMC5333468 DOI: 10.1186/s12936-017-1750-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 02/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria rapid diagnostic tests (RDTs) enable point-of-care testing to be nearly as sensitive and specific as reference microscopy. The Senegal National Malaria Control Programme introduced RDTs in 2007, along with a case management algorithm for uncomplicated febrile illness, in which the first step stipulates that if a febrile patient of any age has symptoms indicative of febrile illness other than malaria (e.g., cough or rash), they would not be tested for malaria, but treated for the apparent illness and receive an RDT for malaria only if they returned in 48 h without improvement. METHODS A year-long study in 16 health posts was conducted to determine the algorithm's capacity to identify patients with Plasmodium falciparum infection identifiable by RDT. Health post personnel enrolled patients of all ages with fever (≥37.5 °C) or history of fever in the previous 2 days. After clinical assessment, a nurse staffing the health post determined whether a patient should receive an RDT according to the diagnostic algorithm, but performed an RDT for all enrolled patients. RESULTS Over 1 year, 6039 patients were enrolled and 58% (3483) were determined to require an RDT according to the algorithm. Overall, 23% (1373/6039) had a positive RDT, 34% (1130/3376) during rainy season and 9% (243/2661) during dry season. The first step of the algorithm identified only 78% of patients with a positive RDT, varying by transmission season (rainy 80%, dry 70%), malaria transmission zone (high 75%, low 95%), and age group (under 5 years 68%, 5 years and older 84%). CONCLUSIONS In all but the lowest malaria transmission zone, use of the algorithm excludes an unacceptably large proportion of patients with malaria from receiving an RDT at their first visit, denying them timely diagnosis and treatment. While the algorithm was adopted within a context of malaria control and scarce resources, with the goal of treating patients with symptomatic malaria, Senegal has now adopted a policy of universal diagnosis of patients with fever or history of fever. In addition, in the current context of malaria elimination, the paradigm of case management needs to shift towards the identification and treatment of all patients with malaria infection.
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Affiliation(s)
- Julie Thwing
- U.S. Centers for Disease Control and Prevention and President's Malaria Initiative, Atlanta, USA.
| | - Fatou Ba
- Senegal National Malaria Control Programme, Dakar, Senegal
| | - Alou Diaby
- Pediatrics Service Hôpital le Dantec, Dakar, Senegal
| | | | - Assane Sylla
- Pediatrics Service Hôpital le Dantec, Dakar, Senegal
| | - Guelaye Sall
- Pediatrics Service Hôpital le Dantec, Dakar, Senegal
| | | | | | - Seynabou Gaye
- Senegal National Malaria Control Programme, Dakar, Senegal
| | - Medoune Ndiop
- Senegal National Malaria Control Programme, Dakar, Senegal
| | | | | | - Mady Ba
- Senegal National Malaria Control Programme, Dakar, Senegal.,WHO, Dakar, Senegal
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16
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Lal S, Ndyomugenyi R, Paintain L, Alexander ND, Hansen KS, Magnussen P, Chandramohan D, Clarke SE. Community health workers adherence to referral guidelines: evidence from studies introducing RDTs in two malaria transmission settings in Uganda. Malar J 2016; 15:568. [PMID: 27881136 PMCID: PMC5121932 DOI: 10.1186/s12936-016-1609-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many malaria-endemic countries have implemented national community health worker (CHW) programmes to serve remote populations that have poor access to malaria diagnosis and treatment. Despite mounting evidence of CHWs' ability to adhere to malaria rapid diagnostic tests (RDTs) and treatment guidelines, there is limited evidence whether CHWs adhere to the referral guidelines and refer severely ill children for further management. In southwest Uganda, this study examined whether CHWs referred children according to training guidelines and described factors associated with adherence to the referral guideline. METHODS A secondary analysis was undertaken of data collected during two cluster-randomized trials conducted between January 2010 and July 2011, one in a moderate-to-high malaria transmission setting and the other in a low malaria transmission setting. All CHWs were trained to prescribe artemisinin-based combination therapy (ACT) and recognize symptoms in children that required immediate referral to the nearest health centre. Intervention arm CHWs had additional training on how to conduct an RDT; CHWs in the control arm used a presumptive diagnosis for malaria using clinical signs and symptoms. CHW treatment registers were reviewed to identify children eligible for referral according to training guidelines (temperature of ≥38.5 °C), to assess whether CHWs adhered to the guidelines and referred them. Factors associated with adherence were examined with logistic regression models. RESULTS CHWs failed to refer 58.8% of children eligible in the moderate-to-high transmission and 31.2% of children in the low transmission setting. CHWs using RDTs adhered to the referral guidelines more frequently than CHWs not using RDTs (moderate-to-high transmission: 50.1 vs 18.0%, p = 0.003; low transmission: 88.5 vs 44.1%, p < 0.001). In both settings, fewer than 20% of eligible children received pre-referral treatment with rectal artesunate. Children who were prescribed ACT were very unlikely to be referred in both settings (97.7 and 73.3% were not referred in the moderate-to-high and low transmission settings, respectively). In the moderate-to-high transmission setting, day and season of visit were also associated with the likelihood of adherence to the referral guidelines, but not in the low transmission setting. CONCLUSIONS CHW adherence to referral guidelines was poor in both transmission settings. However, training CHWs to use RDT improved correct referral of children with a high fever compared to a presumptive diagnosis using sign and symptoms. As many countries scale up CHW programmes, routine monitoring of reported data should be examined carefully to assess whether CHWs adhere to referral guidelines and take remedial actions where required.
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Affiliation(s)
- Sham Lal
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
| | | | - Lucy Paintain
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Neal D Alexander
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian S Hansen
- Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Institute of International Health, Immunology and Microbiology & Institute of Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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17
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Lal S, Ndyomugenyi R, Magnussen P, Hansen KS, Alexander ND, Paintain L, Chandramohan D, Clarke SE. Referral Patterns of Community Health Workers Diagnosing and Treating Malaria: Cluster-Randomized Trials in Two Areas of High- and Low-Malaria Transmission in Southwestern Uganda. Am J Trop Med Hyg 2016; 95:1398-1408. [PMID: 27799650 PMCID: PMC5154457 DOI: 10.4269/ajtmh.16-0598] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/06/2016] [Indexed: 11/07/2022] Open
Abstract
Malaria-endemic countries have implemented community health worker (CHW) programs to provide malaria diagnosis and treatment to populations living beyond the reach of health systems. However, there is limited evidence describing the referral practices of CHWs. We examined the impact of malaria rapid diagnostic tests (mRDTs) on CHW referral in two cluster-randomized trials, one conducted in a moderate-to-high malaria transmission setting and one in a low-transmission setting in Uganda, between January 2010 and July 2012. All CHWs were trained to prescribe artemisinin-based combination therapy (ACT) for malaria and recognize signs and symptoms for referral to health centers. CHWs in the control arm used a presumptive diagnosis for malaria based on clinical symptoms, whereas intervention arm CHWs used mRDTs. CHWs recorded ACT prescriptions, mRDT results, and referral in patient registers. An intention-to-treat analysis was undertaken using multivariable logistic regression. Referral was more frequent in the intervention arm versus the control arm (moderate-to-high transmission, P < 0.001; low transmission, P < 0.001). Despite this increase, referral advice was not always given when ACTs or prereferral rectal artesunate were prescribed: 14% prescribed rectal artesunate in the moderate-to-high setting were not referred. In addition, CHWs considered factors alongside mRDTs when referring. Child visits during the weekends or the rainy season were less likely to be referred, whereas visits to CHWs more distant from health centers were more likely to be referred (low transmission only). CHWs using mRDTs and ACTs increased referral compared with CHWs using a presumptive diagnosis. To address these concerns, referral training should be emphasized in CHW programs as they are scaled-up.
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Affiliation(s)
- Sham Lal
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Pascal Magnussen
- Department of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of International Health, Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristian S Hansen
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Neal D Alexander
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lucy Paintain
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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18
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Chandler CIR, Burchett H, Boyle L, Achonduh O, Mbonye A, DiLiberto D, Reyburn H, Onwujekwe O, Haaland A, Roca-Feltrer A, Baiden F, Mbacham WF, Ndyomugyenyi R, Nankya F, Mangham-Jefferies L, Clarke S, Mbakilwa H, Reynolds J, Lal S, Leslie T, Maiteki-Sebuguzi C, Webster J, Magnussen P, Ansah E, Hansen KS, Hutchinson E, Cundill B, Yeung S, Schellenberg D, Staedke SG, Wiseman V, Lalloo DG, Whitty CJM. Examining Intervention Design: Lessons from the Development of Eight Related Malaria Health Care Intervention Studies. Health Syst Reform 2016; 2:373-388. [PMID: 31514719 PMCID: PMC6176770 DOI: 10.1080/23288604.2016.1179086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract—Rigorous evidence of “what works” to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This article presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; and (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (1) intended pathways of change and (2) how their intervention would be implemented.The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical but as the result of micro and macro social, political, and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.
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Affiliation(s)
- Clare I R Chandler
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Helen Burchett
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Louise Boyle
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Olivia Achonduh
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | - Anthony Mbonye
- School of Public Health-Makerere University & Commissioner Health Services, Ministry of Health , Kampala , Uganda
| | - Deborah DiLiberto
- Clinical Research Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hugh Reyburn
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics , University of Nigeria Enugu-Campus , Enugu , Nigeria
| | - Ane Haaland
- Institute of Health and Society , Department of Community Medicine , Blindern , Oslo , Norway
| | | | - Frank Baiden
- Malaria Group, Kintampo Health Research Centre , Kintampo , Ghana
| | - Wilfred F Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | | | - Florence Nankya
- Infectious Diseases Research Collaboration , Kampala , Uganda
| | - Lindsay Mangham-Jefferies
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sian Clarke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hilda Mbakilwa
- Joint Malaria Programme, Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Joanna Reynolds
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sham Lal
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Toby Leslie
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | | | - Jayne Webster
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen , Denmark
| | - Evelyn Ansah
- Dangme West District Health Directorate, Ghana Health Service , Dodowa , Ghana
| | - Kristian S Hansen
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Eleanor Hutchinson
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Bonnie Cundill
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Shunmay Yeung
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - David Schellenberg
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Sarah G Staedke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Virginia Wiseman
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK.,School of Public Health and Community Medicine , Kensington , New South Wales , Australia
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