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Kirui J, Malinga J, Sang E, Ambani G, Abel L, Nalianya E, Namae J, Boyce M, Laktabai J, Menya D, O'Meara W. Supply-side and demand-side factors influencing uptake of malaria testing services in the community: lessons for scale-up from a post-hoc analysis of a cluster randomised, community-based trial in western Kenya. BMJ Open 2023; 13:e070482. [PMID: 37369403 PMCID: PMC10410802 DOI: 10.1136/bmjopen-2022-070482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVES Maximising the impact of community-based programmes requires understanding how supply of, and demand for, the intervention interact at the point of delivery. DESIGN Post-hoc analysis from a large-scale community health worker (CHW) study designed to increase the uptake of malaria diagnostic testing. SETTING Respondents were identified during a household survey in western Kenya between July 2016 and April 2017. PARTICIPANTS Household members with fever in the last 4 weeks were interviewed at 12 and 18 months post-implementation. We collected monthly testing data from 244 participating CHWs and conducted semistructured interviews with a random sample of 70 CHWs. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was diagnostic testing before treatment for a recent fever. The secondary outcomes were receiving a test from a CHW and tests done per month by each CHW. RESULTS 55% (n=948 of 1738) reported having a malaria diagnostic test for their recent illness, of which 38.4% were tested by a CHW. Being aware of a local CHW (adjusted OR=1.50, 95% CI: 1.10 to 2.04) and belonging to the wealthiest households (vs least wealthy) were associated with higher testing (adjusted OR=1.53, 95% CI: 1.14 to 2.06). Wealthier households were less likely to receive their test from a CHW compared with poorer households (adjusted OR=0.32, 95% CI: 0.17 to 0.62). Confidence in artemether-lumefantrine to cure malaria (adjusted OR=2.75, 95% CI: 1.54 to 4.92) and perceived accuracy of a malaria rapid diagnostic test (adjusted OR=2.43, 95% CI: 1.12 to 5.27) were positively associated with testing by a CHW. Specific CHW attributes were associated with performing a higher monthly number of tests including formal employment, serving more than 50 households (vs <50) and serving areas with a higher test positivity. On demand side, confidence of the respondent in a test performed by a CHW was strongly associated with seeking a test from a CHW. CONCLUSION Scale-up of community-based malaria testing is feasible and effective in increasing uptake among the poorest households. To maximise impact, it is important to recognise factors that may restrict delivery and demand for such services. TRIAL REGISTRATION NUMBER NCT02461628; Post-results.
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Affiliation(s)
- Joseph Kirui
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Josephine Malinga
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Edna Sang
- Duke Global Health Institute, Duke Glopbal Inc, Nairobi, Kenya
| | - George Ambani
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Lucy Abel
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Erick Nalianya
- Duke Global Health Institute, Duke Glopbal Inc, Nairobi, Kenya
| | - Jane Namae
- School of Medicine, Department of Family Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Matthew Boyce
- Center for Global Health Science & Security, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Jeremiah Laktabai
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- School of Medicine, Department of Family Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Diana Menya
- School of Public Health, Departmental of Epidemiology and Medical Statistics, Moi University College of Health Sciences, Eldoret, Kenya
| | - Wendy O'Meara
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- School of Public Health, Departmental of Epidemiology and Medical Statistics, Moi University College of Health Sciences, Eldoret, Kenya
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Laktabai J, Platt AC, Turner E, Saran I, Kipkoech J, Menya D, O’Meara WP. Community-Based Malaria Testing Reduces Polypharmacy in a Population-Based Survey of Febrile Illness in Western Kenya. Int J Public Health 2022; 67:1604826. [PMID: 36090831 PMCID: PMC9453644 DOI: 10.3389/ijph.2022.1604826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: The objective was to describe the relationship between the location of care, the malaria test result, and the type of medicine consumed for the fever, and to determine whether community-based access to malaria testing reduced polypharmacy. Methods: This is a secondary analysis of a cluster-randomized trial of an intervention designed to increase diagnostic testing and targeting of Artemesinin Combined Therapies (ACTs). Data collected at baseline, 12, and 18 months were analyzed to determine the impact of diagnostic testing on drug consumption patterns among febrile individuals. Results: Of the 5,756 participants analyzed, 60.1% were female, 42% were aged 5–17 years, and 58.1% sought care for fever in a retail outlet. Consumption of both ACT and antibiotics was 22.1% (n = 443/2008) at baseline. At endline, dual consumption had declined to 16.6%. There was reduced antibiotic consumption among those testing positive for malaria (39.5%–26.5%) and those testing negative (63.4%–55.1%), accompanied by a substantial decline in ACT use among malaria-negative participants. Conclusion: Diagnostic testing for malaria reduces dual consumption of ACTs and antibiotics, especially among those testing outside the formal healthcare sector.
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Affiliation(s)
- Jeremiah Laktabai
- School of Medicine, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- *Correspondence: Jeremiah Laktabai,
| | - Alyssa C. Platt
- Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Elizabeth Turner
- Duke Global Health Institute, Duke University, Durham, NC, United States
- Department of Biostatistics and Bioinformatics, School of Medicine, Duke University, Durham, NC, United States
| | - Indrani Saran
- School of Social Work, Boston College, Chestnut Hill, MA, United States
| | - Joseph Kipkoech
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Diana Menya
- Moi University School of Public Health, Eldoret, Kenya
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Maffioli EM, Mohanan M, Saran I, O'Meara WP. Does improving appropriate use of malaria medicines change population beliefs in testing and treatment? Evidence from a randomized controlled trial. Health Policy Plan 2020; 35:556-566. [PMID: 32129851 DOI: 10.1093/heapol/czaa010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2020] [Indexed: 01/08/2023] Open
Abstract
A major puzzle in malaria treatment remains the dual problem of underuse and overuse of malaria medications, which deplete scarce public resources used for subsidies and lead to drug resistance. One explanation is that health behaviour, especially in the context of incomplete information, could be driven by beliefs, pivotal to the success of health interventions. The objective of this study is to investigate how population beliefs change in response to an experimental intervention which was shown to improve access to rapid diagnostic testing (RDT) through community health workers (CHWs) and to increase appropriate use of anti-malaria medications. By collecting data on individuals' beliefs on malaria testing and treatment 12 and 18 months after the experimental intervention started, we find that the intervention increases the belief that a negative test result is correct, and the belief that the first-line anti-malaria drugs (artemisinin-based combination therapies or ACTs) are effective. Using mediation analysis, we also explore some possible mechanisms through which the changes happen. We find that the experience and knowledge about RDT and experience with CHWs explain 62.4% of the relationship between the intervention and the belief that a negative test result is correct. Similarly, the targeted use of ACTs and taking the correct dose-in addition to experience with RDT-explain 96.8% of the relationship between the intervention and the belief that the ACT taken is effective. As beliefs are important determinants of economic behaviour and might guide individuals' future decisions, understanding how they change after a health intervention has important implications for long-term changes in population behaviour.
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Affiliation(s)
- Elisa M Maffioli
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA
| | - Manoj Mohanan
- Sanford School of Public Policy, Duke University, Durham, NC 27708, USA.,Department of Economics, Duke University, Durham, NC 27708, USA.,Duke Global Health Institute, Duke University, Durham, NC 27708, USA.,Duke Population Research Institute, Duke University, Durham, NC 27708, USA
| | - Indrani Saran
- Boston College School of Social Work, Boston, MA 02467, USA
| | - Wendy Prudhomme O'Meara
- Duke Global Health Institute, Duke University, Durham, NC 27708, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC 27708, USA.,Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
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Suchman L, Hart E, Montagu D. Public-private partnerships in practice: collaborating to improve health finance policy in Ghana and Kenya. Health Policy Plan 2018; 33:777-785. [PMID: 29905855 PMCID: PMC6097457 DOI: 10.1093/heapol/czy053] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2018] [Indexed: 01/11/2023] Open
Abstract
Social health insurance (SHI), one mechanism for achieving universal health coverage, has become increasingly important in low- and middle-income countries (LMICs) as they work to achieve this goal. Although small private providers supply a significant proportion of healthcare in LMICs, integrating these providers into SHI systems is often challenging. Public-private partnerships in health are one way to address these challenges, but we know little about how these collaborations work, how effectively, and why. Drawing on semi-structured interviews conducted with National Health Insurance (NHI) officials in Kenya and Ghana, as well as with staff from several international NGOs (INGOs) representing social franchise networks that are partnering to increase private provider accreditation into the NHIs, this article examines one example of public-private collaboration in practice. We found that interviewees initially had incomplete knowledge about the potential for cross-sector synergy, but both sides were motivated to work together around shared goals and the potential for mutual benefit. The public-private relationship then evolved over time through regular face-to-face interactions, reciprocal feedback, and iterative workplan development. This process led to a collegial relationship that also has given small private providers more voice in the health system. In order to sustain this relationship, we recommend that both public and private sector representatives develop formalized protocols for working together, as well as less formal open channels for communication. Models for aggregating small private providers and delivering them to government programmes as a package have potential to facilitate public-private partnerships as well, but there is little evidence on how these models work in LMICs thus far.
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Affiliation(s)
- Lauren Suchman
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, 3rd Floor Box 1224, San Francisco, USA
| | - Elizabeth Hart
- Department of Sociology University of California Davis, 1 Shields Avenue, Davis, USA
| | - Dominic Montagu
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, 3rd Floor Box 1224, San Francisco, USA
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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: 8] [Impact Index Per Article: 1.3] [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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Winn LK, Lesser A, Menya D, Baumgartner JN, Kipkoech Kirui J, Saran I, Prudhomme-O’Meara W. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health 2018. [DOI: 10.7189/jogh.06.0207028.010401] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Boyce MR, Menya D, Turner EL, Laktabai J, Prudhomme-O'Meara W. Evaluation of malaria rapid diagnostic test (RDT) use by community health workers: a longitudinal study in western Kenya. Malar J 2018; 17:206. [PMID: 29776359 PMCID: PMC5960182 DOI: 10.1186/s12936-018-2358-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/15/2018] [Indexed: 12/26/2022] Open
Abstract
Background Malaria rapid diagnostic tests (RDTs) are a simple, point-of-care technology that can improve the diagnosis and subsequent treatment of malaria. They are an increasingly common diagnostic tool, but concerns remain about their use by community health workers (CHWs). These concerns regard the long-term trends relating to infection prevention measures, the interpretation of test results and adherence to treatment protocols. This study assessed whether CHWs maintained their competency at conducting RDTs over a 12-month timeframe, and if this competency varied with specific CHW characteristics. Methods From June to September, 2015, CHWs (n = 271) were trained to conduct RDTs using a 3-day validated curriculum and a baseline assessment was completed. Between June and August, 2016, CHWs (n = 105) were randomly selected and recruited for follow-up assessments using a 20-step checklist that classified steps as relating to safety, accuracy, and treatment; 103 CHWs participated in follow-up assessments. Poisson regressions were used to test for associations between error count data at follow-up and Poisson regression models fit using generalized estimating equations were used to compare data across time-points. Results At both baseline and follow-up observations, at least 80% of CHWs correctly completed 17 of the 20 steps. CHWs being 50 years of age or older was associated with increased total errors and safety errors at baseline and follow-up. At follow-up, prior experience conducting RDTs was associated with fewer errors. Performance, as it related to the correct completion of all checklist steps and safety steps, did not decline over the 12 months and performance of accuracy steps improved (mean error ratio: 0.51; 95% CI 0.40–0.63). Visual interpretation of RDT results yielded a CHW sensitivity of 92.0% and a specificity of 97.3% when compared to interpretation by the research team. None of the characteristics investigated was found to be significantly associated with RDT interpretation. Conclusions With training, most CHWs performing RDTs maintain diagnostic testing competency over at least 12 months. CHWs generally perform RDTs safely and accurately interpret results. Younger age and prior experiences with RDTs were associated with better testing performance. Future research should investigate the mode by which CHW characteristics impact RDT procedures. Electronic supplementary material The online version of this article (10.1186/s12936-018-2358-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew R Boyce
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Diana Menya
- Department of Epidemiology and Biostatistics, Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
| | - Elizabeth L Turner
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Jeremiah Laktabai
- Department of Family Medicine, Moi University School of Medicine, Eldoret, Kenya
| | - Wendy Prudhomme-O'Meara
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Epidemiology and Biostatistics, Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya.,Duke University Medical Center, Durham, NC, USA
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Winn LK, Lesser A, Menya D, Baumgartner JN, Kipkoech Kirui J, Saran I, Prudhomme-O'Meara W. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health 2018; 8:010401. [PMID: 29497500 PMCID: PMC5823030 DOI: 10.7189/jogh.08.010401] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background The continued success of community case management (CCM) programs in low-resource settings depends on the ability of these programs to retain the community health workers (CHWs), many of whom are volunteers, and maintain their high-quality performance. This study aims to identify factors related to the motivation and satisfaction of CHWs working in a malaria CCM program in two sub-counties in Western Kenya. Methods We interviewed 70 CHWs who were trained to administer malaria rapid diagnostic tests as part of a broader study evaluating a malaria CCM program. We identified factors related to CHWs' motivation and their satisfaction with participation in the program, as well as the feasibility of program scale-up. We used principal components analysis to develop an overall CHW satisfaction score and assessed associations between this score and individual CHW characteristics as well as their experiences in the program. Results The majority of CHWs reported that they were motivated to perform their role in this malaria CCM program by a personal desire to help their community (69%). The most common challenge CHWs reported was a lack of community understanding about malaria diagnostic testing and CHWs' role in the program (39%). Most CHWs (89%) reported that their involvement in the diagnostic testing intervention had either a neutral or a net positive effect on their other CHW activities, including improving skills applicable to other tasks. CHWs who said they strongly agreed with the statement that their work with the malaria program was appreciated by the community had a 0.76 standard deviation (SD) increase in their overall satisfaction score (95% confidence interval CI = 0.10-1.24, P = 0.03). Almost all CHWs (99%) strongly agreed that they wanted to continue their role in the malaria program. Conclusions Overall, CHWs reported high satisfaction with their role in community-based malaria diagnosis, though they faced challenges primarily related to community understanding and appreciation of the services they provided. CHWs' perceptions that the malaria program generally did not interfere with their other activities is encouraging for the sustainability and scale-up of similar CHW programs.
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Affiliation(s)
| | - Adriane Lesser
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | - Diana Menya
- Moi University, School of Public Health, Eldoret, Kenya
| | - Joy N Baumgartner
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | | | - Indrani Saran
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | - Wendy Prudhomme-O'Meara
- Duke University, Durham, North Carolina, USA.,Duke University, Duke Global Health Institute, Durham, North Carolina, USA.,Moi University, School of Public Health, Eldoret, Kenya
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Laktabai J, Platt A, Menya D, Turner EL, Aswa D, Kinoti S, O’Meara WP. A mobile health technology platform for quality assurance and quality improvement of malaria diagnosis by community health workers. PLoS One 2018; 13:e0191968. [PMID: 29389958 PMCID: PMC5794091 DOI: 10.1371/journal.pone.0191968] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/15/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) play an important role in improving access to services in areas with limited health infrastructure or workforce. Supervision of CHWs by qualified health professionals is the main link between this lay workforce and the formal health system. The quality of services provided by lay health workers is dependent on adequate supportive supervision. It is however one of the weakest links in CHW programs due to logistical and resource constraints, especially in large scale programs. Interventions such as point of care testing using malaria rapid diagnostic tests (RDTs) require real time monitoring to ensure diagnostic accuracy. In this study, we evaluated the utility of a mobile health technology platform to remotely monitor malaria RDT (mRDT) testing by CHWs for quality improvement. METHODS As part of a large implementation trial involving mRDT testing by CHWs, we introduced the Fionet system composed of a mobile device (Deki Reader, DR) to assist in processing and automated interpretation of mRDTs, which connects to a cloud-based database which captures reports from the field in real time, displaying results in a custom dashboard of key performance indicators. A random sample of 100 CHWs were trained and provided with the Deki Readers and instructed to use it on 10 successive patients. The CHWs interpretation was compared with the Deki Reader's automatic interpretation, with the errors in processing and interpreting the RDTs recorded. After the CHW entered their interpretation on the DR, the DR provided immediate, automated feedback and interpretation based on its reading of the same cassette. The study team monitored the CHW performance remotely and provided additional support. RESULTS A total of 1251 primary and 113 repeat tests were performed by the 97 CHWs who used the DR. 91.6% of the tests had agreement between the DR and the CHWs. There were 61 (4.9%) processing and 52 (4.2%) interpretation errors among the primary tests. There was a tendency towards lower odds of errors with increasing number and frequency of tests, though not statistically significant. Of the 62 tests that were repeated due to errors, 79% achieved concordance between the CHW and the DR. Satisfaction with the use of the DR by the CHWs was high. CONCLUSIONS Use of innovative mHealth strategies for monitoring and quality control can ensure quality within a large scale implementation of community level testing by lay health workers.
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Affiliation(s)
- Jeremiah Laktabai
- Department of Family Medicine, Moi University School of Medicine, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- * E-mail:
| | - 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
| | - Diana Menya
- Department of Epidemiology and Biostatistics, Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
| | - 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
| | - Daniel Aswa
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Wendy Prudhomme O’Meara
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Epidemiology and Biostatistics, Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, United States of America
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Saran I, Maffioli EM, Menya D, O'Meara WP. Household beliefs about malaria testing and treatment in Western Kenya: the role of health worker adherence to malaria test results. Malar J 2017; 16:349. [PMID: 28830439 PMCID: PMC5568326 DOI: 10.1186/s12936-017-1993-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/10/2017] [Indexed: 12/02/2022] Open
Abstract
Background Although use of malaria diagnostic tests has increased in recent years, health workers often prescribe anti-malarial drugs to individuals who test negative for malaria. This study investigates how health worker adherence to malaria case management guidelines influences individuals’ beliefs about whether their illness was malaria, and their confidence in the effectiveness of artemisinin-based combination therapy (ACT). Methods A survey was conducted with 2065 households in Western Kenya about a household member’s treatment actions for a recent febrile illness. The survey also elicited the individual’s (or their caregiver’s) beliefs about the illness and about malaria testing and treatment. Logistic regressions were used to test the association between these beliefs and whether the health worker adhered to malaria testing and treatment guidelines. Results Of the 1070 individuals who visited a formal health facility during their illness, 82% were tested for malaria. ACT rates for malaria-positive and negative individuals were 89 and 49%, respectively. Overall, 65% of individuals/caregivers believed that the illness was “very likely” malaria. Individuals/caregivers had higher odds of saying that the illness was “very likely” malaria when the individual was treated with ACT, and this was the case both among individuals not tested for malaria [adjusted odds ratio (AOR) 3.42, 95% confidence interval (CI) [1.65 7.10], P = 0.001] and among individuals tested for malaria, regardless of their test result. In addition, 72% of ACT-takers said the drug was “very likely” effective in treating malaria. However, malaria-negative individuals who were treated with ACT had lower odds of saying that the drugs were “very likely” effective than ACT-takers who were not tested or who tested positive for malaria (AOR 0.29, 95% CI [0.13 0.63], P = 0.002). Conclusion Individuals/caregivers were more likely to believe that the illness was malaria when the patient was treated with ACT, regardless of their test result. Moreover, malaria-negative individuals treated with ACT had lower confidence in the drug than other individuals who took ACT. These results suggest that ensuring health worker adherence to malaria case management guidelines will not only improve ACT targeting, but may also increase patient/caregivers’ confidence in malaria testing and treatment. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1993-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Indrani Saran
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27701, USA.
| | | | - Diana Menya
- School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Wendy Prudhomme O'Meara
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27701, USA.,School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya.,Duke University Medical Center, Duke University, Durham, USA
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Turner EL, Li F, Gallis JA, Prague M, Murray DM. Review of Recent Methodological Developments in Group-Randomized Trials: Part 1-Design. Am J Public Health 2017; 107:907-915. [PMID: 28426295 PMCID: PMC5425852 DOI: 10.2105/ajph.2017.303706] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2017] [Indexed: 11/04/2022]
Abstract
In 2004, Murray et al. reviewed methodological developments in the design and analysis of group-randomized trials (GRTs). We have highlighted the developments of the past 13 years in design with a companion article to focus on developments in analysis. As a pair, these articles update the 2004 review. We have discussed developments in the topics of the earlier review (e.g., clustering, matching, and individually randomized group-treatment trials) and in new topics, including constrained randomization and a range of randomized designs that are alternatives to the standard parallel-arm GRT. These include the stepped-wedge GRT, the pseudocluster randomized trial, and the network-randomized GRT, which, like the parallel-arm GRT, require clustering to be accounted for in both their design and analysis.
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Affiliation(s)
- Elizabeth L Turner
- Elizabeth L. Turner and John A. Gallis are with the Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, and the Duke Global Health Institute, Duke University. Fan Li is with the Department of Biostatistics and Bioinformatics, Duke University. Melanie Prague is with the Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, and Inria, project team SISTM, Bordeaux, France. David M. Murray is with the Office of Disease Prevention, Division of Program Coordination and Strategic Planning, and the Office of the Director, National Institutes of Health, Rockville, MD
| | - Fan Li
- Elizabeth L. Turner and John A. Gallis are with the Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, and the Duke Global Health Institute, Duke University. Fan Li is with the Department of Biostatistics and Bioinformatics, Duke University. Melanie Prague is with the Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, and Inria, project team SISTM, Bordeaux, France. David M. Murray is with the Office of Disease Prevention, Division of Program Coordination and Strategic Planning, and the Office of the Director, National Institutes of Health, Rockville, MD
| | - John A Gallis
- Elizabeth L. Turner and John A. Gallis are with the Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, and the Duke Global Health Institute, Duke University. Fan Li is with the Department of Biostatistics and Bioinformatics, Duke University. Melanie Prague is with the Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, and Inria, project team SISTM, Bordeaux, France. David M. Murray is with the Office of Disease Prevention, Division of Program Coordination and Strategic Planning, and the Office of the Director, National Institutes of Health, Rockville, MD
| | - Melanie Prague
- Elizabeth L. Turner and John A. Gallis are with the Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, and the Duke Global Health Institute, Duke University. Fan Li is with the Department of Biostatistics and Bioinformatics, Duke University. Melanie Prague is with the Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, and Inria, project team SISTM, Bordeaux, France. David M. Murray is with the Office of Disease Prevention, Division of Program Coordination and Strategic Planning, and the Office of the Director, National Institutes of Health, Rockville, MD
| | - David M Murray
- Elizabeth L. Turner and John A. Gallis are with the Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, and the Duke Global Health Institute, Duke University. Fan Li is with the Department of Biostatistics and Bioinformatics, Duke University. Melanie Prague is with the Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, and Inria, project team SISTM, Bordeaux, France. David M. Murray is with the Office of Disease Prevention, Division of Program Coordination and Strategic Planning, and the Office of the Director, National Institutes of Health, Rockville, MD
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