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Soremekun S, Källander K, Lingam R, Branco ACC, Batura N, Strachan DL, Muiambo A, Salomao N, Condoane J, Benhane F, Kasteng F, Vassall A, Hill Z, Ten Asbroek G, Meek S, Tibenderana J, Kirkwood B. Improving outcomes for children with malaria, diarrhoea and pneumonia in Mozambique: A cluster randomised controlled trial of the inSCALE technology innovation. PLOS DIGITAL HEALTH 2023; 2:e0000235. [PMID: 37307522 DOI: 10.1371/journal.pdig.0000235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 03/20/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND The majority of post-neonatal deaths in children under 5 are due to malaria, diarrhoea and pneumonia (MDP). The WHO recommends integrated community case management (iCCM) of these conditions using community-based health workers (CHW). However iCCM programmes have suffered from poor implementation and mixed outcomes. We designed and evaluated a technology-based (mHealth) intervention package 'inSCALE' (Innovations At Scale For Community Access and Lasting Effects) to support iCCM programmes and increase appropriate treatment coverage for children with MDP. METHODS This superiority cluster randomised controlled trial allocated all 12 districts in Inhambane Province in Mozambique to receive iCCM only (control) or iCCM plus the inSCALE technology intervention. Population cross-sectional surveys were conducted at baseline and after 18 months of intervention implementation in approximately 500 eligible households in randomly selected communities in all districts including at least one child less than 60 months of age where the main caregiver was available to assess the impact of the intervention on the primary outcome, the coverage of appropriate treatment for malaria, diarrhoea and pneumonia in children 2-59months of age. Secondary outcomes included the proportion of sick children who were taken to the CHW for treatment, validated tool-based CHW motivation and performance scores, prevalence of cases of illness, and a range of secondary household and health worker level outcomes. All statistical models accounted for the clustered study design and variables used to constrain the randomisation. A meta-analysis of the estimated pooled impact of the technology intervention was conducted including results from a sister trial (inSCALE-Uganda). FINDINGS The study included 2740 eligible children in control arm districts and 2863 children in intervention districts. After 18 months of intervention implementation 68% (69/101) CHWs still had a working inSCALE smartphone and app and 45% (44/101) had uploaded at least one report to their supervising health facility in the last 4 weeks. Coverage of the appropriate treatment of cases of MDP increased by 26% in the intervention arm (adjusted RR 1.26 95% CI 1.12-1.42, p<0.001). The rate of care seeking to the iCCM-trained community health worker increased in the intervention arm (14.4% vs 15.9% in control and intervention arms respectively) but fell short of the significance threshold (adjusted RR 1.63, 95% CI 0.93-2.85, p = 0.085). The prevalence of cases of MDP was 53.5% (1467) and 43.7% (1251) in the control and intervention arms respectively (risk ratio 0.82, 95% CI 0.78-0.87, p<0.001). CHW motivation and knowledge scores did not differ between intervention arms. Across two country trials, the estimated pooled effect of the inSCALE intervention on coverage of appropriate treatment for MDP was RR 1.15 (95% CI 1.08-1.24, p <0.001). INTERPRETATION The inSCALE intervention led to an improvement in appropriate treatment of common childhood illnesses when delivered at scale in Mozambique. The programme will be rolled out by the ministry of health to the entire national CHW and primary care network in 2022-2023. This study highlights the potential value of a technology intervention aimed at strengthening iCCM systems to address the largest causes of childhood morbidity and mortality in sub-Saharan Africa.
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Affiliation(s)
- Seyi Soremekun
- Department of Infection Biology, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom
| | - Karin Källander
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Road, London, United Kingdom
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- UNICEF Programme Division, Health Section, New York, New York State, United States of America
| | - Raghu Lingam
- Population Child Health Research Group, School of Women's and Children's Health, University of New South Wales, Australia
| | | | - Neha Batura
- Institute for Global Health, University College London, 30 Guilford Street, London, United Kingdom
| | - Daniel Ll Strachan
- The Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne Victoria, Australia
| | - Abel Muiambo
- Malaria Consortium, Rua Joseph Ki-Zerbo 191, PO Box 3655, Coop, Maputo, Mozambique
| | - Nelson Salomao
- Malaria Consortium, Rua Joseph Ki-Zerbo 191, PO Box 3655, Coop, Maputo, Mozambique
| | - Juliao Condoane
- Malaria Consortium, Rua Joseph Ki-Zerbo 191, PO Box 3655, Coop, Maputo, Mozambique
| | - Fenias Benhane
- Malaria Consortium, Rua Joseph Ki-Zerbo 191, PO Box 3655, Coop, Maputo, Mozambique
| | - Frida Kasteng
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom
| | - Zelee Hill
- Institute for Global Health, University College London, 30 Guilford Street, London, United Kingdom
| | - Guus Ten Asbroek
- Department of Global Health, Amsterdam University Medical Centres, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands and Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, 1105 BP Amsterdam, The Netherlands
| | - Sylvia Meek
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Road, London, United Kingdom
| | - James Tibenderana
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Road, London, United Kingdom
| | - Betty Kirkwood
- Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
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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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Stokes K, Oronti B, Cappuccio FP, Pecchia L. Use of technology to prevent, detect, manage and control hypertension in sub-Saharan Africa: a systematic review. BMJ Open 2022; 12:e058840. [PMID: 35383086 PMCID: PMC8984054 DOI: 10.1136/bmjopen-2021-058840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To identify and assess the use of technologies, including mobile health technology, internet of things (IoT) devices and artificial intelligence (AI) in hypertension healthcare in sub-Saharan Africa (SSA). DESIGN Systematic review. DATA SOURCES Medline, Embase, Scopus and Web of Science. ELIGIBILITY CRITERIA Studies addressing outcomes related to the use of technologies for hypertension healthcare (all points in the healthcare cascade) in SSA. METHODS Databases were searched from inception to 2 August 2021. Screening, data extraction and risk of bias assessment were done in duplicate. Data were extracted on study design, setting, technology(s) employed and outcomes. Blood pressure (BP) reduction due to intervention was extracted from a subset of randomised controlled trials. Methodological quality was assessed using the Mixed Methods Appraisal Tool. RESULTS 1717 hits were retrieved, 1206 deduplicated studies were screened and 67 full texts were assessed for eligibility. 22 studies were included, all reported on clinical investigations. Two studies were observational, and 20 evaluated technology-based interventions. Outcomes included BP reduction/control, treatment adherence, retention in care, awareness/knowledge of hypertension and completeness of medical records. All studies used mobile technology, three linked with IoT devices. Short Message Service (SMS) was the most popular method of targeting patients (n=6). Moderate BP reduction was achieved in three randomised controlled trials. Patients and healthcare providers reported positive perceptions towards the technologies. No studies using AI were identified. CONCLUSIONS There are a range of successful applications of key enabling technologies in SSA, including BP reduction, increased health knowledge and treatment adherence following targeted mobile technology interventions. There is evidence to support use of mobile technology for hypertension management in SSA. However, current application of technologies is highly heterogeneous and key barriers exist, limiting efficacy and uptake in SSA. More research is needed, addressing objective measures such as BP reduction in robust randomised studies. PROSPERO REGISTRATION NUMBER CRD42020223043.
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Affiliation(s)
- Katy Stokes
- School of Engineering, University of Warwick, Coventry, UK
| | - Busola Oronti
- School of Engineering, University of Warwick, Coventry, UK
| | - Francesco P Cappuccio
- Division of Health Sciences, University of Warwick, Warwick Medical School, Coventry, UK
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Taheri Moghadam S, Sadoughi F, Velayati F, Ehsanzadeh SJ, Poursharif S. The effects of clinical decision support system for prescribing medication on patient outcomes and physician practice performance: a systematic review and meta-analysis. BMC Med Inform Decis Mak 2021; 21:98. [PMID: 33691690 PMCID: PMC7944637 DOI: 10.1186/s12911-020-01376-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 12/18/2020] [Indexed: 12/14/2022] Open
Abstract
Background Clinical Decision Support Systems (CDSSs) for Prescribing are one of the innovations designed to improve physician practice performance and patient outcomes by reducing prescription errors. This study was therefore conducted to examine the effects of various CDSSs on physician practice performance and patient outcomes. Methods This systematic review was carried out by searching PubMed, Embase, Web of Science, Scopus, and Cochrane Library from 2005 to 2019. The studies were independently reviewed by two researchers. Any discrepancies in the eligibility of the studies between the two researchers were then resolved by consulting the third researcher. In the next step, we performed a meta-analysis based on medication subgroups, CDSS-type subgroups, and outcome categories. Also, we provided the narrative style of the findings. In the meantime, we used a random-effects model to estimate the effects of CDSS on patient outcomes and physician practice performance with a 95% confidence interval. Q statistics and I2 were then used to calculate heterogeneity. Results On the basis of the inclusion criteria, 45 studies were qualified for analysis in this study. CDSS for prescription drugs/COPE has been used for various diseases such as cardiovascular diseases, hypertension, diabetes, gastrointestinal and respiratory diseases, AIDS, appendicitis, kidney disease, malaria, high blood potassium, and mental diseases. In the meantime, other cases such as concurrent prescribing of multiple medications for patients and their effects on the above-mentioned results have been analyzed. The study shows that in some cases the use of CDSS has beneficial effects on patient outcomes and physician practice performance (std diff in means = 0.084, 95% CI 0.067 to 0.102). It was also statistically significant for outcome categories such as those demonstrating better results for physician practice performance and patient outcomes or both. However, there was no significant difference between some other cases and traditional approaches. We assume that this may be due to the disease type, the quantity, and the type of CDSS criteria that affected the comparison. Overall, the results of this study show positive effects on performance for all forms of CDSSs. Conclusions Our results indicate that the positive effects of the CDSS can be due to factors such as user-friendliness, compliance with clinical guidelines, patient and physician cooperation, integration of electronic health records, CDSS, and pharmaceutical systems, consideration of the views of physicians in assessing the importance of CDSS alerts, and the real-time alerts in the prescription.
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Affiliation(s)
- Sharare Taheri Moghadam
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Farahnaz Sadoughi
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Rashid Yasemi Street, Vali-e Asr Avenue, Tehran, 1996713883, Iran.
| | - Farnia Velayati
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Jafar Ehsanzadeh
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Gebrekidan MG, Gebremedhin GB, Gebregiorgis YS, Gezehegn AA, Weldearegay KT. Artemether-lumefantrin treatment adherence among uncomplicated plasmodium falciparum malaria patients, visiting public health facilities in AsgedeTsimbla district, Tigray, Ethiopia: a cross-sectional study. Antimicrob Resist Infect Control 2020; 9:184. [PMID: 33168093 PMCID: PMC7653737 DOI: 10.1186/s13756-020-00846-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/29/2020] [Indexed: 01/15/2023] Open
Abstract
Background Ethiopia has set a goal to eliminate malaria by 2030; Artemether–lumefantrine (AL) is put as one of the cornerstone strategies for uncomplicated plasmodium falciparum malaria treatment. However, only focusing on prescribing of the treatment without assessing patients’ adherence could lead to the resistance of the drug. In Ethiopia, there is limited evidence about patients’ adherence to AL and its influencing factors. Therefore, this study aimed at addressing this information gap. Methods A health facility based cross-sectional study was employed. Participants were selected using simple random sampling technique from registration books of the public health facilities in AsgedeTsimbla. Data were collected from March 24th to April 30th, 2018. We interviewed participants using a pre-tested structured questionnaire, and the blister pack was also inspected at their homes on day 4. Data were entered into Epi-Info and analyzed using SPSS 21. Odds ratios with 95% Confidence Intervals were estimated and the level of significance was declared at p-value ≤ 0.05. Results A total of 384 study participants were interviewed with a response rate of 95.5%. The overall AL adherence was 53.6% (95% CI 48.4–58.3%). Children aged < 5 years [AOR: 0.4, 95% CI (0.2–0.8)], and being treated in health post [AOR: 0.3, 95% CI (0.1–0.5)] were more likely to show AL adherence whereas illiteracy [AOR: 9.4, 95% CI (4.2–21.3)], didn’t know the consequence of discontinued AL [AOR: 4.0, 95% CI (2.1–7.6)], had concomitant drugs [AOR: 2.5, 95% CI (1.4–4.5)], and stopped/saved drug when improved before tablet got finished [AOR: 3.2, 95% CI (1.7–5.9)] were factors less likely to be associated with AL adherence. Conclusion AL adherence was low. Children aged < 5 years, and being treated in health post were determinants of AL adherence whereas illiteracy, didn’t know the consequence of discontinued the drug, had concomitant drugs, and stopped/saved drug when improved before tablet got finished were factors that hindered the AL adherence. Stakeholders should emphasize designing appropriate strategies including educational interventions to increase the AL adherence and prevent drug resistance. Further research should be conducted to evaluate AL resistance.
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Affiliation(s)
| | - Gebretsadik Berhe Gebremedhin
- College of Health Sciences, School of Public Health, Department of Epidemiology, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Yosef Sibhatu Gebregiorgis
- College of Health Sciences, School of Public Health, Department of Epidemiology, Mekelle University, Mekelle, Tigray, Ethiopia.
| | | | - Kissanet Tesfay Weldearegay
- College of Health Sciences, School of Public Health, Department of Epidemiology, Mekelle University, Mekelle, Tigray, Ethiopia
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Steinhardt LC, Mathanga DP, Mwandama D, Nsona H, Moyo D, Gumbo A, Kobayashi M, Namuyinga R, Shah MP, Bauleni A, Troell P, Zurovac D, Rowe AK. The Effect of Text Message Reminders to Health Workers on Quality of Care for Malaria, Pneumonia, and Diarrhea in Malawi: A Cluster-Randomized, Controlled Trial. Am J Trop Med Hyg 2019; 100:460-469. [PMID: 30628566 DOI: 10.4269/ajtmh.18-0529] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The use of mobile technologies in medicine, or mHealth, holds promise to improve health worker (HW) performance, but evidence is mixed. We conducted a cluster-randomized controlled trial to evaluate the effect of text message reminders to HWs in outpatient health facilities (HFs) on quality of care for malaria, pneumonia, and diarrhea in Malawi. After a baseline HF survey (2,360 patients) in January 2015, 105 HFs were randomized to three arms: 1) text messages to HWs on malaria case management; 2) text messages to HWs on malaria, pneumonia, and diarrhea case management (latter two for children < 5 years); and 3) control arm (no messages). Messages were sent beginning April 2015 twice daily for 6 months, followed by an endline HF survey (2,536 patients) in November 2015. An intention-to-treat analysis with difference-in-differences binomial regression modeling was performed. The proportion of patients with uncomplicated malaria managed correctly increased from 42.8% to 59.6% in the control arm, from 43.7% to 55.8% in arm 1 (effect size -4.7%-points, 95% confidence interval (CI): -18.2, 8.9, P = 0.50) and from 30.2% to 50.9% in arm 2 (effect size 3.9%-points, 95% CI: -14.1, 22.0, P = 0.67). Prescription of first-line antibiotics to children < 5 years with clinically defined pneumonia increased in all arms, but decreased in arm 2 (effect size -4.1%-points, 95% CI: -42.0, 33.8, P = 0.83). Prescription of oral rehydration solution to children with diarrhea declined slightly in all arms. We found no significant improvements in malaria, pneumonia, or diarrhea treatment after HW reminders, illustrating the importance of rigorously testing new interventions before adoption.
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Affiliation(s)
- Laura C Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Don P Mathanga
- Malaria Alert Centre, College of Medicine, Blantyre, Malawi
| | - Dyson Mwandama
- Malaria Alert Centre, College of Medicine, Blantyre, Malawi
| | | | | | | | - Miwako Kobayashi
- Respiratory Diseases Branch, Division of Bacterial Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ruth Namuyinga
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monica P Shah
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Andy Bauleni
- Malaria Alert Centre, College of Medicine, Blantyre, Malawi
| | - Peter Troell
- US President's Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Dejan Zurovac
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, Georgia
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Kaunda-Khangamwa BN, Steinhardt LC, Rowe AK, Gumbo A, Moyo D, Nsona H, Troell P, Zurovac D, Mathanga D. The effect of mobile phone text message reminders on health workers' adherence to case management guidelines for malaria and other diseases in Malawi: lessons from qualitative data from a cluster-randomized trial. Malar J 2018; 17:481. [PMID: 30567603 PMCID: PMC6299948 DOI: 10.1186/s12936-018-2629-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/13/2018] [Indexed: 11/15/2022] Open
Abstract
Background Mobile health (mHealth), which uses technology such as mobile phones to improve patient health and health care delivery, is increasingly being tested as an intervention to promote health worker (HW) performance. This study assessed the effect of short messaging services (SMS) reminders in a study setting. Following a trial of text-message reminders to HWs to improve case management of malaria and other childhood diseases in southern Malawi that showed little effect, qualitative data was collected to explore the reasons why the intervention was ineffective and describe lessons learned. Methods Qualitative data collection was undertaken to lend insight into quantitative results from a trial in which 105 health facilities were randomized to three arms: (1) twice-daily text-message reminders to HWs, including clinicians and drug dispensers, on case management of malaria; (2) twice-daily text-message reminders to HWs on case management of malaria, pneumonia and diarrhoea; and, (3) a control arm. In-depth interviews were conducted with 50 HWs in the intervention arms across seven districts. HWs were asked about acceptability and feasibility of the text-messaging intervention and its perceived impact on recommended case management. The interviews were recorded, transcribed and translated into English for a thematic and framework analysis. Nvivo 11 software was used for data management and analysis. Results A total of 50 HWs were interviewed at 22 facilities. HWs expressed high acceptance of text-message reminders and appreciated messages as job aids and practical reference material for their day-to-day work. However, HWs said that health systems barriers, including very high outpatient workload, commodity stock-outs, and lack of supportive supervision and financial incentives demotivated them, limited their ability to act on messages and therefore adherence to case management guidelines. Drug dispensers were more likely than clinicians to report usage of text-message reminders. Despite these challenges, nearly all HWs expressed a desire for a longer duration of the SMS intervention. Conclusions Text-message reminders to HWs can provide a platform to improve understanding of treatment guidelines and case management decision-making skills, but might not improve actual adherence to guidelines. More interaction, for example through targeted supervision or two-way technology communication, might be an essential intervention component to help address structural barriers and facilitate improved clinical practice.
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Affiliation(s)
- Blessings N Kaunda-Khangamwa
- Malaria Alert Centre (MAC), Communicable Disease Action Centre, University of Malawi College of Medicine, Blantyre, Malawi.,School of Public Health, The University of Witwatersrand, Johannesburg, South Africa
| | - Laura C Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Austin Gumbo
- National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi
| | - Dubulao Moyo
- Integrated Management of Childhood Diseases Program, Ministry of Health, Lilongwe, Malawi
| | - Humphreys Nsona
- Integrated Management of Childhood Diseases Program, Ministry of Health, Lilongwe, Malawi
| | - Peter Troell
- President's Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Dejan Zurovac
- KEMRI-Wellcome Trust-Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Don Mathanga
- Malaria Alert Centre (MAC), Communicable Disease Action Centre, University of Malawi College of Medicine, Blantyre, Malawi
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Berhe DF, Taxis K, Haaijer‐Ruskamp FM, Mol PGM. Healthcare professionals' level of medication knowledge in Africa: a systematic review. Br J Clin Pharmacol 2018; 84:2729-2746. [PMID: 30171617 PMCID: PMC6256006 DOI: 10.1111/bcp.13746] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 07/14/2018] [Accepted: 08/17/2018] [Indexed: 01/21/2023] Open
Abstract
AIMS Understanding how much healthcare professionals (HCPs) know about medication can help in devising strategies to improve rational medication use. This study aimed to synthesize information on the level of medication knowledge of HCPs in Africa. METHOD We performed a systematic literature study in Embase and PubMed. We included original studies quantifying HCPs' medication knowledge, published between 2012 and 2016. We extracted disease focus, country, number and type of HCPs included and all medication-related knowledge questions and scored the quality of papers. The outcome measure was the percentage of HCPs who correctly answered medication knowledge questions. RESULTS We identified 64 studies from 12 African countries, comprising 13 911 HCPs, mostly nurses/midwifes and physicians. We extracted 306 medication-related knowledge questions, and only 52% (SD 28) of HCPs correctly answered them. Knowledge questions were mainly about medication prescribed for communicable diseases (70%), followed by non-communicable diseases (11%), and family planning/gynaecology (10%). Most papers concluded that there was a considerable medication knowledge gap among HCPs. CONCLUSION We found a low level of medication knowledge across different disease areas, countries and HCPs. This underlines the continuous need to strengthen the undergraduate and postgraduate education in (clinical) pharmacology and therapeutics in Africa.
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Affiliation(s)
- Derbew Fikadu Berhe
- Department of Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Center GroningenThe Netherlands
- School of Pharmacy, College of Health SciencesMekelle UniversityMekelleEthiopia
| | - Katja Taxis
- Department of Pharmacy, Unit Pharmacotherapy, ‐epidemiology and ‐economicsUniversity of GroningenGroningenThe Netherlands
| | - Flora M. Haaijer‐Ruskamp
- Department of Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Center GroningenThe Netherlands
| | - Peter G. M. Mol
- Department of Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Center GroningenThe Netherlands
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Banek K, Webb EL, Smith SJ, Chandramohan D, Staedke SG. Adherence to treatment with artemether-lumefantrine or amodiaquine-artesunate for uncomplicated malaria in children in Sierra Leone: a randomized trial. Malar J 2018; 17:222. [PMID: 29866192 PMCID: PMC5987409 DOI: 10.1186/s12936-018-2370-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/28/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Prompt, effective treatment of confirmed malaria cases with artemisinin-based combination therapy (ACT) is a cornerstone of malaria control. Maximizing adherence to ACT medicines is key to ensuring treatment effectiveness. METHODS This open-label, randomized trial evaluated caregiver adherence to co-formulated artemether-lumefantrine (AL) and fixed-dose amodiaquine-artesunate (AQAS) in Sierra Leone. Children aged 6-59 months diagnosed with malaria were recruited from two public clinics, randomized to receive AL or AQAS, and visited at home the day after completing treatment. Analyses were stratified by site, due to differences in participant characteristics and outcomes. RESULTS Of the 784 randomized children, 680 (85.6%) were included in the final per-protocol analysis (340 AL, 340 AQAS). Definite adherence (self-reported adherence plus empty package) was higher for AL than AQAS at both sites (Site 1: 79.4% AL vs 63.4% AQAS, odds ratio [OR] 2.16, compared to probable adherence plus probable or definite non-adherence, 95% confidence interval [CI] 1.34-3.49; p = 0.001; Site 2: 52.1% AL vs 37.5% AQAS, OR 1.53, 95% CI 1.00-2.33, p = 0.049). However, self-reported adherence (ignoring drug package inspection) was higher for both regimens at both sites and there was no strong evidence of variation by treatment (Site 1: 96.6% AL vs 95.9% AQAS, OR 1.19, 95% CI 0.39-3.63, p = 0.753; Site 2: 91.5% AL vs 96.4% AQAS, OR 0.40, 95% CI 0.15-1.07, p = 0.067). In Site 2, correct treatment (correct dose + timing + duration) was lower for AL than AQAS (75.8% vs 88.1%, OR 0.42, 95% CI 0.23-0.76, p = 0.004). In both sites, more caregivers in the AQAS arm reported adverse events (Site 1: 3.4% AL vs 15.7% AQAS, p < 0.001; Site 2: 15.2% AL vs 24.4% AQAS, p = 0.039). CONCLUSIONS Self-reported adherence was high for both AL and AQAS, but varied by site. These results suggest that each regimen has potential disadvantages that might affect adherence; AL was less likely to be taken correctly at one site, but was better tolerated than AQAS at both sites. Measuring adherence to anti-malarials remains challenging, but important. Future research should focus on comparative studies of new drug regimens, and improving the methodology of measuring adherence. TRIAL REGISTRATION Clinicaltrials.gov, NCT01967472. Retrospectively registered 18 October 2013, https://clinicaltrials.gov/ct2/show/NCT01967472.
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Affiliation(s)
- Kristin Banek
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Emily L Webb
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Samuel Juana Smith
- National Malaria Control Programme, Ministry of Health and Sanitation-Sierra Leone, Freetown, Sierra Leone
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Abstract
This systematic review describes mHealth interventions directed at healthcare workers in low-resource settings from the PubMed database from March 2009 to May 2015. Thirty-one articles were selected for final review. Four categories emerged from the reviewed articles: data collection during patient visits, communication between health workers and patients, communication between health workers, and public health surveillance. Most studies used a combination of quantitative and qualitative methods to assess acceptability of use, barriers to use, changes in healthcare delivery, and improved health outcomes. Few papers included theory explicitly to guide development and evaluation of their mHealth programs. Overall, evidence indicated that mobile technology tools, such as smartphones and tablets, substantially benefit healthcare workers, their patients, and healthcare delivery. Limitations to mHealth tools included insufficient program use and sustainability, unreliable Internet and electricity, and security issues. Despite these limitations, this systematic review demonstrates the utility of using mHealth in low-resource settings and the potential for widespread health system improvements using technology.
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Ndounga Diakou LA, Ntoumi F, Ravaud P, Boutron I. Published randomized trials performed in Sub-Saharan Africa focus on high-burden diseases but are frequently funded and led by high-income countries. J Clin Epidemiol 2017; 82:29-36.e6. [DOI: 10.1016/j.jclinepi.2016.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/10/2016] [Accepted: 10/26/2016] [Indexed: 01/05/2023]
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Talisuna AO, Oburu A, Githinji S, Malinga J, Amboko B, Bejon P, Jones C, Snow RW, Zurovac D. Efficacy of text-message reminders on paediatric malaria treatment adherence and their post-treatment return to health facilities in Kenya: a randomized controlled trial. Malar J 2017; 16:46. [PMID: 28122622 PMCID: PMC5267364 DOI: 10.1186/s12936-017-1702-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Short Message Service (SMS) reminders have been suggested as a potential intervention for improving adherence to medications and health facility attendance. METHODS An open-label, randomized, controlled trial to test the efficacy of automated SMS reminders in improving adherence to artemether-lumefantrine (AL) and post-treatment attendance in comparison with standard care was conducted at four health facilities in western Kenya. Children below five years of age with uncomplicated malaria were randomized to intervention (SMS reminders) or control groups. Within each study group they were further randomized to three categories, which determined the timing of home visits to measure adherence to complete AL course and to individual AL doses. A sub-set of caregivers was advised to return to the facility on day 3 and all were advised to return after 28 days. The primary outcomes were adherence to medication and return on day 3. The primary analysis was by intention-to-treat. RESULTS Between 9 June, 2014 and 26 February, 2016, 1677 children were enrolled. Of 562 children visited at home on day 3, all AL doses were completed for 97.6% (282/289) of children in the control and 97.8% (267/273) in the intervention group (OR = 1.10; 95% CI = 0.37-3.33; p = 0.860). When correct timing in taking each dose was considered a criteria for adherence, 72.3% (209/289) were adherent in the control and 69.2% (189/273) in the intervention group (OR = 0.82; 95% CI = 0.56-1.19; p = 0.302). Sending SMS reminders significantly increased odds of children returning to the facility on day 3 (81.4 vs 74.0%; OR = 1.55; 95% CI = 1.15-2.08; p = 0.004) and on day 28 (63.4 vs 52.5%; OR = 1.58; 95% CI = 1.30-1.92; p < 0.001). CONCLUSIONS In this efficacy trial, SMS reminders increased post-treatment return to the health facility, but had no effect on AL adherence which was high in both control and intervention groups. Further effectiveness studies under the real world conditions are needed to determine the optimum role of SMS reminders. Trial registration ISRCTN39512726.
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Affiliation(s)
- Ambrose O. Talisuna
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Amos Oburu
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
| | | | | | | | - Philip Bejon
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Caroline Jones
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert W. Snow
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Dejan Zurovac
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Zhou H, Sun S, Luo R, Sylvia S, Yue A, Shi Y, Zhang L, Medina A, Rozelle S. Impact of Text Message Reminders on Caregivers' Adherence to a Home Fortification Program Against Child Anemia in Rural Western China: A Cluster-Randomized Controlled Trial. Am J Public Health 2016; 106:1256-62. [PMID: 27077354 DOI: 10.2105/ajph.2016.303140] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To test whether text message reminders sent to caregivers improve the effectiveness of a home micronutrient fortification program in western China. METHODS We carried out a cluster-randomized controlled trial in 351 villages (clusters) in Shaanxi Province in 2013 and 2014, enrolling children aged 6 to 12 months. We randomly assigned each village to 1 of 3 groups: free delivery group, text messaging group, or control group. We collected information on compliance with treatments and hemoglobin concentrations from all children at baseline and 6-month follow-up. We estimated the intent-to-treat effects on compliance and child anemia using a logistic regression model. RESULTS There were 1393 eligible children. We found that assignment to the text messaging group led to an increase in full compliance (marginal effect = 0.10; 95% confidence interval [CI] = 0.03, 0.16) compared with the free delivery group and decrease in the rate of anemia at end line relative to the control group (marginal effect = -0.07; 95% CI = -0.12, -0.01), but not relative to the free delivery group (marginal effect = -0.03; 95% CI = -0.09, 0.03). CONCLUSIONS Text messages improved compliance of caregivers to a home fortification program and children's nutrition.
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Affiliation(s)
- Huan Zhou
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Shuai Sun
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Renfu Luo
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Sean Sylvia
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Ai Yue
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Yaojiang Shi
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Linxiu Zhang
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Alexis Medina
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
| | - Scott Rozelle
- Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA
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Saran I, Yavuz E, Kasozi H, Cohen J. Can Rapid Diagnostic Testing for Malaria Increase Adherence to Artemether-Lumefantrine?: A Randomized Controlled Trial in Uganda. Am J Trop Med Hyg 2016; 94:857-67. [PMID: 26928828 DOI: 10.4269/ajtmh.15-0420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 11/06/2015] [Indexed: 11/07/2022] Open
Abstract
Most patients with suspected malaria do not receive diagnostic confirmation before beginning antimalarial treatment. We investigated the extent to which uncertainty about malaria diagnosis contributes to patient nonadherence to artemether-lumefantrine (AL) treatment through a randomized controlled trial in central Uganda. Among 1,525 patients purchasing a course of AL at private drug shops, we randomly offered 37.6% a free malaria rapid diagnostic test (RDT) and then assessed adherence through home visits 3 days later. Of these subjects, 68.4% tested positive for malaria and 65.8% adhered overall. Patients who tested positive did not have significantly higher odds of adherence than those who were not offered the test (adjusted odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.734-1.57,P= 0.719). Patients who received a positive malaria test had 0.488 fewer pills remaining than those not offered the test (95% CI: -1.02 to 0.043,P= 0.072). We found that patients who felt relatively healthy by the second day of treatment had lower odds of completing treatment (adjusted OR: 0.532, 95% CI: 0.394-0.719,P< 0.001). Our results suggest that diagnostic testing may not improve artemisinin-based combination therapy adherence unless efforts are made to persuade patients to continue taking the full course of drugs even if symptoms have resolved.
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Affiliation(s)
- Indrani Saran
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Innovations for Poverty Action, Kampala, Uganda
| | - Elif Yavuz
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Innovations for Poverty Action, Kampala, Uganda
| | - Howard Kasozi
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Innovations for Poverty Action, Kampala, Uganda
| | - Jessica Cohen
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Innovations for Poverty Action, Kampala, Uganda
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15
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Riley C, Dellicour S, Ouma P, Kioko U, ter Kuile FO, Omar A, Kariuki S, Buff AM, Desai M, Gutman J. Knowledge and Adherence to the National Guidelines for Malaria Case Management in Pregnancy among Healthcare Providers and Drug Outlet Dispensers in Rural, Western Kenya. PLoS One 2016; 11:e0145616. [PMID: 26789638 PMCID: PMC4720358 DOI: 10.1371/journal.pone.0145616] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 12/07/2015] [Indexed: 02/07/2023] Open
Abstract
Background Although prompt, effective treatment is a cornerstone of malaria control, information on provider adherence to malaria in pregnancy (MIP) treatment guidelines is limited. Incorrect or sub-optimal treatment can adversely affect the mother and fetus. This study assessed provider knowledge of and adherence to national case management guidelines for uncomplicated MIP. Methods We conducted a cross-sectional study from September to November 2013, in 51 health facilities (HF) and a randomly-selected sample of 39 drug outlets (DO) in the KEMRI/CDC Health and Demographic Surveillance System area in western Kenya. Provider knowledge of national treatment guidelines was assessed with standardized questionnaires. Correct practice required adequate diagnosis, pregnancy assessment, and treatment with correct drug and dosage. In HF, we conducted exit interviews in all women of childbearing age assessed for fever. In DO, simulated clients posing as first trimester pregnant women or as relatives of third trimester pregnant women collected standardized information. Results Correct MIP case management knowledge and practice were observed in 45% and 31% of HF and 0% and 3% of DO encounters, respectively. The correct drug and dosage for pregnancy trimester was prescribed in 62% of HF and 42% of DO encounters; correct prescription occurred less often in first than in second/ third trimesters (HF: 24% vs. 65%, p<0.01; DO: 0% vs. 40%, p<0.01). Sulfadoxine-pyrimethamine, which is not recommended for malaria treatment, was prescribed in 3% of HF and 18% of DO encounters. Exposure to artemether-lumefantrine in first trimester, which is contraindicated, occurred in 29% and 49% of HF and DO encounters, respectively. Conclusion This study highlights knowledge inadequacies and incorrect prescribing practices in the treatment of MIP. Particularly concerning is the prescription of contraindicated medications in the first trimester. These issues should be addressed through comprehensive trainings and increased supportive supervision. Additional innovative means to improve care should be explored.
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Affiliation(s)
- Christina Riley
- Rollins School of Public Health, Emory University, Atlanta, United States of America
- * E-mail: (JG); (CR)
| | | | - Peter Ouma
- KEMRI, Centre for Global Health Research, Kisumu, Kenya
| | - Urbanus Kioko
- Malaria Control Unit, Ministry of Health, Nairobi, Kenya
| | | | - Ahmeddin Omar
- Malaria Control Unit, Ministry of Health, Nairobi, Kenya
| | - Simon Kariuki
- KEMRI, Centre for Global Health Research, Kisumu, Kenya
| | - Ann M. Buff
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, United States of America
- US President’s Malaria Initiative, Nairobi, Kenya
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, United States of America
- Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Julie Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, United States of America
- * E-mail: (JG); (CR)
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Githinji S, Jones C, Malinga J, Snow RW, Talisuna A, Zurovac D. Development of a text-messaging intervention to improve treatment adherence and post-treatment review of children with uncomplicated malaria in western Kenya. Malar J 2015; 14:320. [PMID: 26283229 PMCID: PMC4539928 DOI: 10.1186/s12936-015-0825-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/28/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patients' low adherence to artemisinin-based combination therapy has been reported in areas of Kenya bordering the Lake Victoria region, where the burden of malaria remains high. A randomized controlled trial is underway to determine the efficacy of short message service (SMS) text reminders on adherence to artemether-lumefantrine and post-treatment review of children under the age of five. This paper reports on the iterative process of intervention and delivery system development. METHODS An intervention development workshop involving the research team and other stakeholders was held to determine the content of the text messages. Three focus group discussions were conducted to test caregivers' understanding of the messages developed during the workshop. The tested messages were refined and incorporated into an automated SMS distribution system and piloted with 20 caregivers drawn from facilities neighbouring the study sites. The automated SMS distribution system was repeatedly refined following the pilot and implemented at the start of the trial. RESULTS The content of SMS messages underwent major revisions following the focus group discussions. Technical terms and abbreviations were replaced with simplified general terms. Message sign-off was modified to reflect the name of health facility, removing references to health workers. Day 3 post-treatment review visit reminder was modified to state the purpose of the visit while wording 'day 28' was added to the last post-treatment review visit reminder to help the caregiver recall the appointment date. The unscheduled visit prompt was modified to reflect flexibility and practicality of taking the child back to the facility if unwell. Reception of SMS reminders during the pilot was low with only 169/240 (70%) of scheduled messages delivered to the caregivers. The automated distribution system underwent major refinement and repeated testing following the pilot until effective delivery of all scheduled messages was achieved and sustained over a period of 3 months. CONCLUSIONS Text message interventions should be carefully developed, tested and refined before implementation to ensure they are written in the most appropriate way for their target population. SMS distribution systems should be rigorously tested to ensure efficient delivery of the messages before they are deployed.
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Affiliation(s)
- Sophie Githinji
- Department of Public Health Research, KEMRI-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya.
| | - Caroline Jones
- Department of Public Health Research, KEMRI-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya.
- Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Josephine Malinga
- Department of Public Health Research, KEMRI-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya.
| | - Robert W Snow
- Department of Public Health Research, KEMRI-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya.
- Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Ambrose Talisuna
- Department of Public Health Research, KEMRI-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya.
- Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Dejan Zurovac
- Department of Public Health Research, KEMRI-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya.
- Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
- Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA.
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Bruxvoort K, Festo C, Cairns M, Kalolella A, Mayaya F, Kachur SP, Schellenberg D, Goodman C. Measuring Patient Adherence to Malaria Treatment: A Comparison of Results from Self-Report and a Customised Electronic Monitoring Device. PLoS One 2015. [PMID: 26214848 PMCID: PMC4516331 DOI: 10.1371/journal.pone.0134275] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Self-report is the most common and feasible method for assessing patient adherence to medication, but can be prone to recall bias and social desirability bias. Most studies assessing adherence to artemisinin-based combination therapies (ACTs) have relied on self-report. In this study, we use a novel customised electronic monitoring device--termed smart blister packs--to examine the validity of self-reported adherence to artemether-lumefantrine (AL) in southern Tanzania. METHODS Smart blister packs were designed to look identical to locally available AL blister packs and to record the date and time each tablet was removed from packaging. Patients obtaining AL at randomly selected health facilities and drug stores were followed up at home three days later and interviewed about each dose of AL taken. Blister packs were requested for pill count and extraction of smart blister pack data. RESULTS Data on adherence from both self-report verified by pill count and smart blister packs were available for 696 of 1,204 patients. There was no difference between methods in the proportion of patients assessed to have completed treatment (64% and 67%, respectively). However, the percentage taking the correct number of pills for each dose at the correct times (timely completion) was higher by self-report than smart blister packs (37% vs. 24%; p<0.0001). By smart blister packs, 64% of patients completing treatment did not take the correct number of pills per dose or did not take each dose at the correct time interval. CONCLUSION Smart blister packs resulted in lower estimates of timely completion of AL and may be less prone to recall and social desirability bias. They may be useful when data on patterns of adherence are desirable to evaluate treatment outcomes. Improved methods of collecting self-reported data are needed to minimise bias and maximise comparability between studies.
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Affiliation(s)
- Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Impact Evaluation Thematic Group, Ifakara Health Institute, Dar es Salaam, Tanzania
- * E-mail:
| | - Charles Festo
- Impact Evaluation Thematic Group, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Matthew Cairns
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Frank Mayaya
- Impact Evaluation Thematic Group, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - S. Patrick Kachur
- Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, United States of America
| | - David Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Bruxvoort K, Kalolella A, Cairns M, Festo C, Kenani M, Lyaruu P, Kachur SP, Schellenberg D, Goodman C. Are Tanzanian patients attending public facilities or private retailers more likely to adhere to artemisinin-based combination therapy? Malar J 2015; 14:87. [PMID: 25889767 PMCID: PMC4340668 DOI: 10.1186/s12936-015-0602-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 02/02/2015] [Indexed: 11/30/2022] Open
Abstract
Background Artemisinin combination therapy (ACT) is first-line treatment for malaria in most endemic countries and is increasingly available in the private sector. Most studies on ACT adherence have been conducted in the public sector, with minimal data from private retailers. Methods Parallel studies were conducted in Tanzania, in which patients obtaining artemether-lumefantrine (AL) at 40 randomly selected public health facilities and 37 accredited drug dispensing outlets (ADDOs) were visited at home and questioned about doses taken. The effect of sector on adherence, controlling for potential confounders was assessed using logistic regression with a random effect for outlet. Results Of 572 health facility patients and 450 ADDO patients, 74.5% (95% CI: 69.8, 78.8) and 69.8% (95% CI: 64.6, 74.5), respectively, completed treatment and 46.0% (95% CI: 40.9, 51.2) and 34.8% (95% CI: 30.1, 39.8) took each dose at the correct time (‘timely completion’). ADDO patients were wealthier, more educated, older, sought care later in the day, and were less likely to test positive for malaria than health facility patients. Controlling for patient characteristics, the adjusted odds of completed treatment and of timely completion for ADDO patients were 0.65 (95% CI: 0.43, 1.00) and 0.69 (95% CI: 0.47, 1.01) times that of health facility patients. Higher socio-economic status was associated with both adherence measures. Higher education was associated with completed treatment (adjusted OR = 1.68, 95% CI: 1.20, 2.36); obtaining AL in the evening was associated with timely completion (adjusted OR = 0.35, 95% CI: 0.19, 0.64). Factors associated with adherence in each sector were examined separately. In both sectors, recalling correct instructions was positively associated with both adherence measures. In health facility patients, but not ADDO patients, taking the first dose of AL at the outlet was associated with timely completion (adjusted OR = 2.11, 95% CI: 1.46, 3.04). Conclusion When controlling for patient characteristics, there was some evidence that the adjusted odds of adherence for ADDO patients was lower than that for public health facility patients. Better understanding is needed of which patient care aspects are most important for adherence, including the role of effective provision of advice. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0602-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Matthew Cairns
- London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Mitya Kenani
- Ifakara Health Institute, Dar es Salaam, Tanzania.
| | - Peter Lyaruu
- Ifakara Health Institute, Dar es Salaam, Tanzania.
| | - S Patrick Kachur
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, USA.
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Bruxvoort K, Goodman C, Kachur SP, Schellenberg D. How patients take malaria treatment: a systematic review of the literature on adherence to antimalarial drugs. PLoS One 2014; 9:e84555. [PMID: 24465418 PMCID: PMC3896377 DOI: 10.1371/journal.pone.0084555] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 11/16/2013] [Indexed: 11/18/2022] Open
Abstract
Background High levels of patient adherence to antimalarial treatment are important in ensuring drug effectiveness. To achieve this goal, it is important to understand levels of patient adherence, and the range of study designs and methodological challenges involved in measuring adherence and interpreting results. Since antimalarial adherence was reviewed in 2004, there has been a major expansion in the use of artemisinin-based combination therapies (ACTs) in the public sector, as well as initiatives to make them more widely accessible through community health workers and private retailers. These changes and the large number of recent adherence studies raise the need for an updated review on this topic. Objective We conducted a systematic review of studies reporting quantitative results on patient adherence to antimalarials obtained for treatment. Results The 55 studies identified reported extensive variation in patient adherence to antimalarials, with many studies reporting very high adherence (90–100%) and others finding adherence of less than 50%. We identified five overarching approaches to assessing adherence based on the definition of adherence and the methods used to measure it. Overall, there was no clear pattern in adherence results by approach. However, adherence tended to be higher among studies where informed consent was collected at the time of obtaining the drug, where patient consultations were directly observed by research staff, and where a diagnostic test was obtained. Conclusion Variations in reported adherence may reflect factors related to patient characteristics and the nature of their consultation with the provider, as well as methodological variations such as interaction between the research team and patients before and during the treatment. Future studies can benefit from an awareness of the impact of study procedures on adherence outcomes, and the identification of improved measurement methods less dependent on self-report.
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Affiliation(s)
- Katia Bruxvoort
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Ifakara Health Institute, Dar es Salaam, Tanzania
- * E-mail:
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S. Patrick Kachur
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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