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Adhikari B, Tripura R, Peto TJ, Callery JJ, von Seidlein L, Dysoley L, Dondorp AM. Village malaria workers for the community-based management of vivax malaria. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 9:100128. [PMID: 37383038 PMCID: PMC10306055 DOI: 10.1016/j.lansea.2022.100128] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/23/2022] [Accepted: 11/25/2022] [Indexed: 06/30/2023]
Abstract
In Cambodia, malaria cases are on a trajectory towards the goal of malaria elimination by 2025. Vivax malaria is difficult to eliminate because of hypnozoites that can cause relapse. Primaquine, an 8-aminoquinoline, clears hypnozoites but requires testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency. Routine primaquine treatment of vivax malaria has recently been implemented in Cambodia in which Village Malaria Workers (VMWs) diagnose vivax malaria by rapid diagnostic test and refer patients to health centres for G6PD testing and further treatment. Patients are referred back to the VMWs for monitoring adverse symptoms and treatment adherence. This article explores how VMWs' roles might be optimized for the community-based management of vivax malaria. With sufficient training and supervision, the role of VMWs might be expanded to include G6PD testing, making referral to the health centre superfluous. Community-based management of vivax malaria could increase the coverage of radical cure and accelerate vivax malaria elimination.
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Affiliation(s)
- Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Rupam Tripura
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Thomas J. Peto
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - James J. Callery
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Lek Dysoley
- C.N.M National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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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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Cheng B, Htoo SN, Mhote NPP, Davison CM. Association between biological sex and insecticide-treated net use among household members in ethnic minority and internally displaced populations in eastern Myanmar. PLoS One 2021; 16:e0252896. [PMID: 34143807 PMCID: PMC8213136 DOI: 10.1371/journal.pone.0252896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/25/2021] [Indexed: 11/25/2022] Open
Abstract
Malaria prevalence in Myanmar is highest among remote and ethnic minority populations living near forest fringes along the country’s international borders. Insecticide-treated nets (ITNs) are a key intervention used to prevent malaria transmission, but insufficient ITN availability and low use can hinder effectiveness. This study assessed age and sex disparities in ITN possession, access, and use among household members of ethnic minority and internally displaced populations in eastern Myanmar. Cross-sectional data from the 2013 Eastern Burma Retrospective Mortality Survey were used to describe prevalence of ITN possession, access, and use. The association between a household member’s biological sex and their ITN use was assessed using multilevel log binomial regression. Age and household ITN supply were tested as potential effect modifiers. Of 37927 household members, 89.8% (95% CI: 89.5, 90.1) of people lived in households with at least one ITN. Approximately half belonged to households with sufficient ITN supply and used an ITN. Pregnant women and children under five had the highest proportion of ITN use regardless of sufficient household ITN status. Female adults aged 15 to 49 years old (Risk ratio or RR: 1.4, 95% CI: 1.29, 1.52) were more likely to use ITNs. This relationship did not differ by sufficient household ITN status. The findings suggest that among ethnic minority populations in areas where ITN use is indicated, many households do not have adequate ITN supply, and many individuals are not using ITNs. Children under five and pregnant women appear to be prioritized for ITN use and overall, women are slightly more likely to use ITNs than men. This study’s findings can support efforts ensuring that all household members belonging to ethnic minority and displaced populations in Eastern Myanmar benefit from sufficient ITN access and use for malaria prevention.
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Affiliation(s)
- Breagh Cheng
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | | | | | - Colleen M. Davison
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
- * E-mail:
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Win Han Oo, Hoban E, Gold L, Kyu Kyu Than, Thazin La, Aung Thi, Fowkes FJI. Optimizing Myanmar's community-delivered malaria volunteer model: a qualitative study of stakeholders' perspectives. Malar J 2021; 20:79. [PMID: 33557847 PMCID: PMC7871594 DOI: 10.1186/s12936-021-03612-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/28/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In parallel with the change of malaria policy from control to elimination and declines in the malaria burden in Greater Mekong Sub-region, the motivation and social role of malaria volunteers has declined. To address this public health problem, in Myanmar, the role and responsibilities of malaria volunteers have been transformed into integrated community malaria volunteers (ICMV), that includes the integration of activities for five additional diseases (dengue, lymphatic filariasis, tuberculosis, HIV/AIDS and leprosy) into their current activities. However, this transformation was not evidence-based and did not consider inputs of different stakeholders. Therefore, qualitative stakeholder consultations were performed to optimize future malaria volunteer models in Myanmar. METHODS Semi-structured interviews were conducted with key health stakeholders from the Myanmar Ministry of Health and Sports (MoHS) and malaria implementing partners to obtain their perspectives on community-delivered malaria models. A qualitative descriptive approach was used to explore the experiences of the stakeholders in policymaking and programme implementation. Interview topic guides were used during the interviews and inductive thematic data analysis was performed. RESULTS While ICMVs successfully provided malaria services in the community, the stakeholders considered the ICMV model as not optimal and suggested that many aspects needed to be improved including better training, supervision, support, and basic health staff's recognition for ICMVs. Stakeholders believe that the upgraded ICMV model could contribute significantly to achieving malaria elimination and universal health care in Myanmar. DISCUSSION AND CONCLUSION In the context of high community demand for non-malaria treatment services from volunteers, the integrated volunteer service package must be developed carefully in order to make it effective in malaria elimination programme and to contribute in Myanmar's pathway to universal health coverage (UHC), but without harming the community. An evidenced-based, community-delivered and preferred model, that is also accepted by the MoHS, is yet to be developed to effectively contribute to achieving malaria elimination and UHC goals in Myanmar by 2030.
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Affiliation(s)
- Win Han Oo
- School of Health and Social Development, Faculty of Health, Deakin University, VIC, Australia. .,Disease Elimination Program, Burnet Institute, VIC, Australia.
| | - Elizabeth Hoban
- School of Health and Social Development, Faculty of Health, Deakin University, VIC, Australia
| | - Lisa Gold
- School of Health and Social Development, Faculty of Health, Deakin University, VIC, Australia
| | - Kyu Kyu Than
- Disease Elimination Program, Burnet Institute, VIC, Australia
| | - Thazin La
- Disease Elimination Program, Burnet Institute, VIC, Australia
| | - Aung Thi
- Department of Public Health, Myanmar Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Freya J I Fowkes
- Disease Elimination Program, Burnet Institute, VIC, Australia.,Melbourne School of Population and Global Health, University of Melbourne, VIC, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia
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Performance of Malaria Volunteers regarding Malaria Control Activities in Southeastern Myanmar: A Study in the Areas under Coverage of an Ethnic Health Organization. J Trop Med 2021; 2021:6642260. [PMID: 33510797 PMCID: PMC7822669 DOI: 10.1155/2021/6642260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/17/2022] Open
Abstract
Malaria volunteers (MVs) play an essential role in resolving malaria problems by delivering greater access to diagnosis and treatment services, mainly for the underserved community residing in hard-to-reach rural areas. The Karen Department of Health and Welfare (KDHW) has implemented community-based malaria control activities among the ethnic minorities in southeastern Myanmar by promoting the roles of MVs. This study aimed to explore the factors influencing the performance of MVs regarding malaria control activities in the area. From July to August 2019, a cross-sectional study was conducted in 12 townships of southeastern Myanmar under the umbrella of the KDHW malaria project. A total of 140 MVs were employed as study participants. Data were collected through face-to-face interviews using a structured questionnaire. For data analyses, descriptive statistics, chi-squared tests, and logistics regression models were applied. More than half of the MVs perceived a good level of performance on malaria control activities. A higher level of performance has been observed among the MVs who had another job (AOR: 1.9, 95% CI: 1.2–3.9), those experienced in health-related fields (AOR: 1.9, 95% CI: 1.4–4.9), who received good community support (AOR: 2.1, 95% CI: 1.3–10.9), who were volunteers beyond three years (AOR: 4.0, 95% CI: 2.8–9.2), and whose family income totaled over 500,000 MMK (AOR: 2.8, 95% CI: 1.6–4.2). The results mentioned the characteristics which should be prioritized in recruiting MVs. MV network and their workforce need to be nurtured by encouraging community support. For performance sustainability, attractive incentive schemes or a salary should be subsidized in support of their livelihoods.
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Win Han Oo, Hoban E, Gold L, Kyu Kyu Than, Thazin La, Aung Thi, Fowkes FJI. Community demand for comprehensive primary health care from malaria volunteers in South-East Myanmar: a qualitative study. Malar J 2021; 20:19. [PMID: 33407489 PMCID: PMC7789746 DOI: 10.1186/s12936-020-03555-4] [Citation(s) in RCA: 6] [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: 07/28/2020] [Accepted: 12/16/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Malaria volunteers have contributed significantly to malaria control achieving a reduction of annual parasite incidence to pre-elimination levels in several townships across Myanmar. However, the volunteers' role is changing as Myanmar transitions from a malaria control to elimination programme and towards the goal of universal health coverage. The aim of the study is to explore the perspectives of community leaders, members and malaria volunteers in South-East Myanmar on community-delivered models to inform an optimal design that targets malaria elimination in the context of primary health care in Myanmar. METHODS Qualitative methods including focus group discussions (FGDs) with community members and current or ex-malaria volunteers, and participatory workshops with community leaders were conducted. All data collection tools were pilot tested with similar participants. The FGDs were stratified into male and female participants in consideration of diverse gender roles among the ethnic groups of Myanmar. Data saturation was the key cut-off point to cease recruitment of participants. Inductive thematic analysis was used. RESULTS Community members were willing to be tested for malaria because they were concerned about the consequences of malaria although they were aware that malaria prevalence is low in their villages. Malaria volunteers were the main service providers for malaria and other infectious diseases in the community. Apart from malaria, the community identified common health problems such as the flu (fever, sneezing and coughing), diarrhoea, skin infections and tuberculosis as priority diseases in this order. Incorporating preventive, and whenever possible curative, services for those diseases into the current malaria volunteer model was recommended. DISCUSSION AND CONCLUSION There was a gap between the communities' expectations of health services and the health services currently being delivered by volunteers in the community that highlights the need for reassessment and reform of the volunteer model in the changing context. An evidence-based, community preferred, pragmatic community-delivered integrated model should be constructed based on the context of malaria elimination and progressing towards universal health coverage in Myanmar.
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Affiliation(s)
- Win Han Oo
- School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, VIC, Australia.
- Disease Elimination Programme, Burnet Institute, Melbourne, VIC, Australia.
| | - Elizabeth Hoban
- School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, VIC, Australia
| | - Lisa Gold
- School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, VIC, Australia
| | - Kyu Kyu Than
- Disease Elimination Programme, Burnet Institute, Melbourne, VIC, Australia
| | - Thazin La
- Disease Elimination Programme, Burnet Institute, Melbourne, VIC, Australia
| | - Aung Thi
- Department of Public Health, Myanmar Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Freya J I Fowkes
- Disease Elimination Programme, Burnet Institute, Melbourne, VIC, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Win Han Oo, Gold L, Moore K, Agius PA, Fowkes FJI. The impact of community-delivered models of malaria control and elimination: a systematic review. Malar J 2019; 18:269. [PMID: 31387588 PMCID: PMC6683427 DOI: 10.1186/s12936-019-2900-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background Community-delivered models have been widely used to reduce the burden of malaria. This review aimed to explore different community-delivered models and their relative effectiveness in terms of coverage and malaria-metric outcomes in order to inform the design and implementation of Community Health Worker (CHW) programmes for malaria control and elimination. Methods A systematic review of studies investigating the impact of community-delivered models on coverage and malaria-metric (parasitaemia and hyperparasitaemia, malaria case and mortality, anaemia, and fever) outcomes compared to non- community-delivered models was undertaken by searching in five databases of published papers and grey literature databases. Data were extracted from studies meeting inclusion and quality criteria (assessed using relevant tools for the study design) by two independent authors. Meta-analyses were performed where there was sufficient homogeneity in effect and stratified by community-delivered models to assess the impact of each model on coverage and malaria-metric outcomes. Results 28 studies were included from 7042 records identified. The majority of studies (25/28) were performed in high transmission settings in Africa and there was heterogeneity in the type of, and interventions delivered as part of the community-delivered models. Compared to non- community-delivered models, community-delivered models increased coverage of actual bed net usage (Relative Risk (RR) = 1.64 95% CI 1.39, 1.95), intermittent preventive treatment in pregnancy (RR = 1.36 95% CI 1.29, 1.44) and appropriate and timely treatment of febrile children, and improved malaria-metric outcomes such as malaria mortality (RR = 0.58 95% CI 0.52, 0.65). However, the considerable heterogeneity was found in the impact of community-delivered models in reducing, parasitaemia and hyperparasitaemia prevalence, anaemia incidence, fever prevalence and malaria caseload. Statistical comparisons of different community-delivered models were not undertaken due to the heterogeneity of the included studies in terms of method and interventions provided. Conclusion Overall, the community-delivered model is effective in improving the coverage of malaria interventions and reducing malaria-associated mortality. The heterogeneity of the community-delivered models and their impact on malaria-metric indices suggests that evidence for context-specific solutions is required. In particular, community-delivered models for malaria elimination, integrated with services for other common primary health problems, are yet to be evaluated. Electronic supplementary material The online version of this article (10.1186/s12936-019-2900-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Win Han Oo
- School of Health and Social Development, Deakin University, 221 Burwood Hwy, Burwood, VIC, 3125, Australia. .,Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia.
| | - Lisa Gold
- School of Health and Social Development, Deakin University, 221 Burwood Hwy, Burwood, VIC, 3125, Australia
| | - Kerryn Moore
- Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie St, Carlton, Melbourne, VIC, 3053, Australia
| | - Paul A Agius
- Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Judith Lumley Centre, La Trobe University, Level 3, George Singer Building Bundoora, Melbourne, VIC, 3086, Australia
| | - Freya J I Fowkes
- Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie St, Carlton, Melbourne, VIC, 3053, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Dolovich L, Oliver D, Lamarche L, Thabane L, Valaitis R, Agarwal G, Carr T, Foster G, Griffith L, Javadi D, Kastner M, Mangin D, Papaioannou A, Ploeg J, Raina P, Richardson J, Risdon C, Santaguida P, Straus S, Price D. Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial. CMAJ 2019; 191:E491-E500. [PMID: 31061074 PMCID: PMC6509035 DOI: 10.1503/cmaj.181173] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) intervention was designed to improve primary care teamwork and promote optimal aging. We evaluated the effectiveness of Health TAPESTRY in attaining goals of older adults (e.g., physical activity, productivity, social connection, medical status) and other outcomes. METHODS We conducted a pragmatic randomized controlled trial between January and October 2015 in a primary care practice in Hamilton, Ontario. Older adults were randomized (1:1) to Health TAPESTRY (n = 158) or control (n = 154). Trained community volunteers gathered information on people's goals, needs and risks in their homes, using electronic forms. Interprofessional primary care teams reviewed summaries and addressed issues. Participants reported goal attainment (primary outcome), self-efficacy, quality of life, optimal aging, social support, empowerment, physical activity, falls, and access to and comprehensiveness of the health system. We determined use of health care resources through chart audit. RESULTS There were no differences between groups in goal attainment or many other patient-reported outcome and experience assessments at 6 months. More primary care visits took place in the intervention versus control group over 6 months (mean ± standard deviation [SD] 4.93 ± 3.86 v. 3.50 ± 3.53; difference of 1.52 [95% confidence interval (CI) 0.84 to 2.19]). The odds of having 1 or more hospital admission were lower for the intervention group (odds ratio [OR] 0.44 [95% CI 0.20 to 0.95]). INTERPRETATION Health TAPESTRY did not improve the primary outcome of goal attainment but showed signals of shifting care from reactive to active preventive care. Further evaluation will help in understanding effective components, costs and consequences of the intervention. Trial registration: ClinicalTrials.gov, no. NCT02283723.
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Affiliation(s)
- Lisa Dolovich
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont.
| | - Doug Oliver
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Larkin Lamarche
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Lehana Thabane
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Ruta Valaitis
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Gina Agarwal
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Tracey Carr
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Gary Foster
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Lauren Griffith
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Dena Javadi
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Monika Kastner
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Dee Mangin
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Alexandra Papaioannou
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Jenny Ploeg
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Parminder Raina
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Julie Richardson
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Cathy Risdon
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Pasqualina Santaguida
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - Sharon Straus
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
| | - David Price
- Departments of Family Medicine (Dolovich, Oliver, Lamarche, Agarwal, Carr, Javadi, Mangin, Risdon, Price), Medicine (Papaioannou), and Health Research Methods, Evidence and Impact (Thabane, Foster, Griffith, Raina, Santaguida, Papaioannou), McMaster Institute for Research on Aging (Raina), Schools of Rehabilitation Science (Richardson) and of Nursing (Valaitis, Ploeg), McMaster University; Hamilton Health Sciences (Price), Hamilton, Ont.; Leslie Dan Faculty of Pharmacy (Dolovich); University of Toronto; Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Straus), Toronto, Ont
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9
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McLean ARD, Wai HP, Thu AM, Khant ZS, Indrasuta C, Ashley EA, Kyaw TT, Day NPJ, Dondorp A, White NJ, Smithuis FM. Malaria elimination in remote communities requires integration of malaria control activities into general health care: an observational study and interrupted time series analysis in Myanmar. BMC Med 2018; 16:183. [PMID: 30343666 PMCID: PMC6196466 DOI: 10.1186/s12916-018-1172-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/11/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) can provide diagnosis and treatment of malaria in remote rural areas and are therefore key to the elimination of malaria. However, as incidence declines, uptake of their services could be compromised if they only treat malaria. METHODS We conducted a retrospective analysis of 571,286 malaria rapid diagnostic tests conducted between 2011 and 2016 by 1335 CHWs supported by Medical Action Myanmar. We assessed rates of decline in Plasmodium falciparum and Plasmodium vivax incidence and rapid diagnostic test (RDT) positivity rates using negative binomial mixed effects models. We investigated whether broadening the CHW remit to provide a basic health care (BHC) package was associated with a change in malaria blood examination rates. RESULTS Communities with CHWs providing malaria diagnosis and treatment experienced declines in P. falciparum and P. vivax malaria incidence of 70% (95% CI 66-73%) and 64% (59-68%) respectively each year of operation. RDT positivity rates declined similarly with declines of 70% (95% CI 66-73%) for P. falciparum and 65% (95% CI 61-69%) for P. vivax with each year of CHW operation. In four cohorts studied, adding a BHC package was associated with an immediate and sustained increase in blood examination rates (step-change rate ratios 2.3 (95% CI 2.0-2.6), 5.4 (95% CI 4.0-7.3), 1.7 (95% CI 1.4-2.1), and 1.1 (95% CI 1.0.1.3)). CONCLUSIONS CHWs have overseen dramatic declines in P. falciparum and P. vivax malaria in rural Myanmar. Expanding their remit to general health care has sustained community uptake of malaria services. In similar settings, expanding health services offered by CHWs beyond malaria testing and treatment can improve rural health care while ensuring continued progress towards the elimination of malaria.
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Affiliation(s)
- Alistair R D McLean
- Medical Action Myanmar, Yangon, Myanmar.,Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar
| | | | | | | | | | | | - Thar Tun Kyaw
- Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Arjen Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Frank M Smithuis
- Medical Action Myanmar, Yangon, Myanmar. .,Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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10
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Linn NYY, Tripathy JP, Maung TM, Saw KK, Maw LYW, Thapa B, Lin Z, Thi A. How are the village health volunteers deliver malaria testing and treatment services and what are the challenges they are facing? A mixed methods study in Myanmar. Trop Med Health 2018; 46:28. [PMID: 30123042 PMCID: PMC6090948 DOI: 10.1186/s41182-018-0110-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022] Open
Abstract
Background Village health volunteers (VHVs) play a key role in delivering community-based malaria care especially in the hard-to-reach areas in Myanmar. It is necessary to assess their performance and understand the challenges encountered by them for effective community management of malaria. This mixed methods study was conducted to (i) understand the cascade of malaria services (testing, diagnosis, referral, and treatment of malaria) provided by the VHVs under the National Malaria Control Programme (NMCP) in Myanmar in 2016 and compare with other health care providers and (ii) explore the challenges in the delivery of malaria services by VHVs. Methods A sequential mixed methods study was designed with a quantitative followed by a descriptive qualitative component. The quantitative study was a cohort design involving analysis of secondary data available from NMCP database whereas the qualitative part involved 16 focus group discussions (eight each with community and VHVs) and 14 key informant interviews with program stakeholders in four selected townships. Results Among 444,268 cases of undifferentiated fever identified by VHVs in 2016, 444,190 were tested using a rapid diagnostic test. Among those tested, 20,375 (4.6%) cases of malaria were diagnosed, of whom 16,910 (83.0%) received appropriate treatment, with 7323 (35.9%) receiving treatment within 24 h. Of all malaria cases, 296 (1.5%) were complicated, of whom 79 (26.7%) were referred to the higher facility. More than two thirds of all cases were falciparum malaria (13,970, 68.6%) followed by vivax (5619, 27.6%). Primaquine was given to 83.6% of all cases. VHVs managed 34.0% of all undifferentiated fever cases, 35.9% of all malaria cases, and identified 38.0% of all Plasmodium falciparum cases reported under NMCP. The key barriers identified are work-related (challenges in reporting, referral, management of malaria especially primaquine therapy, and lack of community support) and logistics related (challenges in transportation, financial constraints, time and shortage of drugs, and test kits). On the other hand, they also enjoy good community support and acceptance in most areas. Conclusion VHVs play an important role in malaria care in Myanmar, especially in the hard-to-reach areas. More programmatic support is needed in terms of logistics, transportation allowance, and supervision to improve their performance.
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Affiliation(s)
- Nay Yi Yi Linn
- Vector Borne Disease Control Program, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Jaya Prasad Tripathy
- 2International Union Against Tuberculosis and Lung Disease, The Union South East Asia Office, New Delhi, India.,3International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Thae Maung Maung
- 4Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Khine Khine Saw
- Vector Borne Disease Control Program, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | | | - Badri Thapa
- Malaria Unit, World Health Organization Country Office, Yangon, Myanmar
| | - Zaw Lin
- Vector Borne Disease Control Program, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Aung Thi
- Vector Borne Disease Control Program, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
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11
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Linn NYY, Kathirvel S, Das M, Thapa B, Rahman MM, Maung TM, Kyaw AMM, Thi A, Lin Z. Are village health volunteers as good as basic health staffs in providing malaria care? A country wide analysis from Myanmar, 2015. Malar J 2018; 17:242. [PMID: 29925375 PMCID: PMC6011412 DOI: 10.1186/s12936-018-2384-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 06/12/2018] [Indexed: 11/10/2022] Open
Abstract
Background Malaria is one of the major public health problems in Myanmar. Village health volunteers (VHV) are the key malaria diagnosis and treatment service provider at community level in addition to basic health staffs (BHS). This countrywide analysis aimed to assess and compare the accessibility to- and quality of malaria care (treatment initiation, treatment within 24 h and complete treatment delivery) between VHV and BHS in Myanmar. Methods This was a retrospective cohort study using record review of routinely collected programme data available in electronic format. All patients with undifferentiated fever screened and diagnosed for malaria in January–December 2015 by VHV and BHS under National Malaria Control Programme in Myanmar were included in the study. Unadjusted and adjusted prevalence ratios (aPR) were calculated to assess the effect of VHV/BHS on receipt of treatment by patients. Results Of 978,735 undifferentiated fever patients screened in 2015, 11.0% of patients were found malaria positive and the malaria positivity in VHV and BHS group were 11.1 and 10.9% respectively. Access to malaria care: higher proportion of children aged 5–14 years (21.8% vs 17.3%) and females (43.7% vs 41.8%) with fever were screened for malaria by VHV compared to BHS. However, the same for children aged < 5 years was 2.2% lower in VHV group compared to BHS. Quality of malaria care: the proportion of malaria cases that received treatment was 96.6 and 94.9; treatment initiation within 24 h of fever was 44.7 and 34.1; and, complete treatment delivery was 80.9 and 88.2, respectively, in VHV and BHS groups. After adjustment for potential confounders, patients with malaria provided care by VHV had 1.02 times higher chance of receiving treatment compared to BHS [aPR (95% confidence interval) 1.017 (1.015, 1.020)]. Conclusions The VHV were more accessible to children and women than BHS in providing malaria screening services. The malaria treatment services provided by VHV was as good as BHS. Further qualitative research to explore and address the challenges on initiation and delivering complete treatment by VHV including inventory assessment and cost-effectiveness studies on integration of VHV in routine health system are needed.
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Affiliation(s)
- Nay Yi Yi Linn
- National Malaria Control Programme, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar.
| | - Soundappan Kathirvel
- The International Union of Tuberculosis and Lung Diseases, Union South-East Asia Regional Office, New Delhi, India.,Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Badri Thapa
- World Health Organization Country Office for Myanmar, Yangon, Myanmar
| | | | - Thae Maung Maung
- Department of Medical Research, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Aye Mon Mon Kyaw
- National Malaria Control Programme, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Aung Thi
- National Malaria Control Programme, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Zaw Lin
- National Malaria Control Programme, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
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12
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Makuuchi R, Jere S, Hasejima N, Chigeda T, Gausi J. The correlation between malaria RDT (Paracheck pf.®) faint test bands and microscopy in the diagnosis of malaria in Malawi. BMC Infect Dis 2017; 17:317. [PMID: 28464837 PMCID: PMC5414284 DOI: 10.1186/s12879-017-2413-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 04/21/2017] [Indexed: 11/25/2022] Open
Abstract
Background Faint test bands of Paracheck Pf.® are interpreted as malaria positive according to world health organization (WHO) guideline. However if there are conspicuous number of faint test bands, a performance of Paracheck Pf.® could be influenced depending on whether interpreting faint test bands as malaria positive or negative. Finding out the frequency and accurate interpretation of faint test bands are important to prevent the overdiagnosis and drug resistance. Methods A cross-sectional, descriptive study was conducted to find out the frequency of faint test bands and evaluate the performance of Paracheck Pf.® by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of diagnosis of Paracheck Pf.® using microscopy as the gold standard. 388 suspected patients with malaria in Malawi were recruited in this study. Malaria rapid diagnostic tests (RDTs) and microscopy were used and patients’ information which includes age, sex, body temperature and signs or symptoms of malaria were recorded. Results Among all patients involved in the study, 29.1% (113/388) were found malaria positive by RDT. Overall 5.4% (21/388) of all Paracheck Pf.® tests resulted in a “faint test band” and 85.7% (18/21) corresponded with malaria negative by microscopy. Faint test bands which corresponded with malaria positive by microscopy were lower parasite density and there are no patients who showed definitive symptom of malaria, such as fever. When Paracheck Pf.® “faint test bands” were classified as positive, accuracy of diagnosis was 76.5% (95% CI 72%–80.7%) as compared to 80.4% (95% CI 76.1%–84.2%) when Paracheck Pf.® “faint test bands” were classified as negative. Conclusions This study shows that frequency of faint test bands is 5.4% in all malaria RDTs. The accuracy of diagnosis was improved when faint test bands were interpreted as malaria negative. However information and data obtained in this study may not be enough and more intensive research including a frequency and property of faint test bands is needed for significant interpretation of faint test bands.
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Affiliation(s)
- Ryoko Makuuchi
- Nippon International Cooperation for Community Development, 101 Nishi-rokkaku-cho, Nakagyo-ku, Kyoto, 604-8217, Japan.
| | - Sandy Jere
- Ministry of health, Community Health Science Unit, PO Box 30377, Lilongwe, Malawi
| | - Nobuchika Hasejima
- Nippon International Cooperation for Community Development, 101 Nishi-rokkaku-cho, Nakagyo-ku, Kyoto, 604-8217, Japan
| | - Thoms Chigeda
- Lilongwe District Health Office, PO Box 1274, Lilongwe, Malawi
| | - January Gausi
- Lilongwe District Health Office, PO Box 1274, Lilongwe, Malawi
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13
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Thein ST, Khin HSS, Thi A. Anti-malarial landscape in Myanmar: results from a nationally representative survey among community health workers and the private sector outlets in 2015/2016. Malar J 2017; 16:129. [PMID: 28438197 PMCID: PMC5404301 DOI: 10.1186/s12936-017-1761-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 02/28/2017] [Indexed: 11/11/2022] Open
Abstract
Background In 2015/2016, an ACTwatch outlet survey was implemented to assess the anti-malarial and malaria testing landscape in Myanmar across four domains (Eastern, Central, Coastal, Western regions). Indicators provide an important benchmark to guide Myanmar’s new National Strategic Plan to eliminate malaria by 2030. Methods This was a cross-sectional survey, which employed stratified cluster-random sampling across four regions in Myanmar. A census of community health workers (CHWs) and private outlets with potential to distribute malaria testing and/or treatment was conducted. An audit was completed for all anti-malarials, malaria rapid diagnostic tests. Results A total of 28,664 outlets were approached and 4416 met the screening criteria. The anti-malarial market composition comprised CHWs (41.5%), general retailers (27.9%), itinerant drug vendors (11.8%), pharmacies (10.9%), and private for-profit facilities (7.9%). Availability of different anti-malarials and diagnostic testing among anti-malarial-stocking CHWs was as follows: artemisinin-based combination therapy (ACT) (81.3%), chloroquine (67.0%), confirmatory malaria test (77.7%). Less than half of the anti-malarial-stocking private sector had first-line treatment in stock: ACT (41.7%) chloroquine (41.8%), and malaria diagnostic testing was rare (15.4%). Oral artemisinin monotherapy (AMT) was available in 27.7% of private sector outlets (Western, 54.1%; Central, 31.4%; Eastern; 25.0%, Coastal; 15.4%). The private-sector anti-malarial market share comprised ACT (44.0%), chloroquine (26.6%), and oral AMT (19.6%). Among CHW the market share was ACT (71.6%), chloroquine (22.3%); oral AMT (3.8%). More than half of CHWs could correctly state the national first-line treatment for uncomplicated falciparum and vivax malaria (59.2 and 56.9%, respectively) compared to the private sector (15.8 and 13.2%, respectively). Indicators on support and engagement were as follows for CHWs: reportedly received training on malaria diagnosis (60.7%) or national malaria treatment guidelines (59.6%), received a supervisory or regulatory visit within 12 months (39.1%), kept records on number of patients tested or treated for malaria (77.3%). These indicators were less than 20% across the private sector. Conclusion CHWs have a strong foundation for achieving malaria goals and their scale-up is merited, however gaps in malaria commodities and supplies must be addressed. Intensified private sector strategies are urgently needed and must be scaled up to improve access and coverage of first-line treatments and malaria diagnosis, and remove oral AMT from the market place. Future policies and interventions on malaria control and elimination in Myanmar should take these findings into consideration across all phases of implementation. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1761-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Si Thu Thein
- Population Services International Myanmar, No. 16, West Shwe Gone Dine 4th Street, Yangon, Myanmar
| | - Hnin Su Su Khin
- Population Services International Myanmar, No. 16, West Shwe Gone Dine 4th Street, Yangon, Myanmar
| | - Aung Thi
- National Malaria Control Programme, Department of Public Health, Ministry of Health, Naypyidaw, Myanmar
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14
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Sunguya BF, Mlunde LB, Ayer R, Jimba M. Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review. Malar J 2017; 16:10. [PMID: 28049486 PMCID: PMC5209914 DOI: 10.1186/s12936-016-1667-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 12/22/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Human resource for health crisis has impaired global efforts against malaria in highly endemic countries. To address this, the World Health Organization (WHO) recommended scaling-up of community health workers (CHWs) and related cadres owing to their documented success in malaria and other disease prevention and management. Evidence is inconsistent on the roles and challenges they encounter in malaria interventions. This systematic review aims to summarize evidence on roles and challenges of CHWs and related cadres in integrated community case management for malaria (iCCM). METHODS This systematic review retrieved evidence from PubMed, CINAHL, ISI Web of Knowledge, and WHO regional databases. Terms extracted from the Boolean phrase used for PubMed were also used in other databases. The review included studies with Randomized Control Trial, Quasi-experimental, Pre-post interventional, Longitudinal and cohort, Cross-sectional, Case study, and Secondary data analysis. Because of heterogeneity, only narrative synthesis was conducted for this review. RESULTS A total of 66 articles were eligible for analysis out of 1380 studies retrieved. CHWs and related cadre roles in malaria interventions included: malaria case management, prevention including health surveillance and health promotion specific to malaria. Despite their documented success, CHWs and related cadres succumb to health system challenges. These are poor and unsustainable finance for iCCM, workforce related challenges, lack of and unsustainable supply of medicines and diagnostics, lack of information and research, service delivery and leadership challenges. CONCLUSIONS Community health workers and related cadres had important preventive, case management and promotive roles in malaria interventions. To enable their effective integration into the health systems, the identified challenges should be addressed. They include: introducing sustainable financing on iCCM programmes, tailoring their training to address the identified gaps, improving sustainable supply chain management of malaria drugs and diagnostics, and addressing regulatory challenges in the local contexts.
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Affiliation(s)
- Bruno F. Sunguya
- Department of Community Health, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Linda B. Mlunde
- Management for Development and Health, Dar es Salaam, Tanzania
| | - Rakesh Ayer
- Department of Community and Global Health, The University of Tokyo, Tokyo, Japan
| | - Masamine Jimba
- Department of Community and Global Health, The University of Tokyo, Tokyo, Japan
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Nyunt MH, Aye KM, Kyaw KT, Han SS, Aye TT, Wai KT, Kyaw MP. Challenges encountered by local health volunteers in early diagnosis and prompt treatment of malaria in Myanmar artemisinin resistance containment zones. Malar J 2016; 15:308. [PMID: 27267877 PMCID: PMC4895800 DOI: 10.1186/s12936-016-1368-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/02/2016] [Indexed: 11/25/2022] Open
Abstract
Background After artemisinin resistance was reported, the Myanmar artemisinin resistance containment (MARC) project was initiated in 2011. One of the activities of MARC is to train volunteers for early diagnosis and prompt treatment by providing rapid diagnostic tests (RDT) and artemisinin combination therapy. This study aimed to fulfil the gap of information on the challenges faced by malaria volunteers in artemisinin-containment areas. Methods A cross-sectional, descriptive study was conducted in 11 townships in MARC areas to assess the challenges in early diagnosis of malaria and treatment by malaria volunteers using qualitative and quantitative approaches. Results Altogether 405 volunteers participated in the study. Although 97.5 % of volunteers can interpret a positive result for malaria, only 41.2 % correctly stated the persistence of a positive result in recently infected cases. Over 80 % knew the effects of temperature and humidity on performance of the malaria RDT. Unexpectedly, 15.1 % perceived that expired RDTs can still be useful for diagnosis although 98.3 % of respondents cited that the overall results of RDTs were reliable. Although most of them knew the treatment for malaria based on RDT results, some could not give the correct answer, while a few (2 %) mentioned artesunate monotherapy for RDT-negative cases. Training received by volunteers was also varied in study sites and 92.1 % believed that it was not sufficient. A certain portion of them faced the problem of regular supply of RDTs (9.9 %) and drugs (47.5 %), interpretation of result of RDTs (30 %), and performing blood test (20 %). The median RDT tested per month (25th, 75th percentile) was 6.0 (2.0, 15.0) indicating the need for prioritization based on endemicity. Regular reporting, supervision, monitoring system, and proper refresher training using uniform content of guideline to correct misconception of the volunteers, were needed to be strengthened. Moreover, the reliable and regular supply of materials and exchange system for expired RDTs and anti-malarials was important in the effectiveness of volunteers in MARC zones. Conclusions Adequate refresher training, monitoring, supervision, and regular reliable supply of RDTs and anti-malarials were needed for capacity strengthening of volunteers in MARC zones.
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Affiliation(s)
- Myat Htut Nyunt
- Department of Medical Research, Yangon, Republic of the Union of Myanmar.
| | - Khin Myo Aye
- Department of Medical Research, Yangon, Republic of the Union of Myanmar
| | - Khin Thiri Kyaw
- Department of Medical Research, Yangon, Republic of the Union of Myanmar
| | - Soe Soe Han
- Department of Medical Research, Yangon, Republic of the Union of Myanmar
| | - Thin Thin Aye
- Department of Medical Research, Yangon, Republic of the Union of Myanmar
| | - Khin Thet Wai
- Department of Medical Research, Yangon, Republic of the Union of Myanmar
| | - Myat Phone Kyaw
- Department of Medical Research, Yangon, Republic of the Union of Myanmar
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Kyaw SS, Drake T, Thi A, Kyaw MP, Hlaing T, Smithuis FM, White LJ, Lubell Y. Malaria community health workers in Myanmar: a cost analysis. Malar J 2016; 15:41. [PMID: 26809885 PMCID: PMC4727315 DOI: 10.1186/s12936-016-1102-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 01/14/2016] [Indexed: 11/10/2022] Open
Abstract
Background Myanmar has the highest malaria incidence and attributed mortality in South East Asia with limited healthcare infrastructure to manage this burden. Establishing malaria Community Health Worker (CHW) programmes is one possible strategy to improve access to malaria diagnosis and treatment, particularly in remote areas. Despite considerable donor support for implementing CHW programmes in Myanmar, the cost implications are not well understood. Methods An ingredients based micro-costing approach was used to develop a model of the annual implementation cost of malaria CHWs in Myanmar. A cost model was constructed based on activity centres comprising of training, patient malaria services, monitoring and supervision, programme management, overheads and incentives. The model takes a provider perspective. Financial data on CHWs programmes were obtained from the 2013 financial reports of the Three Millennium Development Goal fund implementing partners that have been working on malaria control and elimination in Myanmar. Sensitivity and scenario analyses were undertaken to outline parameter uncertainty and explore changes to programme cost for key assumptions. Results The range of total annual costs for the support of one CHW was US$ 966–2486. The largest driver of CHW cost was monitoring and supervision (31–60 % of annual CHW cost). Other important determinants of cost included programme management (15–28 % of annual CHW cost) and patient services (6–12 % of annual CHW cost). Within patient services, malaria rapid diagnostic tests are the major contributor to cost (64 % of patient service costs). Conclusion The annual cost of a malaria CHW in Myanmar varies considerably depending on the context and the design of the programme, in particular remoteness and the approach to monitoring and evaluation. The estimates provide information to policy makers and CHW programme planners in Myanmar as well as supporting economic evaluations of their cost-effectiveness.
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Affiliation(s)
- Shwe Sin Kyaw
- Mathematical and Economic Modelling, Mahidol-Oxford Tropical Medicine Research Unit, 420/6 Rajvithi Rd, Bangkok, 10400, Thailand.
| | - Tom Drake
- Mathematical and Economic Modelling, Mahidol-Oxford Tropical Medicine Research Unit, 420/6 Rajvithi Rd, Bangkok, 10400, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Aung Thi
- Department of Public Health, Ministry of Health, Nay Pyi Taw, Myanmar.
| | - Myat Phone Kyaw
- Department of Medical Research, Ministry of Health, Yangon, Myanmar.
| | - Thaung Hlaing
- Department of Public Health, Ministry of Health, Nay Pyi Taw, Myanmar.
| | - Frank M Smithuis
- Medical Action Myanmar, Yangon, Myanmar. .,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.
| | - Lisa J White
- Mathematical and Economic Modelling, Mahidol-Oxford Tropical Medicine Research Unit, 420/6 Rajvithi Rd, Bangkok, 10400, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Yoel Lubell
- Mathematical and Economic Modelling, Mahidol-Oxford Tropical Medicine Research Unit, 420/6 Rajvithi Rd, Bangkok, 10400, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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17
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Witek-McManus S, Mathanga DP, Verney A, Mtali A, Ali D, Sande J, Mwenda R, Ndau S, Mazinga C, Phondiwa E, Chimuna T, Melody D, Roschnik N, Brooker SJ, Halliday KE. Design, implementation and evaluation of a training programme for school teachers in the use of malaria rapid diagnostic tests as part of a basic first aid kit in southern Malawi. BMC Public Health 2015; 15:904. [PMID: 26377070 PMCID: PMC4573472 DOI: 10.1186/s12889-015-2228-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 09/04/2015] [Indexed: 11/12/2022] Open
Abstract
Background With increasing levels of enrolment, primary schools present a pragmatic opportunity to improve the access of school children to timely diagnosis and treatment of malaria, increasingly recognised as a major health problem within this age group. The expanded use of malaria rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACT) by community health workers (CHWs) has raised the prospect of whether teachers can provide similar services for school children. We describe and evaluate the training of primary school teachers to use a first aid kit containing malaria RDTs and ACT for the diagnosis and treament of uncomplicated malaria in school children in southern Malawi. Methods We outline the development of the intervention as: (1) conception and design, (2) pilot training, (3) final training, and (4) 7-month follow up. The training materials were piloted at a four-day workshop in July 2013 following their design at national stakeholders meetings. The evaluation of the pilot training and materials were assessed in relation to increased knowledge and skill sets using checklist evaluations and questionnaires, the results of which informed the design of a final seven-day training programme held in December 2013. A follow up of trained teachers was carried out in July 2014 following 7 months of routine implementation. A total of 15 teachers were evaluated at four stages: pilot training, two weeks following pilot, final training and seven months following final training. Results A total of 15 and 92 teachers were trained at the pilot and final training respectively. An average of 93 % of the total steps required to use RDTs were completed correctly at the final training, declining to 87 % after 7 months. All teachers were observed correctly undertaking safe blood collection and handling, accurate RDT interpretation, and correct dispensing of ACT. The most commonly observed errors were a failure to wait 20 minutes before reading the test result, and adding an incorrect volume of buffer to the test cassette. Conclusion Following training, teachers are able to competently use RDTs and ACTs test and treat children at school for uncomplicated malaria safely and accurately. Teachers demonstrate a comparable level of RDT use relative to non-health professional users of RDTs, and sustain this competency over a period of seven months during routine implementation.
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Affiliation(s)
- Stefan Witek-McManus
- Save the Children International, Zomba, Malawi. .,Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
| | - Don P Mathanga
- Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi.
| | | | | | - Doreen Ali
- National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi.
| | - John Sande
- National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi.
| | - Reuben Mwenda
- Health Technical Support Services-Diagnostics, Ministry of Health, Lilongwe, Malawi.
| | - Saidi Ndau
- Zomba District Health Office, Ministry of Health, Zomba, Malawi.
| | - Charles Mazinga
- Department of School Health, Nutrition, HIV & AIDS, Ministry of Education, Science & Technology, Lilongwe, Malawi.
| | - Emmanuel Phondiwa
- Zomba District Education Office, Ministry of Education, Science & Technology, Zomba, Malawi.
| | | | | | | | - Simon J Brooker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
| | - Katherine E Halliday
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
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18
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Aung T, White C, Montagu D, McFarland W, Hlaing T, Khin HSS, San AK, Briegleb C, Chen I, Sudhinaraset M. Improving uptake and use of malaria rapid diagnostic tests in the context of artemisinin drug resistance containment in eastern Myanmar: an evaluation of incentive schemes among informal private healthcare providers. Malar J 2015; 14:105. [PMID: 25885581 PMCID: PMC4355503 DOI: 10.1186/s12936-015-0621-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/22/2015] [Indexed: 11/10/2022] Open
Abstract
Background As efforts to contain artemisinin resistance and eliminate Plasmodium falciparum intensify, the accurate diagnosis and prompt effective treatment of malaria are increasingly needed in Myanmar and the Greater Mekong Sub-region (GMS). Rapid diagnostic tests (RDTs) have been shown to be safe, feasible, and effective at promoting appropriate treatment for suspected malaria, which are of particular importance to drug resistance containment. The informal private sector is often the first point of care for fever cases in malaria endemic areas across Myanmar and the GMS, but there is little published information about informal private provider practices, quality of service provision, or potential to contribute to malaria control and elimination efforts. This study tested different incentives to increase RDT use and improve the quality of care among informal private healthcare providers in Myanmar. Methods The study randomized six townships in the Mon and Shan states of rural Myanmar into three intervention arms: 1) RDT price subsidies, 2) price subsidies with product-related financial incentives, and 3) price subsidies with intensified information, education and counselling (IEC). The study assessed the uptake of RDT use in the communities by cross-sectional surveys of 3,150 households at baseline and six months post-intervention (6,400 households total, 832 fever cases). The study also used mystery clients among 171 providers to assess quality of service provision across intervention arms. Results The pilot intervention trained over 600 informal private healthcare providers. The study found a price subsidy with intensified IEC, resulted in the highest uptake of RDTs in the community, as compared to subsidies alone or merchandise-related financial incentives. Moreover, intensified IEC led to improvements in the quality of care, with mystery client surveys showing almost double the number of correct treatment following diagnostic test results as compared to a simple subsidy. Conclusions Results show that training and quality supervision of informal private healthcare providers can result in improved demand for, and appropriate use of RDTs in drug resistance containment areas in eastern Myanmar. Future studies should assess the sustainability of such interventions and the scale and level of intensity required over time as public sector service provision expands.
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Affiliation(s)
- Tin Aung
- Population Services International, Yangon, Myanmar.
| | | | - Dominic Montagu
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Willi McFarland
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Thaung Hlaing
- Department of Health, National Malaria Control Programme, Yangon, Myanmar.
| | | | | | - Christina Briegleb
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Ingrid Chen
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - May Sudhinaraset
- Global Health Sciences, University of California, San Francisco, CA, USA.
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19
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Sudhinaraset M, Briegleb C, Aung M, Khin HSS, Aung T. Motivation and challenges for use of malaria rapid diagnostic tests among informal providers in Myanmar: a qualitative study. Malar J 2015; 14:61. [PMID: 25889046 PMCID: PMC4328784 DOI: 10.1186/s12936-015-0585-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/25/2015] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Rapid diagnostic tests (RDTs) for malaria enable proper diagnosis and have been shown to reduce overuse of artemisinin combination therapy. Few studies have evaluated the feasibility and use of RDTs in the private sector in Myanmar. The objectives of the study were to: 1) understand the acceptability of using RDTs in the informal sector in Myanmar; 2) examine motivations for use among informal providers; and, 3) highlight decision-making and knowledge of providers for diagnostic testing and treatment. METHODS Qualitative interviews were conducted with 30 informal providers. Purposeful sampling was used to enrol study participants in the Mon and Shan State in Myanmar. All interviews were conducted in Burmese, translated into English, and two researchers coded all interviews using Atlas ti. RESULTS Major themes identified included: 1) informal provider and outlet characteristics, including demographic and background characteristics; 2) the benefits and challenges of using RDTs according to providers; 3) provider experiences with using RDTs, including motivations for using the RDT; 4) adherence to test results, either positive or negative; and, 5) recommendations from informal providers to promote increased use of RDTs in their communities. This study found that introducing RDTs to informal providers in Myanmar was feasible, resulting in improved provider empowerment and patient-provider relationships. Specific challenges included facility infrastructure to use and dispose RDTs and provider knowledge. This varied across the type of informal provider, with itinerant drug vendors more comfortable and knowledgeable about RDTs compared to general retail sellers and medical drug representatives. CONCLUSIONS This study found informal providers in Myanmar found the introduction of RDTs to be highly acceptable. Providers discussed improvement in service quality including provider empowerment and patient-provider relationships. The study also highlighted a number of challenges that informal providers face which may be used for future development of interventions.
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Affiliation(s)
- May Sudhinaraset
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
- Global Health Group, Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Christina Briegleb
- Global Health Group, Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Moe Aung
- Population Services International, Yangon, Myanmar.
| | | | - Tin Aung
- Population Services International, Yangon, Myanmar.
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20
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Chen IT, Aung T, Thant HNN, Sudhinaraset M, Kahn JG. Cost-effectiveness analysis of malaria rapid diagnostic test incentive schemes for informal private healthcare providers in Myanmar. Malar J 2015; 14:55. [PMID: 25653121 PMCID: PMC4334415 DOI: 10.1186/s12936-015-0569-7] [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: 11/07/2014] [Accepted: 01/16/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The emergence of artemisinin-resistant Plasmodium falciparum parasites in Southeast Asia threatens global malaria control efforts. One strategy to counter this problem is a subsidy of malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) within the informal private sector, where the majority of malaria care in Myanmar is provided. A study in Myanmar evaluated the effectiveness of financial incentives vs information, education and counselling (IEC) in driving the proper use of subsidized malaria RDTs among informal private providers. This cost-effectiveness analysis compares intervention options. METHODS A decision tree was constructed in a spreadsheet to estimate the incremental cost-effectiveness ratios (ICERs) among four strategies: no intervention, simple subsidy, subsidy with financial incentives, and subsidy with IEC. Model inputs included programmatic costs (in dollars), malaria epidemiology and observed study outcomes. Data sources included expenditure records, study data and scientific literature. Model outcomes included the proportion of properly and improperly treated individuals with and without P. falciparum malaria, and associated disability-adjusted life years (DALYs). Results are reported as ICERs in US dollars per DALY averted. One-way sensitivity analysis assessed how outcomes depend on uncertainty in inputs. RESULTS ICERs from the least to most expensive intervention are: $1,169/DALY averted for simple subsidy vs no intervention, $185/DALY averted for subsidy with financial incentives vs simple subsidy, and $200/DALY averted for a subsidy with IEC vs subsidy with financial incentives. Due to decreasing ICERs, each strategy was also compared to no intervention. The subsidy with IEC was the most favourable, costing $639/DALY averted compared with no intervention. One-way sensitivity analysis shows that ICERs are most affected by programme costs, RDT uptake, treatment-seeking behaviour, and the prevalence and virulence of non-malarial fevers. In conclusion, private provider subsidies with IEC or a combination of IEC and financial incentives may be a good investment for malaria control.
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Affiliation(s)
- Ingrid T Chen
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA.
| | - Tin Aung
- Population Services International Myanmar, No 16, Shwe Gon Taing Street 4, Yangon, Myanmar.
| | - Hnin Nwe Nwe Thant
- Population Services International Myanmar, No 16, Shwe Gon Taing Street 4, Yangon, Myanmar.
| | - May Sudhinaraset
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA.
| | - James G Kahn
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA.
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Thandar MM, Kyaw MP, Jimba M, Yasuoka J. Caregivers' treatment-seeking behaviour for children under age five in malaria-endemic areas of rural Myanmar: a cross-sectional study. Malar J 2015; 14:1. [PMID: 25557741 PMCID: PMC4326195 DOI: 10.1186/1475-2875-14-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/15/2014] [Indexed: 11/13/2022] Open
Abstract
Background A community-based malaria intervention was introduced through fixed and mobile clinics in rural Myanmar. This study attempted to identify treatment-seeking behaviour of caregivers for children under five and the determinants of appropriate treatment-seeking behaviour in mobile clinic villages (MV) and non-mobile clinic villages (NMV) in malaria-endemic rural areas in Myanmar. Methods A cross-sectional study was conducted in 23 MV and 25 NMV in Ingapu Township, Myanmar. Appropriate treatment-seeking behaviour was operationally defined as seeking treatment from trained personnel or at a health facility within 24 hours after the onset of fever. Multiple logistic regression analyses were conducted to identify the determinants of appropriate treatment-seeking behaviour. Results Among the 597 participants in both types of villages, 166 (35.3%) caregivers sought appropriate treatment. No significant difference in appropriate treatment-seeking behaviour was found between the two types of villages (adjusted odds ratio (AOR), 0.80; 95% confidence interval (CI), 0.51-1.24). Determinants of behaviour include proximity to public health facilities (AOR, 5.86; 95% CI, 3.43-10.02), knowledge of malaria (AOR, 1.90; 95% CI, 1.14-3.17), malaria prevention behaviour (AOR, 1.76; 95% CI, 1.13-2.76), treatment at home (AOR, 0.26; 95% CI, 0.15-0.45), and treatment and transportation costs (AOR, 0.52; 95% CI, 0.33-0.83). Conclusions Caregivers’ treatment-seeking behaviour was poor for fever cases among children under age five, and did not differ significantly between MV and NMV. It is necessary to educate caregivers, particularly for early treatment seeking and appropriate use of health care options for fever, and catering to their medical needs. These findings can help promote awareness and prevention, and improve the quality of interventions at the community level.
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Affiliation(s)
| | | | | | - Junko Yasuoka
- Community and Global Health Department, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan.
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Lwin MM, Sudhinaraset M, San AK, Aung T. Improving malaria knowledge and practices in rural Myanmar through a village health worker intervention: a cross-sectional study. Malar J 2014; 13:5. [PMID: 24386934 PMCID: PMC3893499 DOI: 10.1186/1475-2875-13-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 12/29/2013] [Indexed: 11/10/2022] Open
Abstract
Background Since 2008 the Sun Primary Health (SPH) franchise programme has networked and branded community health workers in rural Myanmar to provide high quality malaria information and treatment. The purpose of this paper is to compare the malaria knowledge level and health practices of individuals in SPH intervention areas to individuals without SPH intervention Methods This study uses data from a cross-sectional household survey of 1,040 individuals living in eight rural townships to compare the knowledge level of individuals in SPH intervention areas to individuals without SPH intervention. Results This study found that the presence of a SPH provider in the community is associated with increased malaria knowledge and higher likelihood of going to trained providers for fevers. Furthermore, the study found a dose–response, where the longer the duration of the programme in a community, the greater the community knowledge level. Conclusion The study suggests that community health workers might have significant impact on malaria-related mortality and morbidity in rural Myanmar.
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Affiliation(s)
| | - May Sudhinaraset
- Global Health Group, University of California, San Francisco, San Francisco, CA, USA.
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