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Nayiga S, Denyer Willis L, Staedke SG, Chandler CI. Taking Opportunities, Taking Medicines: Antibiotic Use in Rural Eastern Uganda. Med Anthropol 2022; 41:418-430. [PMID: 35324360 PMCID: PMC10040720 DOI: 10.1080/01459740.2022.2047676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The ways in which dimensions of health and healthcare intersect with economics and politics in particular contexts requires close attention. In this article we connect concerns about antibiotic overuse in Uganda to the social milieu created through policies that follow President Museveni's vision for a population who kulembeka, "tap wealth." Ethnographic fieldwork in rural Eastern Uganda illustrates how taking medicines in rural households reflects a wider landscape of everyday imperatives to "tap" opportunities in a context of acute precarity. We argue for a closer connection between medical and economic anthropology to push forward understanding of health, medicines and wellbeing in Africa.
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Affiliation(s)
- Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Sarah G Staedke
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Clare Ir Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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2
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Paton RS, Kamau A, Akech S, Agweyu A, Ogero M, Mwandawiro C, Mturi N, Mohammed S, Mpimbaza A, Kariuki S, Otieno NA, Nyawanda BO, Mohamed AF, Mtove G, Reyburn H, Gupta S, Bejon P, Lourenço J, Snow RW. Malaria infection and severe disease risks in Africa. Science 2021; 373:926-931. [PMID: 34413238 PMCID: PMC7611598 DOI: 10.1126/science.abj0089] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/29/2021] [Indexed: 12/18/2022]
Abstract
The relationship between community prevalence of Plasmodium falciparum and the burden of severe, life-threatening disease remains poorly defined. To examine the three most common severe malaria phenotypes from catchment populations across East Africa, we assembled a dataset of 6506 hospital admissions for malaria in children aged 3 months to 9 years from 2006 to 2020. Admissions were paired with data from community parasite infection surveys. A Bayesian procedure was used to calibrate uncertainties in exposure (parasite prevalence) and outcomes (severe malaria phenotypes). Each 25% increase in prevalence conferred a doubling of severe malaria admission rates. Severe malaria remains a burden predominantly among young children (3 to 59 months) across a wide range of community prevalence typical of East Africa. This study offers a quantitative framework for linking malaria parasite prevalence and severe disease outcomes in children.
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Affiliation(s)
- Robert S Paton
- Department of Zoology, University of Oxford, Oxford, UK.
| | - Alice Kamau
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Kilimanjaro Christian Medical Centre/Joint Malaria Programme, Moshi, Tanzania
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Morris Ogero
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Charles Mwandawiro
- Eastern and Southern Africa Centre of International Parasite Control, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Neema Mturi
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shebe Mohammed
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Arthur Mpimbaza
- Child Health and Development Centre, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI)-Centre for Global Health Research, Kisumu, Kenya
| | - Nancy A Otieno
- Kenya Medical Research Institute (KEMRI)-Centre for Global Health Research, Kisumu, Kenya
| | - Bryan O Nyawanda
- Kenya Medical Research Institute (KEMRI)-Centre for Global Health Research, Kisumu, Kenya
| | - Amina F Mohamed
- Kilimanjaro Christian Medical Centre/Joint Malaria Programme, Moshi, Tanzania
- London School of Hygiene and Tropical Medicine, London, UK
| | - George Mtove
- National Institute for Medical Research, Amani Research Centre, Muheza, Tanzania
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sunetra Gupta
- Department of Zoology, University of Oxford, Oxford, UK
| | - Philip Bejon
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - José Lourenço
- Department of Zoology, University of Oxford, Oxford, UK
| | - Robert W Snow
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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3
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Kigozi SP, Giorgi E, Mpimbaza A, Kigozi RN, Bousema T, Arinaitwe E, Nankabirwa JI, Sebuguzi CM, Kamya MR, Staedke SG, Dorsey G, Pullan RL. Practical Implications of a Relationship between Health Management Information System and Community Cohort-Based Malaria Incidence Rates. Am J Trop Med Hyg 2020; 103:404-414. [PMID: 32274990 DOI: 10.4269/ajtmh.19-0950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Global malaria burden is reducing with effective control interventions, and surveillance is vital to maintain progress. Health management information system (HMIS) data provide a powerful surveillance tool; however, its estimates of burden need to be better understood for effectiveness. We aimed to investigate the relationship between HMIS and cohort incidence rates and identify sources of bias in HMIS-based incidence. Malaria incidence was estimated using HMIS data from 15 health facilities in three subcounties in Uganda. This was compared with a gold standard of representative cohort studies conducted in children aged 0.5 to < 11 years, followed concurrently in these sites. Between October 2011 and September 2014, 153,079 children were captured through HMISs and 995 followed up through enhanced community cohorts in Walukuba, Kihihi, and Nagongera subcounties. Although HMISs substantially underestimated malaria incidence in all sites compared with data from the cohort studies, there was a strong linear relationship between these rates in the lower transmission settings (Walukuba and Kihihi), but not the lowest HMIS performance highest transmission site (Nagongera), with calendar year as a significant modifier. Although health facility accessibility, availability, and recording completeness were associated with HMIS incidence, they were not significantly associated with bias in estimates from any site. Health management information systems still require improvements; however, their strong predictive power of unbiased malaria burden when improved highlights the important role they could play as a cost-effective tool for monitoring trends and estimating impact of control interventions. This has important implications for malaria control in low-resource, high-burden countries.
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Affiliation(s)
- Simon P Kigozi
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Emanuele Giorgi
- CHICAS, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | - Arthur Mpimbaza
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ruth N Kigozi
- USAID's Malaria Action Program for Districts, Kampala, Uganda
| | - Teun Bousema
- Department of Medical Microbiology, Radboud University, Nijmegen, Netherlands
| | | | - Joaniter I Nankabirwa
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Catherine M Sebuguzi
- National Malaria Control Division, Uganda Ministry of Health, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Moses R Kamya
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Grant Dorsey
- Department of Medicine, University of California, San Francisco, San Francisco, California.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Rachel L Pullan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
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4
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Worsley SD, Oude Rengerink K, Irving E, Lejeune S, Mol K, Collier S, Groenwold RHH, Enters-Weijnen C, Egger M, Rhodes T. Series: Pragmatic trials and real world evidence: Paper 2. Setting, sites, and investigator selection. J Clin Epidemiol 2017; 88:14-20. [PMID: 28502811 DOI: 10.1016/j.jclinepi.2017.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/22/2016] [Accepted: 05/03/2017] [Indexed: 11/16/2022]
Abstract
This second article in the series on pragmatic trials describes the challenges in selection of sites for pragmatic clinical trials and the impact on validity, precision, and generalizability of the results. The selection of sites is an important factor for the successful execution of a pragmatic trial and impacts the extent to which the results are applicable to future patients in clinical practice. The first step is to define usual care and understand the heterogeneity of sites, patient demographics, disease prevalence and country choice. Next, specific site characteristics are important to consider such as interest in the objectives of the trial, the level of research experience, availability of resources, and the expected number of eligible patients. It can be advisable to support the sites with implementing the trial-related activities and minimize the additional burden that the research imposes on routine clinical practice. Health care providers should be involved in an early phase of protocol development to generate engagement and ensure an appropriate selection of sites with patients who are representative of the future drug users.
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Affiliation(s)
- Sally D Worsley
- Real World Evidence, GSK R&D, Gunnels Wood Road, Stevenage, Hertfordshire SG12NY, UK.
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Elaine Irving
- Real World Evidence, GSK R&D, Gunnels Wood Road, Stevenage, Hertfordshire SG12NY, UK
| | - Stephane Lejeune
- European Organisation for Research and Treatment of Cancer, 83 Avenue Mounier, Brussels 1200, Belgium
| | - Koen Mol
- EMEA Medical Affairs, Janssen Pharmaceutica NV, Turnhoutseweg 30, Beerse 2340, Belgium
| | - Sue Collier
- Respiratory Therapeutic Area, GSK R&D, Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex UB11 1BT, UK
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Catherine Enters-Weijnen
- Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands; Department of Primary Care Research, Julius Clinical, Zeist 3703 CD, The Netherlands
| | - Matthias Egger
- Institute of Social and Preventive Medicine & Department of Clinical Research, Clinical Trials Unit, University of Bern, Finkenhubelweg 11, Bern CH-3012, Switzerland
| | - Thomas Rhodes
- Center for Observational and Real-world Evidence (CORE) - Pharmacoepidemiology, MSD, 351N. Sumneytown Pike, North Wales, PA 19454, USA
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5
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Chandler CIR, Webb EL, Maiteki-Sebuguzi C, Nayiga S, Nabirye C, DiLiberto DD, Ssemmondo E, Dorsey G, Kamya MR, Staedke SG. The impact of an intervention to introduce malaria rapid diagnostic tests on fever case management in a high transmission setting in Uganda: A mixed-methods cluster-randomized trial (PRIME). PLoS One 2017; 12:e0170998. [PMID: 28288172 PMCID: PMC5347994 DOI: 10.1371/journal.pone.0170998] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 01/12/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Rapid diagnostic tests for malaria (mRDTs) have been scaled-up widely across Africa. The PRIME study evaluated an intervention aiming to improve fever case management using mRDTs at public health centers in Uganda. METHODS A cluster-randomized trial was conducted from 2010-13 in Tororo, a high malaria transmission setting. Twenty public health centers were randomized in a 1:1 ratio to intervention or control. The intervention included training in health center management, fever case management with mRDTs, and patient-centered services; plus provision of mRDTs and artemether-lumefantrine (AL) when stocks ran low. Three rounds of Interviews were conducted with caregivers of children under five years of age as they exited health centers (N = 1400); reference mRDTs were done in children with fever (N = 1336). Health worker perspectives on mRDTs were elicited through semi-structured questionnaires (N = 49) and in-depth interviews (N = 10). The primary outcome was inappropriate treatment of malaria, defined as the proportion of febrile children who were not treated according to guidelines based on the reference mRDT. FINDINGS There was no difference in inappropriate treatment of malaria between the intervention and control arms (24.0% versus 29.7%, adjusted risk ratio 0.81 [95% CI: 0.56, 1.17] p = 0.24). Most children (76.0%) tested positive by reference mRDT, but many were not prescribed AL (22.5% intervention versus 25.9% control, p = 0.53). Inappropriate treatment of children testing negative by reference mRDT with AL was also common (31.3% invention vs 42.4% control, p = 0.29). Health workers appreciated mRDTs but felt that integrating testing into practice was challenging given constraints on time and infrastructure. CONCLUSIONS The PRIME intervention did not have the desired impact on inappropriate treatment of malaria for children under five. In this high transmission setting, use of mRDTs did not lead to the reductions in antimalarial prescribing seen elsewhere. Broader investment in health systems, including infrastructure and staffing, will be required to improve fever case management.
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Affiliation(s)
| | - Emily L. Webb
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Grant Dorsey
- Department of Medicine, University of California, San Francisco, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Sarah G. Staedke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Infectious Diseases Research Collaboration, Kampala, Uganda
- * E-mail:
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6
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Burchett HED, Leurent B, Baiden F, Baltzell K, Björkman A, Bruxvoort K, Clarke S, DiLiberto D, Elfving K, Goodman C, Hopkins H, Lal S, Liverani M, Magnussen P, Mårtensson A, Mbacham W, Mbonye A, Onwujekwe O, Roth Allen D, Shakely D, Staedke S, Vestergaard LS, Whitty CJM, Wiseman V, Chandler CIR. Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence. BMJ Open 2017; 7:e012973. [PMID: 28274962 PMCID: PMC5353269 DOI: 10.1136/bmjopen-2016-012973] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts. DESIGN A comparative case study approach, analysing variation in outcomes across different settings. SETTING Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case. PARTICIPANTS 28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria. INTERVENTIONS The interventions included different mRDT training packages, supervision, supplies and community sensitisation. OUTCOME MEASURES Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (% Plasmodium falciparum positive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (% P. falciparum negative not prescribed/given antimalarial). RESULTS Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs. CONCLUSIONS Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.
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Affiliation(s)
- Helen E D Burchett
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Baptiste Leurent
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Frank Baiden
- Epidemiology Unit, Ensign College of Public Health, Kpong, Ghana
| | - Kimberly Baltzell
- Department of Family Health Care Nursing, and Global Health Science, University of California, Berkeley, California, USA
| | - Anders Björkman
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Siân Clarke
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Deborah DiLiberto
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristina Elfving
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Heidi Hopkins
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Sham Lal
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Mårtensson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Wilfred Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé, Yaoundé, Cameroon
| | - Anthony Mbonye
- School of Public Health- Makerere University and Commissioner Health Services, Ministry of Health, Uganda
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria Enugu-Campus, Nigeria
| | | | - Delér Shakely
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
- Department of Medicine, Kungälv Hospital, Sweden
| | - Sarah Staedke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Lasse S Vestergaard
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Denmark
| | - Christopher J M Whitty
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health and Community Medicine, Australia
| | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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7
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Chandler CIR, Burchett H, Boyle L, Achonduh O, Mbonye A, DiLiberto D, Reyburn H, Onwujekwe O, Haaland A, Roca-Feltrer A, Baiden F, Mbacham WF, Ndyomugyenyi R, Nankya F, Mangham-Jefferies L, Clarke S, Mbakilwa H, Reynolds J, Lal S, Leslie T, Maiteki-Sebuguzi C, Webster J, Magnussen P, Ansah E, Hansen KS, Hutchinson E, Cundill B, Yeung S, Schellenberg D, Staedke SG, Wiseman V, Lalloo DG, Whitty CJM. Examining Intervention Design: Lessons from the Development of Eight Related Malaria Health Care Intervention Studies. Health Syst Reform 2016; 2:373-388. [PMID: 31514719 PMCID: PMC6176770 DOI: 10.1080/23288604.2016.1179086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract—Rigorous evidence of “what works” to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This article presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; and (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (1) intended pathways of change and (2) how their intervention would be implemented.The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical but as the result of micro and macro social, political, and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.
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Affiliation(s)
- Clare I R Chandler
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Helen Burchett
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Louise Boyle
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Olivia Achonduh
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | - Anthony Mbonye
- School of Public Health-Makerere University & Commissioner Health Services, Ministry of Health , Kampala , Uganda
| | - Deborah DiLiberto
- Clinical Research Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hugh Reyburn
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics , University of Nigeria Enugu-Campus , Enugu , Nigeria
| | - Ane Haaland
- Institute of Health and Society , Department of Community Medicine , Blindern , Oslo , Norway
| | | | - Frank Baiden
- Malaria Group, Kintampo Health Research Centre , Kintampo , Ghana
| | - Wilfred F Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | | | - Florence Nankya
- Infectious Diseases Research Collaboration , Kampala , Uganda
| | - Lindsay Mangham-Jefferies
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sian Clarke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hilda Mbakilwa
- Joint Malaria Programme, Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Joanna Reynolds
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sham Lal
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Toby Leslie
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | | | - Jayne Webster
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen , Denmark
| | - Evelyn Ansah
- Dangme West District Health Directorate, Ghana Health Service , Dodowa , Ghana
| | - Kristian S Hansen
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Eleanor Hutchinson
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Bonnie Cundill
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Shunmay Yeung
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - David Schellenberg
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Sarah G Staedke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Virginia Wiseman
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK.,School of Public Health and Community Medicine , Kensington , New South Wales , Australia
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8
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Staedke SG, Maiteki-Sebuguzi C, DiLiberto DD, Webb EL, Mugenyi L, Mbabazi E, Gonahasa S, Kigozi SP, Willey BA, Dorsey G, Kamya MR, Chandler CIR. The Impact of an Intervention to Improve Malaria Care in Public Health Centers on Health Indicators of Children in Tororo, Uganda (PRIME): A Cluster-Randomized Trial. Am J Trop Med Hyg 2016; 95:358-367. [PMID: 27273646 PMCID: PMC4973182 DOI: 10.4269/ajtmh.16-0103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/04/2016] [Indexed: 12/02/2022] Open
Abstract
Optimizing quality of care for malaria and other febrile illnesses is a complex challenge of major public health importance. To evaluate the impact of an intervention aiming to improve malaria case management on the health of community children, a cluster-randomized trial was conducted from 2010–2013 in Tororo, Uganda, where malaria transmission is high. Twenty public health centers were included; 10 were randomized in a 1:1 ratio to intervention or control. Households within 2 km of health centers provided the sampling frame for the evaluation. The PRIME intervention included training in fever case management using malaria rapid diagnostic tests (mRDTs), patient-centered services, and health center management; plus provision of mRDTs and artemether–lumefantrine. Cross-sectional community surveys were conducted at baseline and endline (N = 8,766), and a cohort of children was followed for approximately 18 months (N = 992). The primary outcome was prevalence of anemia (hemoglobin < 11.0 g/dL) in children under 5 years of age in the final community survey. The intervention was delivered successfully; however, no differences in prevalence of anemia or parasitemia were observed between the study arms in the final community survey or the cohort. In the final survey, prevalence of anemia in children under 5 years of age was 62.5% in the intervention versus 63.1% in control (adjusted risk ratio = 1.01; 95% confidence interval = 0.91–1.13; P = 0.82). The PRIME intervention, focusing on training and commodities, did not produce the expected health benefits in community children in Tororo. This challenges common assumptions that improving quality of care and access to malaria diagnostics will yield health gains.
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Affiliation(s)
- Sarah G Staedke
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Deborah D DiLiberto
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emily L Webb
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Levi Mugenyi
- Infectious Diseases Research Collaboration, Kampala, Uganda.,I-Biostat, Hasselt University, Diepenbeek, Belgium
| | - Edith Mbabazi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Simon P Kigozi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Barbara A Willey
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Grant Dorsey
- Department of Medicine, University of California, San Francisco, California
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University College of Health Sciences, Kampala, Uganda
| | - Clare I R Chandler
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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9
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DiLiberto DD, Staedke SG, Nankya F, Maiteki-Sebuguzi C, Taaka L, Nayiga S, Kamya MR, Haaland A, Chandler CIR. Behind the scenes of the PRIME intervention: designing a complex intervention to improve malaria care at public health centres in Uganda. Glob Health Action 2015; 8:29067. [PMID: 26498744 PMCID: PMC4620687 DOI: 10.3402/gha.v8.29067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/20/2015] [Accepted: 09/22/2015] [Indexed: 12/30/2022] Open
Abstract
Background In Uganda, health system challenges limit access to good quality healthcare and contribute to slow progress on malaria control. We developed a complex intervention (PRIME), which was designed to improve quality of care for malaria at public health centres. Objective Responding to calls for increased transparency, we describe the PRIME intervention's design process, rationale, and final content and reflect on the choices and challenges encountered during the design of this complex intervention. Design To develop the intervention, we followed a multistep approach, including the following: 1) formative research to identify intervention target areas and objectives; 2) prioritization of intervention components; 3) review of relevant evidence; 4) development of intervention components; 5) piloting and refinement of workshop modules; and 6) consolidation of the PRIME intervention theories of change to articulate why and how the intervention was hypothesized to produce desired outcomes. We aimed to develop an intervention that was evidence-based, grounded in theory, and appropriate for the study context; could be evaluated within a randomized controlled trial; and had the potential to be scaled up sustainably. Results The process of developing the PRIME intervention package was lengthy and dynamic. The final intervention package consisted of four components: 1) training in fever case management and use of rapid diagnostic tests for malaria (mRDTs); 2) workshops in health centre management; 3) workshops in patient-centred services; and 4) provision of mRDTs and antimalarials when stocks ran low. Conclusions The slow and iterative process of intervention design contrasted with the continually shifting study context. We highlight the considerations and choices made at each design stage, discussing elements we included and why, as well as those that were ultimately excluded. Reflection on and reporting of ‘behind the scenes’ accounts of intervention design may improve the design, assessment, and generalizability of complex interventions and their evaluations.
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Affiliation(s)
- Deborah D DiLiberto
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK;
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Lilian Taaka
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ane Haaland
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Clare I R Chandler
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
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10
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Abstract
Many interventions are not disruptive enough of the patterns that entrench poor health and health inequities. Ways forward may require a break with tradition to embrace system-focussed theory, complex logic modelling, and ways of funding and responding to problems that address the competition of ideas and needs.
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Affiliation(s)
- Penelope Hawe
- Menzies Centre for Health Policy, University of Sydney, NSW, Australia; The Australian Prevention Partnership Centre, Australia.
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11
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Okwaro FM, Chandler CIR, Hutchinson E, Nabirye C, Taaka L, Kayendeke M, Nayiga S, Staedke SG. Challenging logics of complex intervention trials: community perspectives of a health care improvement intervention in rural Uganda. Soc Sci Med 2015; 131:10-7. [PMID: 25748110 DOI: 10.1016/j.socscimed.2015.02.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Health systems in many African countries are failing to provide populations with access to good quality health care. Morbidity and mortality from curable diseases such as malaria remain high. The PRIME trial in Tororo, rural Uganda, designed and tested an intervention to improve care at health centres, with the aim of reducing ill-health due to malaria in surrounding communities. This paper presents the impact and context of this trial from the perspective of community members in the study area. Fieldwork was carried out for a year from the start of the intervention in June 2011, and involved informal observation and discussions as well as 13 focus group discussions with community members, 10 in-depth interviews with local stakeholders, and 162 context descriptions recorded through quarterly interviews with community members, health workers and district officials. Community members observed a small improvement in quality of care at most, but not all, intervention health centres. However, this was diluted by other shortfalls in health services beyond the scope of the intervention. Patients continued to seek care at health centres they considered inadequate as well as positioning themselves and their children to access care through other sources such as research and nongovernmental organization (NGO) projects. These findings point to challenges of designing and delivering interventions within a paradigm that requires factorial (reduced to predictable factors) problem definition with easily actionable and evaluable solutions by small-scale projects. Such requirements mean that interventions often work on the periphery of a health system rather than tackling the murky political and economic realities that shape access to care but are harder to change or evaluate with randomized controlled trials. Highly projectified settings further reduce the ability to genuinely 'control' for different health care access scenarios. We argue for a raised consciousness of how evaluation paradigms impact on intervention choices.
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Affiliation(s)
- Ferdinand M Okwaro
- Department of Global Health & Development, 15-17 Tavistock Place, London School of Hygiene & Tropical Medicine, WC1H 9SH London, UK.
| | - Clare I R Chandler
- Department of Global Health & Development, 15-17 Tavistock Place, London School of Hygiene & Tropical Medicine, WC1H 9SH London, UK.
| | - Eleanor Hutchinson
- Department of Global Health & Development, 15-17 Tavistock Place, London School of Hygiene & Tropical Medicine, WC1H 9SH London, UK.
| | - Christine Nabirye
- Infectious Disease Research Collaboration, Mulago Hospital, P.O. Box 7475, Kampala, Uganda.
| | - Lilian Taaka
- Infectious Disease Research Collaboration, Mulago Hospital, P.O. Box 7475, Kampala, Uganda.
| | - Miriam Kayendeke
- Infectious Disease Research Collaboration, Mulago Hospital, P.O. Box 7475, Kampala, Uganda.
| | - Susan Nayiga
- Infectious Disease Research Collaboration, Mulago Hospital, P.O. Box 7475, Kampala, Uganda.
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, UK.
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12
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Yeka A, Lameyre V, Afizi K, Fredrick M, Lukwago R, Kamya MR, Talisuna AO. Efficacy and safety of fixed-dose artesunate-amodiaquine vs. artemether-lumefantrine for repeated treatment of uncomplicated malaria in Ugandan children. PLoS One 2014; 9:e113311. [PMID: 25436614 PMCID: PMC4249977 DOI: 10.1371/journal.pone.0113311] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 10/21/2014] [Indexed: 11/18/2022] Open
Abstract
The safety and efficacy of the two most widely used fixed-dose artemisinin-based combination therapies (ACT), artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL) are well established for single episodes of uncomplicated Plasmodium falciparum malaria, but the effects of repeated, long-term use are not well documented. We conducted a 2-year randomized, open-label, longitudinal, phase IV clinical trial comparing the efficacy and safety of fixed-dose ASAQ and AL for repeated treatment of uncomplicated malaria in children under 5 years at Nagongera Health Centre, Uganda. Participants were randomized to ASAQ or AL and all subsequent malaria episodes were treated with the same regimen. 413 children were enrolled and experienced a total of 6027 malaria episodes (mean 15; range, 1–26). For the first malaria episode, the PCR-corrected-cure rate for ASAQ (97.5%) was non-inferior to that for AL (97.0%; 95% CI [−0.028; 0.037]). PCR-corrected cure rates for subsequent malaria episodes that had over 100 cases (episodes 2–18), ranged from 88.1% to 98.9% per episode, with no clear difference between the treatment arms. Parasites were completely cleared by day 3 for all malaria episodes and gametocyte carriage was less than 1% by day 21. Fever clearance was faster in the ASAQ group for the first episode. Treatment compliance for subsequent episodes (only first dose administration observed) was close to 100%. Adverse events though common were similar between treatment arms and mostly related to the disease. Serious adverse events were uncommon, comparable between treatment arms and resolved spontaneously. Anemia and neutropenia occurred in <0.5% of cases per episode, abnormal liver function tests occurred in 0.3% to 1.4% of cases. Both regimens were safe and effective for repeated treatment of malaria. Trial Registration Current Controlled Trials NCT00699920
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Affiliation(s)
- Adoke Yeka
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Uganda Malaria Surveillance Program, Kampala, Uganda
- * E-mail:
| | | | - Kibuuka Afizi
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - Moses R. Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Uganda Malaria Surveillance Program, Kampala, Uganda
| | - Ambrose O. Talisuna
- Uganda Malaria Surveillance Program, Kampala, Uganda
- Malaria Public Health Department, University of Oxford-KEMRI-Wellcome Trust Programme, Nairobi, Kenya
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13
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Nayiga S, DiLiberto D, Taaka L, Nabirye C, Haaland A, Staedke SG, Chandler CIR. Strengthening patient-centred communication in rural Ugandan health centres: A theory-driven evaluation within a cluster randomized trial. EVALUATION (LONDON, ENGLAND : 1995) 2014; 20:471-491. [PMID: 25983612 PMCID: PMC4425297 DOI: 10.1177/1356389014551484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This article describes a theory-driven evaluation of one component of an intervention to improve the quality of health care at Ugandan public health centres. Patient-centred services have been advocated widely, but such approaches have received little attention in Africa. A cluster randomized trial is evaluating population-level outcomes of an intervention with multiple components, including 'patient-centred services.' A process evaluation was designed within this trial to articulate and evaluate the implementation and programme theories of the intervention. This article evaluates one hypothesized mechanism of change within the programme theory: the impact of the Patient Centred Services component on health-worker communication. The theory-driven approach extended to evaluation of the outcome measures. The study found that the proximal outcome of patient-centred communication was rated 10 percent higher (p < 0.008) by care seekers consulting with the health workers who were at the intervention health centres compared with those at control health centres. This finding will strengthen interpretation of more distal trial outcomes.
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Affiliation(s)
- Susan Nayiga
- Infectious Disease Research Collaboration, Uganda
| | | | - Lilian Taaka
- Infectious Disease Research Collaboration, Uganda
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14
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Tukwasibwe S, Mugenyi L, Mbogo GW, Nankoberanyi S, Maiteki-Sebuguzi C, Joloba ML, Nsobya SL, Staedke SG, Rosenthal PJ. Differential prevalence of transporter polymorphisms in symptomatic and asymptomatic falciparum malaria infections in Uganda. J Infect Dis 2014; 210:154-7. [PMID: 24446524 DOI: 10.1093/infdis/jiu044] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We explored associations between Plasmodium falciparum drug resistance-mediating polymorphisms and clinical presentations in parasitemic children enrolled in a cross-sectional survey in Tororo, Uganda, using a retrospective case-control design. All 243 febrile children (cases) and 243 randomly selected asymptomatic children (controls) were included. In a multivariate analysis adjusting for age, complexity of infection, and parasite density, the prevalence of wild-type genotypes was significantly higher in febrile children compared to asymptomatic children (pfcrt K76T: odds ratio [OR] 4.41 [95% confidence interval {CI}, 1.28-15.1]; pfmdr1 N86Y: OR 4.08 [95% CI, 2.01-8.31], and pfmdr1 D1246Y: OR 4.90 [95% CI, 1.52-15.8]), suggesting greater virulence for wild-type parasites.
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15
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Chandler CIR, DiLiberto D, Nayiga S, Taaka L, Nabirye C, Kayendeke M, Hutchinson E, Kizito J, Maiteki-Sebuguzi C, Kamya MR, Staedke SG. The PROCESS study: a protocol to evaluate the implementation, mechanisms of effect and context of an intervention to enhance public health centres in Tororo, Uganda. Implement Sci 2013; 8:113. [PMID: 24079992 PMCID: PMC3849653 DOI: 10.1186/1748-5908-8-113] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 09/17/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Despite significant investments into health improvement programmes in Uganda, health indicators and access to healthcare remain poor across the country. The PRIME trial aims to evaluate the impact of a complex intervention delivered in public health centres on health outcomes of children and management of malaria in rural Uganda. The intervention consists of four components: Health Centre Management; Fever Case Management; Patient- Centered Services; and support for supplies of malaria diagnostics and antimalarial drugs. METHODS The PROCESS study will use mixed methods to evaluate the processes, mechanisms of change, and context of the PRIME intervention by addressing five objectives. First, to develop a comprehensive logic model of the intervention, articulating the project's hypothesised pathways to trial outcomes. Second, to evaluate the implementation of the intervention, including health worker training, health centre management tools, and the supply of artemether-lumefantrine (AL) and rapid diagnostic tests (RDTs) for malaria. Third, to understand mechanisms of change of the intervention components, including testing hypotheses and interpreting realities of the intervention, including resistance, in context. Fourth, to develop a contextual record over time of factors that may have affected implementation of the intervention, mechanisms of change, and trial outcomes, including factors at population, health centre and district levels. Fifth, to capture broader expected and unexpected impacts of the intervention and trial activities among community members, health centre workers, and private providers. Methods will include intervention logic mapping, questionnaires, recorded consultations, in-depth interviews, focus group discussions, and contextual data documentation. DISCUSSION The findings of this PROCESS study will be interpreted alongside the PRIME trial results. This will enable a greater ability to generalise the findings of the main trial. The investigators will attempt to assess which methods are most informative in such evaluations of complex interventions in low-resource settings. TRIAL REGISTRATION Clinicaltrials.gov, NCT01024426.
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Affiliation(s)
- Clare IR Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - Deborah DiLiberto
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, WC1E 7HT, London, UK
| | - Susan Nayiga
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | - Lilian Taaka
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | - Christine Nabirye
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | - Miriam Kayendeke
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - James Kizito
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | | | - Moses R Kamya
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, WC1E 7HT, London, UK
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
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