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Laktabai J, Kimachas E, Kipkoech J, Menya D, Arthur D, Zhou Y, Chepkwony T, Abel L, Robie E, Amunga M, Ambani G, Woldeghebriel M, Garber E, Eze N, Mudabai P, Gallis JA, Fashanu C, Saran I, Woolsey A, Visser T, Turner EL, Prudhomme O’Meara W. A cluster-randomized trial of client and provider-directed financial interventions to align incentives with appropriate case management in retail medicine outlets: Results of the TESTsmART Trial in western Kenya. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002451. [PMID: 38324584 PMCID: PMC10849268 DOI: 10.1371/journal.pgph.0002451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/17/2024] [Indexed: 02/09/2024]
Abstract
ACTs are responsible for a substantial proportion of the global reduction in malaria mortality over the last ten years, made possible by publicly-funded subsidies making these drugs accessible and affordable in the private sector. However, inexpensive ACTs available in retail outlets have contributed substantially to overconsumption. We test an innovative, scalable strategy to target ACT-subsidies to clients with a confirmatory diagnosis. We supported malaria testing(mRDTs) in 39 medicine outlets in western Kenya, randomized to three study arms; control arm offering subsidized mRDT testing (0.4USD), client-directed intervention where all clients who received a positive RDT at the outlet were eligible for a free (fully-subsidized) ACT, and a combined client and provider directed intervention where clients with a positive RDT were eligible for free ACT and outlets received 0.1USD for every RDT performed. Our primary outcome was the proportion of ACT dispensed to individuals with a positive diagnostic test. Secondary outcomes included proportion of clients tested at the outlet and adherence to diagnostic test results. 43% of clients chose to test at the outlet. Test results informed treatment decisions, resulting in targeting of ACTs to confirmed malaria cases- 25.3% of test-negative clients purchased an ACT compared to 75% of untested clients. Client-directed and client+provider-directed interventions did not offer further improvements, compared to the control arm, in testing rates(RD = 0.09, 95%CI:-0.08,0.26) or dispensing of ACTs to test-positive clients(RD = 0.01,95% CI:-0.14, 0.16). Clients were often unaware of the price they paid for the ACT leading to uncertainty in whether the ACT subsidy was passed on to the client. This uncertainty undermines our ability to definitively conclude that client-directed subsidies are not effective for improving testing and appropriate treatment. We conclude that mRDTs could reduce ACT overconsumption in the private retail sector, but incentive structures are difficult to scale and their value to private providers is uncertain. Trial registration: ClinicalTrials.gov NCT04428307.
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Affiliation(s)
- Jeremiah Laktabai
- Moi University School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Emmah Kimachas
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Joseph Kipkoech
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Diana Menya
- Moi University School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - David Arthur
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Yunji Zhou
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | | | - Lucy Abel
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Emily Robie
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Mark Amunga
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - George Ambani
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | | | | | - Nwamaka Eze
- Clinton Health Access Initiative (CHAI), Lagos, Nigeria
| | | | - John A. Gallis
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | - Indrani Saran
- School of Social Work, Boston College, Newton, Massachusetts, United States of America
| | - Aaron Woolsey
- Clinton Health Access Initiative (CHAI), Boston, Massachusetts, United States of America
| | - Theodoor Visser
- Clinton Health Access Initiative (CHAI), Boston, Massachusetts, United States of America
| | - Elizabeth L. Turner
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Wendy Prudhomme O’Meara
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
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Odhiambo FO, O'Meara WP, Abade A, Owiny M, Odhiambo F, Oyugi EO. Adherence to national malaria treatment guidelines in private drug outlets: a cross-sectional survey in the malaria-endemic Kisumu County, Kenya. Malar J 2023; 22:307. [PMID: 37821868 PMCID: PMC10568760 DOI: 10.1186/s12936-023-04744-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Malaria prevalence in Kenya is 6%, with a three-fold higher prevalence in western Kenya. Adherence to malaria treatment guidelines improves care for suspected malaria cases and can reduce unnecessary anti-malarial use. Data on adherence to guidelines in retail drug outlets (DOs) is limited, yet approximately 50% of people with fever access treatment first in these outlets. This study assessed adherence to the national malaria treatment guidelines among DOs in a high transmission area of Western Kenya. METHODS In a cross-sectional survey of DOs in Kisumu Central and Seme sub-counties in 2021, DO staff were interviewed using structured questionnaires to assess outlet characteristics (location, testing services), staff demographics (age, sex, training), and health system context (supervision, inspection). Mystery shoppers (research assistants disguised as clients) observed malaria management practices and recorded observations on a standardized tool. Adherence was defined as dispensing artemether-lumefantrine (AL) to patients with a confirmed positive test, accompanied by appropriate medication counseling. Logistic regression was used to test for association between adherence to guidelines and DO-related factors. RESULTS None of the 70 DOs assessed had a copy of the guidelines, and 60 (85.7%) were in an urban setting. Staff adhered to the guidelines in 14 (20%) outlets. The odds of adherence were higher among staff who had a bachelor's degree {odds ratio (OR) 6.0, 95% confidence interval (95% CI) 1.66-21.74}, those trained on malaria rapid diagnostic test (RDT) {OR 4.4, 95% CI 1.29-15.04}, and those who asked about patient's symptoms {OR 3.6, 95% CI 1.08-12.25}. DOs that had higher odds of adherence included those with functional thermometers {OR 5.3, 95% CI 1.46-19.14}, those recently inspected (within three months) by Pharmacy and Poisons Board (PPB) {OR 9.4, 95% CI 2.55-34.67}, and those with all basic infrastructure {OR 3.9, 95% CI 1.01-15.00}. On logistic regression analysis, recent PPB inspection {adjusted OR (AOR) 4.6, 95% CI 1.03-20.77} and malaria RDT-trained staff (aOR 4.5, 95% CI 1.02-19.84) were independently associated with adherence. CONCLUSION Most outlets didn't adhere to malaria guidelines. Regular interaction with regulatory bodies could improve adherence. Ministry of Health should enhance private sector engagement and train DOs on RDT use.
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Affiliation(s)
| | - Wendy P O'Meara
- School of Public Health, Moi University, Eldoret, Kenya
- Duke Global Health Institute, Durham, NC, USA
| | - Ahmed Abade
- Field Epidemiology and Laboratory Training Programme, Nairobi, Kenya
| | - Maurice Owiny
- Field Epidemiology and Laboratory Training Programme, Nairobi, Kenya
| | - Fredrick Odhiambo
- Field Epidemiology and Laboratory Training Programme, Nairobi, Kenya
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Laktabai J, Kimachas E, Kipkoech J, Menya D, Arthur D, Zhou Y, Chepkwony T, Abel L, Robie E, Amunga M, Ambani G, Woldeghebriel M, Garber E, Eze N, Mudabai P, Gallis JA, Fashanu C, Saran I, Woolsey A, Visser T, Turner EL, O'Meara WP. A cluster-randomized trial of client and provider-directed financial interventions to align incentives with appropriate case management in retail medicine outlets: results of the TESTsmART Trial in western Kenya. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.14.23295586. [PMID: 37745516 PMCID: PMC10516073 DOI: 10.1101/2023.09.14.23295586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
ACTs are responsible for a substantial proportion of the global reduction in malaria mortality over the last ten years. These reductions would not have been possible without publicly-funded subsidies making these drugs accessible and affordable in the private sector. However, inexpensive ACTs available in retail outlets have contributed substantially to their overconsumption. We test an innovative, scalable, and sustainable strategy to target ACT subsidies to clients with a confirmatory diagnosis. We supported point-of-care malaria testing (mRDTs) in 39 retail medicine outlets in western Kenya and randomized them to three study arms; control arm offering subsidized RDT testing for 0.4USD, client-directed intervention where all clients who received a positive RDT at the outlet were eligible for a free (fully subsidized) first-line ACT, and a combined client and provider directed intervention where clients with a positive RDT were eligible for free ACT and outlets received 0.1USD for every RDT performed. Our primary outcome was the proportion of ACT dispensed to individuals with a positive diagnostic test. Secondary outcomes included proportion of clients tested at the outlet and adherence to diagnostic test results. 43% of clients chose to test at the outlet. Test results informed treatment decisions and resulted in targeting of ACTs to confirmed malaria cases - 25.3% of test-negative clients purchased an ACT compared to 75% of untested clients. Client-directed and client+provider-directed interventions did not offer further improvements, compared to the control arm, in testing rates (RD=0.09, 95%CI:-0.08,0.26) or dispensing of ACTs to test-positive clients (RD=0.01,95% CI: -0.14, 0.16). Clients were often unaware of the price they paid for the ACT leading to uncertainty in whether the ACT subsidy was passed on to the client. We conclude that mRDTs could reduce ACT overconsumption in the private retail sector, but incentive structures are difficult to scale and their value to private providers is uncertain.
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Affiliation(s)
- J Laktabai
- Moi University School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - E Kimachas
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - J Kipkoech
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - D Menya
- Moi University School of Public Health, College of Health Sciences, Moi University
| | - D Arthur
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC
| | - Y Zhou
- Department of Biostatistics, University of Washington, Seattle WA
| | - T Chepkwony
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - L Abel
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - E Robie
- Duke Global Health Institute
| | - M Amunga
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - G Ambani
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | | | - E Garber
- Clinton Health Access Initiative (CHAI) Nigeria
| | - Nwamaka Eze
- Clinton Health Access Initiative (CHAI) Nigeria
| | | | - J A Gallis
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC
| | | | - I Saran
- School of Social Work, Boston College
| | - A Woolsey
- Clinton Health Access Initiative (CHAI) Boston, Massachusetts
| | - T Visser
- Clinton Health Access Initiative (CHAI) Boston, Massachusetts
| | - E L Turner
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC
| | - W Prudhomme O'Meara
- Duke Global Health Institute and Moi University School of Public Health, College of Health Science
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Nsengimana A, Isimbi J, Uwizeyimana T, Biracyaza E, Hategekimana JC, Uwambajimana C, Gwira O, Kagisha V, Asingizwe D, Adedeji A, Nyandwi JB. Malaria rapid diagnostic tests in community pharmacies in Rwanda: availability, knowledge of community pharmacists, advantages, and disadvantages of licensing their use. Glob Health Res Policy 2023; 8:40. [PMID: 37700374 PMCID: PMC10496312 DOI: 10.1186/s41256-023-00324-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 08/22/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Presumptive treatment of malaria is often practiced in community pharmacies across sub-Saharan Africa (SSA).To address this issue, the World Health Organization (WHO) recommends that malaria Rapid Diagnostic Tests (m-RDTs) be used in these settings, as they are used in the public sector. However, their use remains unlicensed in the community pharmacies in Rwanda. This can lessen their availability and foster presumptive treatment. Therefore, this study investigated the availability of m-RDTs, knowledge of community pharmacists on the use of m-RDTs, and explored Pharmacists' perceptions of the advantages and disadvantages of licensing the use of m-RDTs in community pharmacies. METHODS This was a cross-sectional study among 200 licensed community pharmacists who were purposefully sampled nationwide from 11th February to 12th April 2022. Data was collected using an online data collection instrument composed of open-ended and closed-ended questions. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 25.0. The chi-square test was used to evaluate the association between the availability of m-RDTs and independent variables of interest. Content analysis was used for qualitative data. RESULTS Although 59% were consulted by clients requesting to purchase m-RDTs, only 27% of the participants had m-RDTs in stock, 66.5% had no training on the use of m-RDTs, and 18.5% were not at all familiar with using the m-RDTs. Most of the participants (91.5%) agreed that licensing the use of m-RDTs in community pharmacies could promote the rational use of antimalarials. The chi-square test indicated that being requested to sell m-RDTs (x2 = 6.95, p = 0.008), being requested to perform m-RDTs (x2 = 5.39, p = 0.02),familiarity using m-RDTs (x2 = 17.24, p = 0.002), availability of a nurse in the Pharmacy (x2 = 11.68, p < 0.001), and location of the pharmacy (x2 = 9.13, p = 0.048) were all significantly associated with the availability of m-RDTs in the pharmacy. CONCLUSIONS The availability of m-RDTs remains low in community pharmacies in Rwanda, and less training is provided to community pharmacists regarding the use of m-RDTs. Nevertheless, community pharmacists had positive perceptions of the advantages of licensing the use of m-RDTs. Thus, licensing the use of m-RDTs is believed to be the first step toward promoting the rational use of antimalarial medicines in Rwanda.
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Affiliation(s)
- Amon Nsengimana
- USAID Global Health Supply Chain Program-Procurement and Supply Management, Kigali, Rwanda.
| | - Joyce Isimbi
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | | | - Emmanuel Biracyaza
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montréal, QC, Canada
| | | | - Charles Uwambajimana
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Olivia Gwira
- USAID Global Health Supply Chain Program-Procurement and Supply Management, Kigali, Rwanda
| | - Vedaste Kagisha
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Domina Asingizwe
- Department of Physiotherapy, School of Health Sciences, University of Rwanda, Kigali, Rwanda
- East African Community Regional Center of Excellence for Vaccines, Immunization and Health Supply Chain Management, Kigali, Rwanda
| | - Ahmed Adedeji
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Jean Baptiste Nyandwi
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
- East African Community Regional Center of Excellence for Vaccines, Immunization and Health Supply Chain Management, Kigali, Rwanda
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Chan JTN, Nguyen V, Tran TN, Nguyen NV, Do NTT, van Doorn HR, Lewycka S. Point-of-care testing in private pharmacy and drug retail settings: a narrative review. BMC Infect Dis 2023; 23:551. [PMID: 37612636 PMCID: PMC10463283 DOI: 10.1186/s12879-023-08480-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/23/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Point-of-care testing (POCT) using rapid diagnostic tests for infectious disease can potentially guide appropriate use of antimicrobials, reduce antimicrobial resistance, and economise use of healthcare resources. POCT implementation in private retail settings such as pharmacies and drug shops could lessen the burden on public healthcare. We performed a narrative review on studies of POCTs in low- and middle-income countries (LMICs), and explored uptake, impact on treatment, and feasibility of implementation. METHODS We searched MEDLINE/PubMed for interventional studies on the implementation of POCT for infectious diseases performed by personnel in private retail settings. Data were extracted and analysed by two independent reviewers. RESULTS Of the 848 studies retrieved, 23 were included in the review. Studies were on malaria (19/23), malaria and pneumonia (3/23) or respiratory tract infection (1/23). Nine randomised controlled studies, four controlled, non-randomised studies, five uncontrolled interventions, one interventional pre-post study, one cross-over interventional study and three retrospective analyses of RCTs were included. Study quality was poor. Overall, studies showed that POCT can be implemented successfully, leading to improvements in appropriate treatment as measured by outcomes like adherence to treatment guidelines. Despite some concerns by health workers, customers and shop providers were welcoming of POCT implementation in private retail settings. Main themes that arose from the review included the need for well-structured training with post-training certification covering guidelines for test-negative patients, integrated waste management, community sensitization and demand generation activities, financial remuneration and pricing schemes for providers, and formal linkage to healthcare and support. CONCLUSION Our review found evidence that POCT can be implemented successfully in private retail settings in LMICs, but comprehensive protocols are needed. High-quality randomised studies are needed to understand POCTs for infectious diseases other than malaria.
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Affiliation(s)
| | - Van Nguyen
- Doctor of Medicine Programme, Duke National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Thuy Ngan Tran
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | | | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sonia Lewycka
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Public Health Interventions Delivered by Pharmacy Professionals in Low- and Middle-Income Countries in Africa: A Systematic Scoping Review. PHARMACY 2023; 11:pharmacy11010024. [PMID: 36827662 PMCID: PMC9960443 DOI: 10.3390/pharmacy11010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/03/2023] Open
Abstract
Pharmacists and their teams play an important role in providing public health services, however little is known about their level of contribution and the strength of evidence in Africa's Low- and Middle-Income Countries (LMICs). The purpose of this scoping review was to explore and map the available evidence on pharmacy professional-delivered public health interventions in Africa's LMICs. Six electronic databases (Medline, Embase, International Pharmaceutical Abstract, PsycInfo, Maternity and Infant Care, and Cochrane database), relevant grey literature sources, key journals focused on African health issues, and libraries of relevant organizations were searched between January 2010 and December 2020. Studies were included if they reported public health interventions delivered by pharmacy professionals (pharmacists or pharmacy technicians) or their teams. The quality of the individual studies was assessed using an adapted grading system. Thirty-nine studies were included in this review. Pharmacy professionals delivered a wide range of public health interventions, with the most common themes being noncommunicable diseases, infectious diseases, sexual and reproductive health, antimicrobial resistance, and other health conditions, e.g., dental health, unused drugs or waste, minor ailments. The majority of the studies were classified as low-quality evidence. They were predominantly feasibility and acceptability studies conducted in a narrow study area, in a small number of LMICs in Africa, resulting in little evidence of service effectiveness, issues of broad generalizability of the findings, and sustainability. The major constraints to service provision were identified as a lack of training, public recognition, and supporting policies. Pharmacy professionals and their teams across LMICs in Africa have attempted to expand their practice in public health. However, the pace of the expansion has been slow and lacks strong evidence for its generalizability and sustainability. Future research is needed to improve the quality of evidence, which will subsequently serve as a foundation for policy reform, allowing pharmacy professionals to make significant contributions to the public health initiatives in the region.
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Mangeni JN, Abel L, Taylor SM, Obala A, O'Meara WP, Saran I. Experience and confidence in health technologies: evidence from malaria testing and treatment in Western Kenya. BMC Public Health 2022; 22:1689. [PMID: 36068516 PMCID: PMC9446607 DOI: 10.1186/s12889-022-14102-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Low adoption of effective health technologies increases illness morbidity and mortality worldwide. In the case of malaria, effective tools such as malaria rapid diagnostic tests (RDTs) and artemisinin-combination therapies (ACTs) are both under-used and used inappropriately. Individuals’ confidence in RDTs and ACTs likely affects the uptake of these tools. Methods In a cohort of 36 households (280 individuals) in Western Kenya observed for 30 months starting in June 2017, we examined if experience with RDTs and ACTs changes people’s beliefs about these technologies and how those beliefs affect treatment behavior. Household members requested a free RDT from the study team any time they suspected a malaria illness, and positive RDT results were treated with a free ACT. We conducted annual, monthly, and sick visit surveys to elicit beliefs about the accuracy of malaria RDT results and the effectiveness of ACTs. Beliefs were elicited on a 5-point Likert scale from “very unlikely” to “very likely.” Results Over the study period, the percentage of survey respondents that said a hypothetical negative RDT result was “very likely” to be correct increased from approximately 55% to 75%. Controlling for initial beliefs, people who had been tested at least once with an RDT in the past year had 3.6 times higher odds (95% CI [1 1.718 7.679], P = 0.001) of saying a negative RDT was “very likely” to be correct. Confidence in testing was associated with treatment behavior: those who believed a negative RDT was “very likely” to be correct had 1.78 times higher odds (95% CI [1.079 2.934], P = 0.024) of adhering to a negative RDT result (by not taking ACTs) than those who were less certain about the accuracy of negative RDTs. Adherence to a negative test also affected subsequent beliefs: controlling for prior beliefs, those who had adhered to their previous test result had approximately twice the odds (OR = 2.19, 95% CI [1.661 2.904], P < 0.001) of saying that a hypothetical negative RDT was “very likely” to be correct compared to those who had not adhered. Conclusions Our results suggest that greater experience with RDTs can not only increase people’s confidence in their accuracy but also improve adherence to the test result. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14102-y.
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Affiliation(s)
- Judith N Mangeni
- School of Public Health, College of Health Sciences, Moi University, P.O BOX 512-30100, Eldoret, Kenya.
| | - Lucy Abel
- Academic Model Providing Access to Healthcare, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Steve M Taylor
- Division of Infectious Diseases, School of Medicine, Duke University, Durham, NC, USA
| | - Andrew Obala
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | | | - Indrani Saran
- Boston College of Social Work, McGuinn Hall 305, Newton, MA, USA
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OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:315-325. [DOI: 10.1093/ijpp/riac038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/08/2022] [Indexed: 11/14/2022]
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Cohen JL, Leslie HH, Saran I, Fink G. Quality of clinical management of children diagnosed with malaria: A cross-sectional assessment in 9 sub-Saharan African countries between 2007-2018. PLoS Med 2020; 17:e1003254. [PMID: 32925906 PMCID: PMC7489507 DOI: 10.1371/journal.pmed.1003254] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 08/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries. METHODS AND FINDINGS We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7%), malaria (29.7%), and/or gastrointestinal infection (19.7%). Among the 7,340 children with a malaria diagnosis, 32.5% (95% CI: 30.3%-34.7%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4% to 57.1% across countries. In the more recent surveys (2013-2018), 40.7% (95% CI: 37.7%-43.6%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20% of children diagnosed with malaria received no antimalarial at all, and nearly 10% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2% (95% CI: 34.2%-40.1%) would have received a blood test and appropriate antimalarial (44.4% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied. CONCLUSIONS In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care.
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Affiliation(s)
- Jessica L. Cohen
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Hannah H. Leslie
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Indrani Saran
- Boston College School of Social Work, Chestnut Hill, Massachusetts, United States of America
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Alegana VA, Okiro EA, Snow RW. Routine data for malaria morbidity estimation in Africa: challenges and prospects. BMC Med 2020; 18:121. [PMID: 32487080 PMCID: PMC7268363 DOI: 10.1186/s12916-020-01593-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/14/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The burden of malaria in sub-Saharan Africa remains challenging to measure relying on epidemiological modelling to evaluate the impact of investments and providing an in-depth analysis of progress and trends in malaria response globally. In malaria-endemic countries of Africa, there is increasing use of routine surveillance data to define national strategic targets, estimate malaria case burdens and measure control progress to identify financing priorities. Existing research focuses mainly on the strengths of these data with less emphasis on existing challenges and opportunities presented. CONCLUSION Here we define the current imperfections common to routine malaria morbidity data at national levels and offer prospects into their future use to reflect changing disease burdens.
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Affiliation(s)
- Victor A Alegana
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya.
- Geography and Environmental Science, University of Southampton, Southampton, SO17 1BJ, UK.
- Faculty of Science and Technology, Lancaster University, Lancaster, LAI 4YW, UK.
| | - Emelda A Okiro
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya
| | - Robert W Snow
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, 00100, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ, UK
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Bath D, Goodman C, Yeung S. Modelling the cost-effectiveness of introducing subsidised malaria rapid diagnostic tests in the private retail sector in sub-Saharan Africa. BMJ Glob Health 2020; 5:bmjgh-2019-002138. [PMID: 32439690 PMCID: PMC7247415 DOI: 10.1136/bmjgh-2019-002138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/17/2020] [Accepted: 03/21/2020] [Indexed: 11/18/2022] Open
Abstract
Background Over the last 10 years, there has been a huge shift in malaria diagnosis in public health facilities, due to widespread deployment of rapid diagnostic tests (RDTs), which are accurate, quick and easy to use and inexpensive. There are calls for RDTs to be made available at-scale in the private retail sector where many people with suspected malaria seek care. Retail sector RDT use in sub-Saharan Africa (SSA) is limited to small-scale studies, and robust evidence on value-for-money is not yet available. We modelled the cost-effectiveness of introducing subsidised RDTs and supporting interventions in the SSA retail sector, in a context of a subsidy programme for first-line antimalarials. Methods We developed a decision tree following febrile patients through presentation, diagnosis, treatment, disease progression and further care, to final health outcomes. We modelled results for three ‘treatment scenarios’, based on parameters from three small-scale studies in Nigeria (TS-N), Tanzania (TS-T) and Uganda (TS-U), under low and medium/high transmission (5% and 50% Plasmodium falciparum (parasite) positivity rates (PfPR), respectively). Results Cost-effectiveness varied considerably between treatment scenarios. Cost per disability-adjusted life year averted at 5% PfPR was US$482 (TS-N) and US$115 (TS-T) and at 50% PfPR US$44 (TS-N) and US$45 (TS-T), from a health service perspective. TS-U was dominated in both transmission settings. Conclusion The cost-effectiveness of subsidised RDTs is strongly influenced by treatment practices, for which further evidence is required from larger-scale operational settings. However, subsidised RDTs could promote increased use of first-line antimalarials in patients with malaria. RDTs may, therefore, be more cost-effective in higher transmission settings, where a greater proportion of patients have malaria and benefit from increased antimalarial use. This is contrary to previous public sector models, where RDTs were most cost-effective in lower transmission settings as they reduced unnecessary antimalarial use in patients without malaria.
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Affiliation(s)
- David Bath
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Shunmay Yeung
- Department of Clinical Research, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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National and sub-national variation in patterns of febrile case management in sub-Saharan Africa. Nat Commun 2018; 9:4994. [PMID: 30478314 PMCID: PMC6255762 DOI: 10.1038/s41467-018-07536-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 11/07/2018] [Indexed: 11/08/2022] Open
Abstract
Given national healthcare coverage gaps, understanding treatment-seeking behaviour for fever is crucial for the management of childhood illness and to reduce deaths. Here, we conduct a modelling study triangulating household survey data for fever in children under the age of five years with georeferenced public health facility databases (n = 86,442 facilities) in 29 countries across sub-Saharan Africa, to estimate the probability of seeking treatment for fever at public facilities. A Bayesian item response theory framework is used to estimate this probability based on reported fever episodes, treatment choice, residence, and estimated travel-time to the nearest public-sector health facility. Findings show inter- and intra-country variation, with the likelihood of seeking treatment for fever less than 50% in 16 countries. Results highlight the need to invest in public healthcare and related databases. The variation in public sector use illustrates the need to include such modelling in future infectious disease burden estimation.
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