How country of origin, consumer ethnocentrism and consumer xenocentrism impact upon risk and involvement in the malaria medication decision making process in Tanzania

The aim of this study was to examine how Country of Origin, Consumer Ethnocentrism and Consumer Xenocentrism impact upon risk and involvement in the malaria medication decision making processes in Tanzania. An exploratory research design was adopted which helped to discover ideas and insights underlying consumers’ decisions on malaria medication. The inductive research approach was adopted which helped to get a deep understanding of the underlying factors that influenced consumers in decision making when seeking malaria medication in Tanzania. Non-probability sampling specifically purposive sampling was used to select the participants in this study; clinical officers, laboratory technician, traditional medical practitioners, Tanzania Food and Drug Authority (TFDA) key informants and consumers.The findings from the study revealed that consumers have good knowledge on the causes and treatment of malaria disease. However, consumers were shown to differ in making the decision on malaria medication based on availability, affordability, performance and quality of the malaria medication. Risk in the consumption of the anti-malarial remedies influenced some consumers to be highly involved in making the decision, especially when purchasing anti-malarial remedies. The level of involvement was determined by opinion leaders, self-decision making and past experiences. Country of Origin, Consumer Ethnocentrism, Consumer Xenocentrism and product knowledge were found to be the strategies used by consumers to evaluate anti-malarial remedies in order to reduce risk.The findings of this study are expected to provide health professional bodies with knowledge about the decision making process consumers’ use while purchasing anti-malarial remedies. This will help them to boost the standard of the different domestic medical products and hence increase ethnocentric tendencies among Tanzanian consumers. Also the findings are expected to provide useful knowledge to policy makers such as TFDA and government in general which will help them to have a productive conversation with traditional medical practitioners about how the traditional medicines are produced. Hence more research could be undertaken to find out the efficacy and standards of the traditional medicines. In addition, these findings are expected to educate Tanzanian consumers on the consequences of applying self-medication in treating malaria

An intervention to improve provider-patient interaction at methadone maintenance treatment in China.

BackgroundThis study evaluated an intervention aiming to improve methadone maintenance therapy (MMT) service providers' interaction with their patients in China.MethodsSixty-eight MMT clinics were randomized to either an intervention or a control condition. Providers in the intervention group attended three group training sessions to enhance their communication skills. Trained providers were encouraged to practice the taught communication skills through provider-initiated individual sessions with their patients. A total of 418 service providers completed assessments from baseline to 24-month. Linear mixed-effects regression models were used to compare self-reported short-term and sustained improvement in provider-patient interaction between the intervention and the control conditions.ResultsThe intervention group service providers perceived significantly greater short-term and sustained improvement in provider-patient interaction compared to the control group service providers (estimated difference (±SE): 1.20 (0.24) and 1.35 (0.33), respectively; p-values < 0.0001). Providers' baseline job satisfaction was significantly associated with a greater perceived improvement in provider-patient interaction for both periods (reg. coef. (±SE): 0.02 (0.01) and 0.04 (0.01) for short-term and sustained periods, respectively; p-values < 0.01).ConclusionStudy findings suggest that the intervention could be beneficial for improving perceived provider-patient interaction in MMT programs. Service providers' job satisfaction should be addressed in training programs for the improvement of provider-patient interaction

The effect of motivational factors on community health workers’ level of satisfaction in Kishapu, Tanzania

지역보건원(CHW, Community Health Worker)은 의료인력이 절대적으로 부족한 저개발국가에서 일차보건의료의 필요를 채우는 매우 핵심적인 요소이다. 그래서 1978년 알마아타 선언부터 최근의 보편적의료보장(Universal Health Coverage)에서도 지역보건원의 역할과 활동이 중요시 되고 있다. 문제는 이러한 지역보건원들의 만족도를 어떻게 높이느냐이다. 만약 지역보건원의 선발 시 어떤 지역보건원을 선발하면 향후 만족도가 높을 것인지, 그리고 사업 수행 과정에서 어떤 개입(Intervention)요소를 넣으면 만족도가 높아지는지 알 수 있다면, 지역보건원들의 활동 강화 뿐 만 아니라 장기적인 활동도 기대 할 수 있을 것이다. 이를 확인하기 위해 국제구호개발 NGO, 굿네이버스에서 진행한 ‘탄자니아 키샤푸 지역의 마을보건요원 활성화를 통한 모성보건 증진사업’의 종료선 조사 자료를 기반으로 지역보건원들의 동기부여 요인과 만족도의 연관성을 조사하는 연구를 수행하였다. 그 결과, 지역보건원의 선발 시 교육수준이 높고, 지역사회에 대한 봉사심이 동기요인인 지역보건원을 선발하는 것이 향후 지역보건원의 만족도가 높다는 결과가 나왔다. 또한 사업을 수행하는 과정에서 지역사회의 의료인력과 좋은 관계를 유지하고, 업무량이 지나치게 높지 않으며, 지역보건원들이 적절한 서비스를 제공 할 수 있는 활동물품이 지원 될 때 지역보건원의 만족도가 통계적으로 유의미하게 높은 것을 확인 할 수 있었다. Community health workers (CHWs) are key elements in meeting the needs of primary health care in low- and mid-income countries where medical health workers are absolutely scarce. Therefore, from the Alma-Ata Declaration in 1978 to the recent promotion of Universal Health Coverage, the roles and activities of CHWs have become crucial. The important question is how to increase the satisfaction of these CHWs. When selecting CHWs if we understand what factors influence a CHW to have high motivation and what interventions may improve it, not only will it strengthen CHW activities, but we can also expect long-term mobilization. To understand the relationship between motivational factors and satisfaction of CHWs, this study analyzed the data from the end-line survey of the 'Maternal Health Promotion Project through Mobilization of Community Health Workers in Kishapu, Tanzania' implemented by Good Neighbors, an international development NGO. As a result, CHWs with higher education level and those whose motivation for participation was ‘volunteer work for community’ had higher level of satisfaction. In addition, in the process of carrying out the project, it was found that the satisfaction of CHWs was statistically significantly high when relationship with the medical personnel in the local community is well-maintained, the workload is not too high, and when provided with material that would support their activities.open석

Predicting the cost-effectiveness of strategies for case management of "plasmodium falciparum" malaria in Sub-Saharan Africa

Malaria is an important cause of death and illness in children and adults, particularly in the tropics. The World Health Organization (WHO) estimated that, worldwide, there were 655,000 malaria deaths in 2010, of which 91% were in Africa, and 216 million cases, of which 91% were due to Plasmodium falciparum (P.falciparum). However, case estimates are particularly uncertain, due to the ambiguous definition of a malaria case and methods used for their quantification. Efficacious interventions against malaria exist, but it is not clear what their full impact will be or how they could be most efficiently implemented. A cornerstone of malaria strategies is case management, which consists primarily of administering drug treatment to cure the disease, and was the focus of this thesis. Currently, the aim of most countries in sub-Saharan Africa is to control malaria and reduce the disease burden by increasing coverage of effective preventive and curative interventions. However, in some places successes in reducing disease burden have lead countries to consider whether and how local interruption of malaria transmission could be achieved and maintained. In these settings, improved surveillance is critical, but it is not clear what it should consist of. It is important to consider the long-term effects of intervention and intervention combinations, such as the dynamic effects on population immunity, which are not captured within the time frame of intervention trials, and their impact in real health systems. Mathematical models can offer guidance in these situations. In 2006, Smith and colleagues presented individual-based stochastic simulation models of the biology and epidemiology of P. falciparum malaria. As part of this project, a model for the case management of malaria was developed which permitted simulation of the dynamic effects of treatment on transmission. For this thesis, these models were extended to low-transmission settings and used to predict the levels of passive case detection and treatment that would be needed to prevent local re-establishment of transmission in different settings. We assessed the uncertainties in model predictions resulting from stochastic variation and from the assumptions in our model formulations. We found that, even at rather low levels of receptivity, case management alone could not reliably prevent re-establishment of P. falciparum malaria transmission in the face of medium to high importation rates. Model assumptions regarding rates of decay of natural immunity resulted in significantly different odds of transmission re-establishment, highlighting the urgent need for research in this area. We also developed a literature-based estimate of the per-person cost of screening an entire population for P.falciparum infection using diagnostic tests. We used this cost estimate along with simulation model outputs to analyse the cost-effectiveness of mass screening and treatment (MSAT) as a burden-reducing intervention, relative to the cost-effectiveness of scaling up case management or insecticide-treated net (ITN) coverage. We found that MSAT may be a cost-effective strategy at medium to high transmission levels and at moderate ITN coverage. This finding is in contrast to the current focus on MSAT as an intervention for low or near-elimination settings. Future analyses comparing the cost-effectiveness of case management with that of preventive interventions should include both disability and deaths averted (expressed in DALYs) as an outcome measure. The analysis also highlighted the need for alternative measures of uncomplicated malaria burden to capture the impact of case management in simulation models of its cost-effectiveness. An approach to do this, using data available in community surveys, is presented in this thesis. Finally, the previous case management model was extended to allow a finer-grained simulation of health systems and a drug action model was integrated to allow simulation of the effects of case management on parasite densities. The development and parameterization of the new case management model, and its potential future uses and limitations, are presented in the last sections of this thesis

Targeting malaria elimination : an assessment of malaria control interventions for children in Zanzibar

Background: After decades of neglect, a renewed global focus on malaria was initiated in the 90s, followed by global financial support in the early 2000s. Zanzibar has been in the forefront of these renewed efforts: Case management and vector-control interventions have been implemented and scaled-up rapidly, resulting in markedly reduced malaria transmission and the targeting of malaria elimination. Aim: The overall aim of this thesis was to assess caretakers' uptake of malaria control interventions for under-five children in Zanzibar, an area where malaria transmission has rapidly decreased. Methods: In Study I, a follow-up survey of 210 caretakers was performed to assess caretaker adherence to Artemisinin-based Combination Therapies (ACTs), where caretakers were interviewed in their homes four days after receiving the three-day treatment for their children. In Studies II & III, an assessment of the effective coverage of vector control interventions was carried out in two community-based surveys in 2006 and 2009, with 509 and 560 caretakers, respectively. Both surveys were done in North A and Micheweni districts. In the 2006 survey, the system effectiveness of a targeted free mass distribution of long-lasting insecticidal nets (LLINs) was also assessed, and in the 2009 survey, caretaker perceptions of the malaria situation in Zanzibar and of vector control interventions, were evaluated. Perceptions of malaria and vector control interventions were further explored by conducting in-depth interviews with 19 caretakers (Study IV). Results: Moderate adherence of 77% to Artesunate-Amodiaquine (AsAq) was documented, and was mostly due to misunderstanding or forgetting the correct dose regimen. Factors associated with adherence were caretaker's education exceeding 7 years and receiving the exact number of pills to complete the treatment regimen, while administering the first dose at the health facility resulted in complete adherence (I). System effectiveness of the targeted mass distribution had increased in the distribution scale-up in North A district as compared to the pilot distribution in Micheweni. This resulted in high (87%) and equitable effective coverage of LLINs in under-five children in the North A district. Effective coverage was associated with receiving an LLIN and thinking that LLINs were better than conventional nets (II). Effective coverage of LLINs in under-fives in the 2009 survey was also equitable and relatively high (70%) following an un-targeted mass distribution, while effective coverage of IRS was as high as 95%, resulting in almost perfect effective coverage (98%) of at least one vector control intervention (III). Seasonality was found to interrupt continuous adherence to bed-nets (III & IV). Low risk perceptions of malaria (III & IV) were not significantly associated with effective coverage (III), although the higher perceived risk for children is in line with the finding that children were prioritized for use of bed-nets (III & IV). Vector control interventions were generally well accepted (II-IV), and caretakers appreciated the importance of their continued use as malaria further declines (III). Conclusions: Findings of this thesis indicate that caretaker uptake of malaria control interventions for children remains high in Zanzibar in the face of declining malaria burden. ACTs, freely provided at public health facilities, were relatively well adhered to, and the high effective coverage of IRS, together with satisfactory effective coverage of LLINs, provided an almost perfect effective coverage of vector control interventions. This high effective coverage elevates the prospects of achieving malaria elimination in Zanzibar

Healthcare provider and pregnant women's perspectives on the implementation of intermittent screening and treatment with dihydroartemisinin-piperaquine for malaria in pregnancy in western Kenya: a qualitative study.

BACKGROUND: In malaria endemic regions in Kenya, pregnant women are offered long-lasting insecticidal nets and intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP) at antenatal care (ANC) to prevent the adverse effects of malaria. Fears of growing SP resistance have heightened the search for alternative strategies. The implementation feasibility of intermittent screening and treatment (ISTp) with dihydroartemisinin-piperaquine (DP) in routine ANC settings was evaluated using qualitative and quantitative methods, including the exploration of healthcare provider and pregnant women's perceptions. METHODS: Qualitative methods included data from 13 focus group discussions (FGDs) with pregnant women and 43 in-depth interviews with healthcare providers delivering ANC services. FGDs were conducted with women who had received either ISTp-DP or current policy (IPTp-SP). Thematic analysis was used to explore experiences among women and providers and findings were used to provide insights into results of the parallel quantitative study. RESULTS: Women were accepting of testing with rapid diagnostic tests (RDTs) and receiving treatment if malaria positive. Providers perceived DP to be an effective drug and well tolerated by women. Some providers indicated a preference for test and treat strategies to reduce unnecessary exposure to medication in pregnancy, others preferred a hybrid strategy combining screening at every ANC visit followed by IPTp-SP for women who tested negative, due to the perception that RDTs missed some infections and concerns about the growing resistance to SP. Testing with RDTs during ANC was appreciated as it was perceived to reduce wait times. The positive attitude of healthcare providers towards ISTp supports findings from the quantitative study that showed a high proportion (90%) of women were tested at ANC. There were concerns about affordability of DP and the availability of sufficient RDT stocks. CONCLUSION: In ANC settings, healthcare providers and pregnant women found ISTp-DP to be an acceptable strategy for preventing malaria in pregnancy when compared with IPTp-SP. DP was considered an effective anti-malarial and a suitable alternative to IPTp-SP in the context of SP resistance. Despite providers' lack of confidence in RDT results at current levels of sensitivity and specificity, the quantitative findings show their willingness to test women routinely at ANC

Contextual Effect of the Integrated Non-Communicable Disease Health Post on the Performance of Community Health Workers: A Multilevel Analysis Evidence from Karanganyar, Central Java

Background: Epidemiological transition is causing a shift from Communicable to Non­Communicable Diseases (NCD). NCD is a serious threat because it impacts decreasing productivity and increasing economic and social burdens for the community. The control of NCD risk factors in Indonesia is carried out by empowering the community through the Inte­grated Non­­-­­Com­municable Diseases Health Post (Posbindu NCD). One of the important factors determining the success of imple­menting Posbindu is the role of cadres. This study aims to analyze the factors that affect the performance of Posbindu cadres.Subjects and Method: This was an analytic obser­vational study with a cross-sectional design. The study was conducted in 25 posbindus in Karanganyar, Central Java, from February to April 2020. A sample of 200 cadres from 25 cadres was selected by stratified random sam­pling. The dependent variable was the perform­ance of the Pos­­bindu cadres. The independent variables were training, ability, length of em­ployment, motivation, the leader­­ship of the Posbindu chair­man, social network support and appreciation. Data were analyzed using multilevel logistic regression with Stata 13.Results: Job performance increa­sed with trai­ning (b= 1.75; 95% CI= 0.28 to 3.22; p= 0.019), good ability (b= 2.50; 95% CI= 0.95 to 4.04; p= 0.002)­, tenure ≥1 year (b= 1.99; 95% CI= 0.05 to 3.92; p= 0.044), strong moti­vation (b= 2.57; 95% CI= 1.25 to 3.89; p <0.001), good leadership of Posbindu chairman (b= 1.73; 95% CI= 0.44 to 3.03; p= 0.009), and strong social network support (b= 1.24; 95% CI= 0.14 to 2.34; p= 0.028). Incentive increased job performance, but it was statistically non-signi­ficant (b= 1.19; 95% CI= -0.35 to 2.73; p= 0.132). Posbindu had a strong contextual effect on job performance with an ICC of 62.73%.Conclusion: Job performance in­­creases with training, good abilities, tenure ≥1 year, strong moti­vation, good leadership of Posbindu chair­man, strong social network support, and appro­priate incentives. Posbindu has a strong con­textual effect on job perform­ance.Keywords: performance, cadre, non-communi­cable diseaseCorrespondence: Eka Siti Chasanah. Masters Program in Public Health, Universitas Sebelas Maret. Jl. Ir. Sutami 36A, Surakarta 57126, Central Java. Email: ekas­[email protected]. Mobile: +62­81329017587.Journal of Health Policy and Management (2020), 05(03): 204-214https://doi.org/10.26911/thejhpm.2020.05.03.06

L’efficacité contestée du recours aux agents de santé communautaires pour la prise en charge du paludisme : évaluation du programme burkinabé dans les districts de Kaya et de Zorgho

Contexte. Le paludisme provoque annuellement le décès d’environ 25 000 enfants de moins de cinq ans au Burkina Faso. Afin d’améliorer un accès rapide à des traitements efficaces, les autorités burkinabées ont introduit en 2010 la prise en charge du paludisme par les agents de santé communautaires (ASC). Alors que son efficacité a été démontrée dans des études contrôlées, très peu d’études ont évalué cette stratégie implantée dans des conditions naturelles et à l’échelle nationale. Objectif. L’objectif central de cette thèse est d’évaluer, dans des conditions réelles d’implantation, les effets du programme burkinabé de prise en charge communautaire du paludisme sur le recours aux soins des enfants fébriles. Les objectifs spécifiques sont : (1) de sonder les perceptions des ASC à l’égard du programme et explorer les facteurs contextuels susceptibles d’affecter leur performance ; (2) d’estimer le recours aux ASC par les enfants fébriles et identifier ses déterminants ; (3) de mesurer, auprès des enfants fébriles, le changement des pratiques de recours aux soins induit par l’introduction d’une intervention concomitante – la gratuité des soins dans les centres de santé. Méthodes. L’étude a été conduite dans deux districts sanitaires similaires, Kaya et Zorgho. Le devis d’évaluation combine des volets qualitatifs et quantitatifs. Des entrevues ont été menées avec tous les ASC de la zone à l’étude (N=27). Des enquêtes ont été répétées annuellement entre 2011 et 2013 auprès de 3002 ménages sélectionnés aléatoirement. Les pratiques de recours aux soins de tous les enfants de moins de cinq ans ayant connu un récent épisode de maladie ont été étudiées (N2011=707 ; N2012=787 ; N2013=831). Résultats. Les résultats montrent que le recours aux ASC est très modeste en comparaison de précédentes études réalisées dans des milieux contrôlés. Des obstacles liés à l’implantation du programme de prise en charge communautaire du paludisme ont été identifiés ainsi qu’un défaut de faisabilité dans les milieux urbains. Enfin, l’efficacité du programme communautaire a été négativement affectée par l’introduction de la gratuité dans les centres de santé. Conclusion. La prise en charge communautaire du paludisme rencontre au Burkina Faso des obstacles importants de faisabilité et d’implantation qui compromettent son efficacité potentielle pour réduire la mortalité infantile. Le manque de coordination entre le programme et des interventions locales concomitantes peut générer des effets néfastes et inattendus.Context. In Burkina Faso, malaria causes approximately 25,000 deaths every year in children under five. In 2010, national health authorities introduced case management of malaria by community health workers (CHWs) as a way to increase prompt access to effective treatments. While this strategy’s efficacy has been demonstrated in controlled studies, very few studies evaluated its effectiveness under real-world and nation-wide conditions of implementation. Objective. The overarching aim of this thesis is to evaluate the effects of the Burkinabè program on treatment-seeking practices in febrile children. The specific objectives are: (1) to examine CHWs’ perceptions and investigate the contextual factors likely to affect their performance; (2) to estimate the use of CHWs in febrile children and its determinants; (3) to evalauate changes in treatment-seeking practices induced by the introduction of a concomitant intervention – the removal of user fees at health centres. Methods. The study was conducted in two similar health districts, Kaya and Zorgho. The evaluation design integrates quantitative and qualitative components. Interviews were carried out with all CHWs in the study area (N=27). Surveys were repeated every year from 2011 to 2013 in 3002 randomly selected households. Treatment-seeking practices of all children with a recent sickness episode (N2011=707; N2012=787; N2013=831) were examined. Results. Results show that the use of CHWs is really low in comparison to previous controlled studies. Feasibility issues in urban areas and barriers to implementation of the community case management of malaria programme were identified. Moreover, its effectiveness in rural areas was challenged by the removal of user fees at health centres. Conclusion. In Burkina Faso, community case management of malaria faces serious challenges of feasibility and implentation. These challenges compromise the programme’s potential to reduce child morbidity and mortality. The lack of integration between the programme and local concomitant interventions can generate unpredicted adverse effects

Community case management and referral of children with fever within the primary health care system in Uganda.

Malaria remains a leading cause of under-five childhood morbidity and mortality in Sub- Saharan Africa and a third of febrile children lack prompt access to effective malaria case management services. Community health workers (CHW) provide an opportunity to deliver malaria diagnosis and treatment in primary health care settings closer to populations at risk. Recognising the potential of CHWs, many malaria endemic countries have national CHW programmes to provide case management services for malaria and other common childhood infections. However, for children that present to CHWs with signs and symptoms they are unable to manage current CHW guidelines indicate referral to the nearest health centre. Despite the scale-up of CHW programmes, there is little understanding of the referral processes and this thesis aimed to examine the processes as part of malaria case management trials with CHWs conducted in Rukungiri District, Uganda. The referral process was explored in four objectives that mirrored a child’s continuum of care beginning at the CHW and ending at the public health centre. The first objective assessed CHWs adherence to the referral guidelines; the second examined the effect of CHWs using malaria rapid diagnostic tests (mRDT) on referrals; and the third examined caregiver’s compliance to referral advice. Finally, the fourth objective described changes in outpatient department (OPD) visits and case-mix at health facilities over a 24- month period, before and after the start of the trials. The referral study was carried out as part of two cluster randomised trials which assessed the impact of CHWs using mRDTs on appropriate treatment of malaria when compared to presumptive diagnosis. Secondary analyses of routine CHW records revealed that two-thirds of children eligible for referral were not referred, including children with severe malaria. Although, the use of mRDTs improved the odds of referral compared to presumptive diagnoses, almost 90% of caregivers failed to comply with CHW referral advice which was associated with factors such as distance from health facilities, seasonality and treatment seeking during the weekend. Compared to the pre-trial period, OPD visits at health facilities declined and case-mix changed following the start of the trial. Overall these findings show the referral processes can be monitored using routinely available data using appropriate indicators. Changes in the number and type of visits seen at health facilities, indicate that health resources could be allocated differently. Most importantly, these data show that the referral process intended to ensure the care of children with referral signs and symptoms did not perform well. Referral is key component of primary health care and the process requires strengthening to ensure a continuum of care in community case management settings. New interventions should be developed involving CHWs, caregivers and health facilities to overcome the referral barriers and consequently improve CHWs adherence to referral guidelines as well as caregivers compliance to referral advice

Evidence review and analysis of provider behavior change opportunities

This paper reviews the evidence on the promise of behavioral economics to improve health outcomes through service provider interventions in five critical health areas. This analysis utilizes the limited existing evidence to suggest where and how behavioral economics interventions may be most effective and where further research may contribute most