A mobile health technology platform for quality assurance and quality improvement of malaria diagnosis by community health workers

<div><p>Background</p><p>Community health workers (CHWs) play an important role in improving access to services in areas with limited health infrastructure or workforce. Supervision of CHWs by qualified health professionals is the main link between this lay workforce and the formal health system. The quality of services provided by lay health workers is dependent on adequate supportive supervision. It is however one of the weakest links in CHW programs due to logistical and resource constraints, especially in large scale programs. Interventions such as point of care testing using malaria rapid diagnostic tests (RDTs) require real time monitoring to ensure diagnostic accuracy. In this study, we evaluated the utility of a mobile health technology platform to remotely monitor malaria RDT (mRDT) testing by CHWs for quality improvement.</p><p>Methods</p><p>As part of a large implementation trial involving mRDT testing by CHWs, we introduced the Fionet system composed of a mobile device (Deki Reader, DR) to assist in processing and automated interpretation of mRDTs, which connects to a cloud-based database which captures reports from the field in real time, displaying results in a custom dashboard of key performance indicators. A random sample of 100 CHWs were trained and provided with the Deki Readers and instructed to use it on 10 successive patients. The CHWs interpretation was compared with the Deki Reader’s automatic interpretation, with the errors in processing and interpreting the RDTs recorded. After the CHW entered their interpretation on the DR, the DR provided immediate, automated feedback and interpretation based on its reading of the same cassette. The study team monitored the CHW performance remotely and provided additional support.</p><p>Results</p><p>A total of 1251 primary and 113 repeat tests were performed by the 97 CHWs who used the DR. 91.6% of the tests had agreement between the DR and the CHWs. There were 61 (4.9%) processing and 52 (4.2%) interpretation errors among the primary tests. There was a tendency towards lower odds of errors with increasing number and frequency of tests, though not statistically significant. Of the 62 tests that were repeated due to errors, 79% achieved concordance between the CHW and the DR. Satisfaction with the use of the DR by the CHWs was high.</p><p>Conclusions</p><p>Use of innovative mHealth strategies for monitoring and quality control can ensure quality within a large scale implementation of community level testing by lay health workers.</p></div

Frequency and type of RDT device and processing errors reported by Deki Reader.

<p>Frequency and type of RDT device and processing errors reported by Deki Reader.</p

Interpretation concordance between CHW and Deki Reader.

<p>Interpretation concordance between CHW and Deki Reader.</p

Test-level regressions¹ of association of processing and reading errors from Deki Reader with CHW and test characteristics.

<p>Test-level regressions<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0191968#t005fn001" target="_blank">¹</a> of association of processing and reading errors from Deki Reader with CHW and test characteristics.</p

Deki Reader use.

<p>Deki Reader use.</p

Baseline Health-Related Quality of Life and 10-Year All-Cause Mortality among 1739 Chinese Adults

<div><p>Background and Purpose</p><p>Health-related quality of life (HRQOL) may be associated with the longevity of patients; yet it is not clear whether this association holds in a general population, especially in low- and middle-income countries. The objective of this study was to determine whether baseline HRQOL was associated with 10-year all-cause mortality in a Chinese general population.</p><p>Methods</p><p>A prospective cohort study was conducted from 2002 to 2012 on 1739 participants in 11 villages of Beijing. Baseline data on six domains of HRQOL, chronic diseases and cardiovascular risk factors were collected in either 2002 (n = 1290) or 2005 (n = 449). Subjects were followed through the end of the study period, or until they were censored due to death or loss to follow-up, whichever came first.</p><p>Results</p><p>A multivariable Cox model estimated that <i>Total HRQOL score</i> (bottom 50% versus top 50%) was associated with a 44% increase in all-cause mortality (Hazard Ratio [HR] = 1.44; 95% confidence interval [CI]: 1.00-2.06), after adjusting for sex, age, education levels, occupation, marital status, smoking status, fruit intake, vegetable intake, physical exercise, hypertension, history of a stroke, myocardial infarction, chronic respiratory disease, and kidney disease. Among the six HRQOL domains, the <i>Independence</i> domain had the largest fully adjusted HR (HR = 1.66; 95% CI: 1.13-2.42), followed by <i>Psychological</i> (HR = 1.47; 95% CI: 1.03-2.09), <i>Environmental</i> (HR = 1.43, 95% CI: 1.003-2.03), <i>Physical</i> (HR = 1.38; 95% CI: 0.97-1.95), <i>General</i> (HR = 1.37; 95% CI: 0.97-1.94), and the <i>Social</i> domain (HR = 1.15; 95% CI: 0.81-1.65).</p><p>Conclusion</p><p>Lower HRQOL, especially the inability to live independently, was associated with a significantly increased risk of 10-year all-cause mortality. The inclusion of HRQOL measures in clinical assessment may improve diagnostic accuracy to improve clinical outcomes and better target public health promotions.</p></div

Mortality rates and adjusted hazard ratios by baseline total quality of life scores among residents of Beijing, China (n = 1739).

<p>Abbreviations: HRQOL, quality of life; CI, Confidence Interval; HR, Hazard Ratios.</p>a<p>Hazard ratios (HR) and associated 95% CIs for <b><i>total HRQOL scores</i></b> were calculated by one Cox model which included sex, age, education levels, occupation, marital status, smoking, fruit intake > = 250 g/week, vegetable intake> = 250 g/day, physical exercise, hypertension, and history of stroke, myocardial infarction, chronic respiratory diseases, and kidney diseases.</p

Age-and-sex adjusted and multivariable adjusted hazard ratios of all-cause mortality by baseline six separate HRQOL domains and one HRQOL transition item among residents of Beijing, China (n = 1739).

<p>Abbreviations: HRQOL, health-related quality of life; CI, confidence interval; HR, hazard ratios; SD, standard deviation.</p>a<p>Hazard ratios (HR) and associated 95% CIs were calculated by Cox hazard proportional models after adjusting for sex, age, education levels, occupation, marital status, smoking, alcohol drinking, fruit intake > = 250 g/week, vegetable intake> = 250 g/day, physical exercise, hypertension, diabetes, and history of stroke, myocardial infarction, chronic respiratory diseases, and kidney diseases.</p

Improving rational use of ACTs through diagnosis-dependent subsidies: Evidence from a cluster-randomized controlled trial in western Kenya

<div><p>Background</p><p>More than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector, where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over the counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for nonmalaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy.</p><p>Methods and findings</p><p>We conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population approximately 160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests (RDTs) on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT-positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention, and referral services. We conducted 4 population-based surveys—at baseline, 6 months, 12 months, and 18 months—of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations (GEEs) to account for clustering with prespecified adjustment for gender, age, education, and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria, and 10,870 vouchers were issued. A total of 7,416 randomly selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, <i>n =</i> 4,653). The gender of enrolled participants was balanced in children (49.8%, <i>n =</i> 2,318 boys versus 50.2%, <i>n =</i> 2,335 girls), but more adult women were enrolled than men (78.0%, <i>n =</i> 2,139 versus 22.0%, <i>n =</i> 604). At baseline, 67.6% (<i>n =</i> 1,362) of participants took an ACT for their illness, and 40.3% (<i>n =</i> 810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (<i>n =</i> 454) in the intervention arm and 43.4% (<i>n =</i> 389) in the control arm had a malaria diagnostic test for their recent fever (adjusted risk difference [RD] = 9 percentage points [pp]; 95% CI 2–15 pp; <i>p</i> = 0.015; adjusted risk ratio [RR] = 1.20; 95% CI 1.05–1.38; <i>p</i> = 0.015). By 18 months, the ARR had increased to 1.25 (95% CI 1.09–1.44; <i>p</i> = 0.005). Rational use of ACTs in the intervention area increased from 41.7% (<i>n =</i> 279) at baseline to 59.6% (<i>n =</i> 403) and was 40% higher in the intervention arm at 18 months (ARR 1.40; 95% CI 1.19–1.64; <i>p</i> < 0.001). While intervention effects increased between 12 and 18 months, we were not able to estimate longer-term impact of the intervention and could not independently evaluate the effects of the free testing and the voucher on uptake of testing.</p><p>Conclusions</p><p>Diagnosis-dependent ACT subsidies and community-based interventions that include the private sector can have an important impact on diagnostic testing and population-wide rational use of ACTs. Targeting of the ACT subsidy itself to those with a positive malaria diagnostic test may also improve sustainability and reduce the cost of retail-sector ACT subsidies.</p><p>Trial registration</p><p>ClinicalTrials.gov <a href="https://clinicaltrials.gov/ct2/show/NCT02461628" target="_blank">NCT02461628</a></p></div

Association of total HRQOL score and demographic and health characteristics (n = 1,739).

<p>*Those without serum measurement (N = 19) were excluded.</p><p>#p values were calculated using the Wilcoxon rank test, except where noted.</p><p>∧ p values were calculated using the Kruskal-Wallis rank test.</p