Evaluating Health Workers' Potential Resistance to New Interventions: A Role for Discrete Choice Experiments

BACKGROUND: The currently recommended approach for preventing malaria in pregnancy (MiP), intermittent preventive treatment with sulphadoxine-pyrimethamine (SP-IPT), has been questioned due to the spread of resistance to SP. Whilst trials are underway to test the efficacy of future alternative approaches, it is important to start exploring the feasibility of their implementation. METHODS AND FINDINGS: This study uses a discrete choice experiment (DCE) method to assess the potential resistance of health workers to changing strategies for control of MiP. In Ashanti region in Ghana, 133 antenatal clinic health workers were presented with 16 choice sets of two alternative policy options, each consisting of a bundle of six attributes representing certain clinical guidelines for controlling MiP (type of approach and drug used), possible associated maternal and neo-natal outcomes, workload and financial incentives. The data were analysed using a random effects logit model. Overall, staff showed a preference for a curative approach with pregnant women tested for malaria parasites and treated only if positive, compared to a preventive approach (OR 1.6; p = 0.001). Increasing the incidence of low birth weight or severe anaemia by 1% would reduce the odds of preferring an approach by 18% and 10% respectively. Midwives were more resistant to potential changes to current guidelines than lower-level cadres. CONCLUSIONS: In Ashanti Region, resistance to change by antenatal clinic workers from a policy of SP-IPT to IST would generally be low, and it would disappear amongst midwives if health outcomes for the mother and baby were improved by the new strategy. DCEs are a promising approach to identifying factors that will increase the likelihood of effective implementation of new interventions immediately after their efficacy has been proven

Evaluating Health Workers ’ Potential Resistance to New Interventions: A Role for Discrete Choice Experiments

Background: The currently recommended approach for preventing malaria in pregnancy (MiP), intermittent preventive treatment with sulphadoxine-pyrimethamine (SP-IPT), has been questioned due to the spread of resistance to SP. Whilst trials are underway to test the efficacy of future alternative approaches, it is important to start exploring the feasibility of their implementation. Methods and Findings: This study uses a discrete choice experiment (DCE) method to assess the potential resistance of health workers to changing strategies for control of MiP. In Ashanti region in Ghana, 133 antenatal clinic health workers were presented with 16 choice sets of two alternative policy options, each consisting of a bundle of six attributes representing certain clinical guidelines for controlling MiP (type of approach and drug used), possible associated maternal and neo-natal outcomes, workload and financial incentives. The data were analysed using a random effects logit model. Overall, staff showed a preference for a curative approach with pregnant women tested for malaria parasites and treated only if positive, compared to a preventive approach (OR 1.6; p = 0.001). Increasing the incidence of low birth weight or severe anaemia by 1 % would reduce the odds of preferring an approach by 18 % and 10 % respectively. Midwives were more resistant to potential changes to current guidelines than lower-level cadres. Conclusions: In Ashanti Region, resistance to change by antenatal clinic workers from a policy of SP-IPT to IST woul

Comparison of potential resistance to changes in clinical guidelines from midwives and other ANC staff, under different changes to elements of the current guidelines.

<p>Comparison of potential resistance to changes in clinical guidelines from midwives and other ANC staff, under different changes to elements of the current guidelines.</p

ANC staff preferences for malaria management characteristics, and impact of age, professional status and experience on those preferences.

<p>Note: ***p<0.001, **p<0.01, *p<0.05.</p><p>For categorical variables the reference category is indicated in brackets.</p><p>Interpretation: a negative coefficient indicates reduced preference for the level provided compared to the level in square brackets (for categorical variables) and a reduced preference for an increase in the variable (for quantitative variables).</p

Midwives' and other cadres' preferences for malaria management characteristics, and impact of age and experience on those preferences.

<p>Note: ***p<0.001, **p<0.01, *p<0.05.</p><p>For categorical variables the reference category is indicated in brackets.</p><p>Interpretation: a negative coefficient indicates reduced preference for the level provided compared to the level in square brackets (for categorical variables) and a reduced preference for an increase in the variable (for quantitative variables).</p

Example of a choice scenario.

<p>Example of a choice scenario.</p

Predicted preferences for changes to elements of the current guidelines that recommend SP-IPT for management of malaria in pregnancy.

a<p>Under the current situation, the guidelines for treatment are: preventive approach, use of SP, normal workload, no bonus. This has been shown to lead to the following health outcomes: 10% incidence of low birth weight and 1% incidence of severe anaemia.</p

Description of attributes and levels, coding and priors on preferences.

<p>Description of attributes and levels, coding and priors on preferences.</p

Predicted preferences for changes to elements of the current guidelines, in the event that resistance to SP leads to worse health outcomes.

a<p>Under this scenario, the clinical guidelines for treatment remain the same as currently defined, but resistance to SP would lead to worse health outcomes: 15% incidence of low birth weight and 15% incidence of severe anaemia.</p>b<p>Under this scenario, the clinical guidelines for treatment remain the same as currently defined, but resistance to SP would lead to worse health outcomes: 13% incidence of low birth weight and 5% incidence of severe anaemia.</p>c<p>Under all scenarios of policy 2, the health outcomes are 10% incidence of low birth weight and 1% incidence of severe anaemia.</p