What makes an academic paper useful for health policy?

Evidence-based policy ensures that the best interventions are effectively implemented. Integrating rigorous, relevant science into policy is therefore essential. Barriers include the evidence not being there; lack of demand by policymakers; academics not producing rigorous, relevant papers within the timeframe of the policy cycle. This piece addresses the last problem. Academics underestimate the speed of the policy process, and publish excellent papers after a policy decision rather than good ones before it. To be useful in policy, papers must be at least as rigorous about reporting their methods as for other academic uses. Papers which are as simple as possible (but no simpler) are most likely to be taken up in policy. Most policy questions have many scientific questions, from different disciplines, within them. The accurate synthesis of existing information is the most important single offering by academics to the policy process. Since policymakers are making economic decisions, economic analysis is central, as are the qualitative social sciences. Models should, wherever possible, allow policymakers to vary assumptions. Objective, rigorous, original studies from multiple disciplines relevant to a policy question need to be synthesized before being incorporated into policy

How can malaria rapid diagnostic tests achieve their potential? A qualitative study of a trial at health facilities in Ghana.

BACKGROUND: Rapid diagnostic tests (RDTs) for malaria are at the early stages of introduction across malaria endemic countries. This is central to efforts to decrease malaria overdiagnosis and the consequent overuse of valuable anti-malarials and underdiagnosis of alternative causes of fever. Evidence of the effect of introducing RDTs on the overprescription of anti-malarials is mixed. A recent trial in rural health facilities in Ghana reduced overprescription of anti-malarials, but found that 45.5% patients who tested negative with RDTs were still prescribed an anti-malarial. METHODS: A qualitative study of this trial was conducted, using in-depth interviews with a purposive sample of health workers involved in the trial, ranging from those who continued to prescribe anti-malarials to most patients with negative RDT results to those who largely restricted anti-malarials to patients with positive RDT results. Interviews explored the experiences of using RDTs and their results amongst trial participants. RESULTS: Meanings of RDTs were constructed by health workers through participation with the tests themselves as well as through interactions with colleagues, patients and the research team. These different modes of participation with the tests and their results led to a change in practice for some health workers, and reinforced existing practice for others. Many of the characteristics of RDTs were found to be inherently conducive to change, but the limited support from purveyors, lack of system antecedents for change and limited system readiness for change were apparent in the analysis. CONCLUSIONS: When introduced with a limited supporting package, RDTs were variously interpreted and used, reflecting how health workers had learnt how to use RDT results through participation. To build confidence of health workers in the face of negative RDT results, a supporting package should include local preparation for the innovation; unambiguous guidelines; training in alternative causes of disease; regular support for health workers to meet as communities of practice; interventions that address negotiation of health worker-patient relationships and encourage self-reflection of practice; feedback systems for results of quality control of RDTs; feedback systems of the results of their practice with RDTs; and RDT augmentation such as a technical and/or clinical troubleshooting resource

Requests for malaria prevention advice to Public Health England, Malaria Reference Laboratory: a retrospective observational study.

BACKGROUND: The Malaria Reference Laboratory (MRL) provides a specialist advisory service for complex queries from healthcare professionals. This study was conducted to examine the types of queries that general practitioners and nurses ask around malaria prophylaxis, to identify issues which are not obvious from existing easily available sources. METHODS: We reviewed all the faxed requests received over a period of 6 months at the MRL. RESULTS: There were a total of 608 queries (104 concerning children) relating to 450 travellers. 98% of requests were from general practice (GP or practice nurse). The most common enquiries were about travellers to multiple destinations (95/529, 17.96%), prolonged duration of travel (70/529, 13.23%), the immunosuppressed (38/529, 7.18%), potential drug interactions (69/529, 13.04%), pregnancy and conception (36, 6.81%). 79/529 queries related to patients with multiple conditions requiring expert advice from the MRL. 27% of the enquiries could have been answered by consulting the UK malaria prophylaxis guidelines available on the MRL site. CONCLUSION: Most queries where practitioners requested help were not easily answered with existing guidelines. Pregnancy and epilepsy are areas where guidance needs strengthening. Difficulties for practitioners were multifactorial, it would be difficult to address all scenarios in guidelines without making them unwieldy

Motivation, money and respect: a mixed-method study of Tanzanian non-physician clinicians.

Poor quality of care is a major concern in low-income countries, and is in part attributed to low motivation of healthcare workers. Non-physician clinicians (mid-level cadre healthworkers) are central to healthcare delivery in half of the countries in Africa, but while much is expected from these clinicians, little is known about their expectations and motivation to perform well. Understanding what motivates these healthworkers in their work is essential to provide an empirical base for policy decisions to improve quality of healthcare. In 2006-2007, we conducted a mixed-method study to evaluate factors affecting motivation, including reasons for varying levels of motivation, amongst these clinicians in Tanzania. Using a conceptual framework of 'internal' and 'environmental' domains known to influence healthworker motivation in low-income countries, developed from existing literature, we observed over 2000 hospital consultations, interviewed clinicians to evaluate job satisfaction and morale, then designed and implemented a survey instrument to measure work motivation in clinical settings. Thematic analysis (34 interviews, one focus group) identified social status expectations as fundamental to dissatisfaction with financial remuneration, working environments and relationships between different clinical cadres. The survey included all clinicians working in routine patient care at 13 hospitals in the area; 150 returned sufficiently complete data for psychometric analysis. In regression, higher salary was associated with 'internal' motivation; amongst higher earners, motivation was also associated with higher qualification and salary enhancements. Salary was thus a clear prerequisite for motivation. Our results are consistent with the hypothesis that non-salary motivators will only have an effect where salary requirements are satisfied. As well as improvements to organisational management, we put forward the case for the professionalization of non-physician clinicians

Malaria: an update on treatment of adults in non-endemic countries.

Every year people die from malaria in Britain and other industrialised countries. Most of these deaths are avoidable: they occur because a patient or doctor has underestimated the severity of the disease or has not considered the diagnosis early enough. This article provides the essential facts on treating malaria in adults in a non-endemic setting and is based on the best available evidenc

A randomised trial of an eight-week, once weekly primaquine regimen to prevent relapse of plasmodium vivax in Northwest Frontier Province, Pakistan.

BACKGROUND: Vivax malaria remains a major cause of morbidity in the subtropics. To undermine the stability of the disease, drugs are required that prevent relapse and provide reservoir reduction. A 14-day course of primaquine (PQ) is effective but cannot safely be used in routine practice because of its interaction with glucose-6-phosphate dehydrogenase (G6PD) deficiency for which testing is seldom available. Safe and effective use of PQ without the need for G6PD testing would be ideal. The efficacy and safety of an 8-week, once weekly PQ regimen was compared with current standard treatment (chloroquine alone) and a 14-day PQ regimen. METHODS AND PRINCIPAL FINDINGS: 200 microscopically confirmed Plasmodium vivax patients were randomly assigned to either once weekly 8-week PQ (0.75 mg/kg/week), once weekly 8-week placebo, or 14-day PQ (0.5mg/kg/day) in North West Frontier Province, Pakistan. All patients were treated with a standard chloroquine dose and tested for G6PD deficiency. Deficient patients were assigned to the 8-week PQ group. Failure was defined as any subsequent episode of vivax malaria over 11 months of observation. There were 22/71 (31.0%) failures in the placebo group and 1/55 (1.8%) and 4/75 (5.1%) failures in the 14-day and 8-week PQ groups, respectively. Adjusted odds ratios were: for 8-week PQ vs. placebo-0.05 (95%CI: 0.01-0.2, p<0.001) and for 14-day PQ vs. placebo-0.01 (95%CI: 0.002-0.1, p<0.001). Restricted analysis allowing for a post-treatment prophylactic effect confirmed that the 8-week regimen was superior to current treatment. Only one G6PD deficient patient presented. There were no serious adverse events. CONCLUSIONS: A practical radical treatment for vivax malaria is essential for control and elimination of the disease. The 8-week PQ course is more effective at preventing relapse than current treatment with chloroquine alone. Widespread use of the 8-week regimen could make an important contribution to reservoir reduction or regional elimination where G6PD testing is not available. TRIAL REGISTRATION: ClinicalTrials.gov NCT00158587

Imported malaria: key messages in an era of elimination.

Despite concerted efforts to eliminate malaria, it remains a major global cause of morbidity and mortality with over 200 million annual cases. Significant gains have been made, with the annual global malaria incidence and mortality halving over the past twenty years, using tools such as long-lasting insecticide-treated bed nets and artemisinin-based therapies. Malaria is also a significant cause of life-threatening imported infection in the UK. It is vital for front line clinical staff involved in the assessment of acutely ill patients to be aware of the need for early diagnostic testing, malaria epidemiology, markers of severe infection and developments in antimalarial treatments to optimise patient management. The difference between a good and poor outcome is early diagnosis and treatment. Many of the challenges faced in the quest for global eradication, such as availability of appropriate diagnostic tests, and drug and insecticide resistance could also have future implications for imported malaria

Role of healthcare workers in early epidemic spread of Ebola: policy implications of prophylactic compared to reactive vaccination policy in outbreak prevention and control.

Ebola causes severe illness in humans and has epidemic potential. How to deploy vaccines most effectively is a central policy question since different strategies have implications for ideal vaccine profile. More than one vaccine may be needed. A vaccine optimised for prophylactic vaccination in high-risk areas but when the virus is not actively circulating should be safe, well tolerated, and provide long-lasting protection; a two- or three-dose strategy would be realistic. Conversely, a reactive vaccine deployed in an outbreak context for ring-vaccination strategies should have rapid onset of protection with one dose, but longevity of protection is less important. In initial cases, before an outbreak is recognised, healthcare workers (HCWs) are at particular risk of acquiring and transmitting infection, thus potentially augmenting early epidemics. We hypothesise that many early outbreak cases could be averted, or epidemics aborted, by prophylactic vaccination of HCWs. This paper explores the potential impact of prophylactic versus reactive vaccination strategies of HCWs in preventing early epidemic transmissions. To do this, we use the limited data available from Ebola epidemics (current and historic) to reconstruct transmission trees and illustrate the theoretical impact of these vaccination strategies. Our data suggest a substantial potential benefit of prophylactic versus reactive vaccination of HCWs in preventing early transmissions. We estimate that prophylactic vaccination with a coverage >99% and theoretical 100% efficacy could avert nearly two-thirds of cases studied; 75% coverage would still confer clear benefit (40% cases averted), but reactive vaccination would be of less value in the early epidemic. A prophylactic vaccination campaign for front-line HCWs is not a trivial undertaking; whether to prioritise long-lasting vaccines and provide prophylaxis to HCWs is a live policy question. Prophylactic vaccination is likely to have a greater impact on the mitigation of future epidemics than reactive strategies and, in some cases, might prevent them. However, in a confirmed outbreak, reactive vaccination would be an essential humanitarian priority. The value of HCW Ebola vaccination is often only seen in terms of personal protection of the HCW workforce. A prophylactic vaccination strategy is likely to bring substantial additional benefit by preventing early transmission and might abort some epidemics. This has implications both for policy and for the optimum product profile for vaccines currently in development

Geographical and temporal trends in imported infections from the tropics requiring inpatient care at the Hospital for Tropical Diseases, London - a 15 year study.

BACKGROUND: Understanding geographic and temporal trends in imported infections is key to the management of unwell travellers. Many tropical infections can be managed as outpatients, with admission reserved for severe cases. METHODS: We prospectively recorded the diagnosis and travel history of patients admitted between 2000 and 2015. We describe the common tropical and non-tropical infectious diseases and how these varied based on region, reason for travel and over time. RESULTS: A total of 4362 admissions followed an episode of travel. Falciparum malaria was the most common diagnosis (n=1089). Among individuals who travelled to Africa 1206/1724 (70.0%) had a tropical diagnosis. The risk of a tropical infection was higher among travellers visiting friends and relatives than holidaymakers (OR 2.8, p<0.001). Among travellers to Asia non-tropical infections were more common than tropical infections (349/782, 44.6%), but enteric fever (117, 33.5%) of the tropical infections and dengue (70, 20.1%) remained important. The number of patients admitted with falciparum malaria declined over the study but those of enteric fever and dengue did not. CONCLUSIONS: Most of those arriving from sub-Saharan Africa with an illness requiring admission have a classical tropical infection, and malaria still predominates. In contrast, fewer patients who travelled to Asia have a tropical diagnosis but enteric fever and dengue remain relatively common. Those visiting friends and relatives are most likely to have a tropical infection

Changes in the availability and affordability of subsidised artemisinin combination therapy in the private drug retail sector in rural Ghana: before and after the introduction of the AMFm subsidy.

BACKGROUND: Most people with febrile illness are treated in the private drug retail sector. Ghana was among nine countries piloting the Global Fund Affordable Medicines Facility - malaria (AMFm). AMFm aimed to: increase artemisinin combination therapy (ACT) affordability; increase ACT availability; increase ACT use; and 'crowd out' artemisinin monotherapies. METHODS: Three censuses were carried out 2 months before (2010), 2 months after and 2.5 years after (2013) the first co-paid ACTs to assess changes in antimalarial (AM) availability and price in private retail shops in a Ghanaian rural district to assess the sustainability of the initial gains. Supply, stock-out and cost were explored. RESULTS: Of 62 shops in the district, 56 participated with 398, 388 and 442 brands of AMs in the shops during the 3 censuses. The proportion of ACTs increased over the period while monotherapies reduced. Herbal-based AM preparations comprised 40-45% of AMs in stock with minimal variation over the period. ACTs were the most sold AM type for all ages but overall buying and selling prices of Quality Assured-ACTs increased by 40-100%. CONCLUSIONS: Initial gains in ACT availability were sustained, but not improved on 2.5 years after AMFm. Widespread availability of unproven herbal medicines is a concern; AMFm had little impact on this