Effectiveness of Provider and Community Interventions to Improve Treatment of Uncomplicated Malaria in Nigeria: A Cluster Randomized Controlled Trial

The World Health Organization recommends that malaria be confirmed by parasitological diagnosis before treatment using Artemisinin-based Combination Therapy (ACT). Despite this, many health workers in malaria endemic countries continue to diagnose malaria based on symptoms alone. This study evaluates interventions to help bridge this gap between guidelines and provider practice. A stratified cluster-randomized trial in 42 communities in Enugu state compared 3 scenarios: Rapid Diagnostic Tests (RDTs) with basic instruction (control); RDTs with provider training (provider arm); and RDTs with provider training plus a school-based community intervention (provider-school arm). The primary outcome was the proportion of patients treated according to guidelines, a composite indicator requiring patients to be tested for malaria and given treatment consistent with the test result. The primary outcome was evaluated among 4946 (93%) of the 5311 patients invited to participate. A total of 40 communities (12 in control, 14 per intervention arm) were included in the analysis. There was no evidence of differences between the three arms in terms of our composite indicator (p = 0.36): stratified risk difference was 14% (95% CI -8.3%, 35.8%; p = 0.26) in the provider arm and 1% (95% CI -21.1%, 22.9%; p = 0.19) in the provider-school arm, compared with control. The level of testing was low across all arms (34% in control; 48% provider arm; 37% provider-school arm; p = 0.47). Presumptive treatment of uncomplicated malaria remains an ingrained behaviour that is difficult to change. With or without extensive supporting interventions, levels of testing in this study remained critically low. Governments and researchers must continue to explore alternative ways of encouraging providers to deliver appropriate treatment and avoid the misuse of valuable medicines

Quality of care for the treatment for uncomplicated malaria in South-East Nigeria: how important is socioeconomic status?

Introduction: Ensuring equitable coverage of appropriate malaria treatment remains a high priority for the Nigerian government. This study examines the health seeking behaviour, patient-provider interaction and quality of care received by febrile patients of different socio-economic status (SES) groups. Methods: A total of 1642 febrile patients and caregivers exiting public health centres, pharmacies and patent medicine dealers were surveyed in Enugu state, South-East Nigeria to obtain information on treatment seeking behaviour, patient-provider interactions and treatment received. Socioeconomic status was estimated for each patient using exit survey data on household assets in combination with asset ownership data from the 2008 Nigeria Demographic and Health Survey. Results: Among the poorest SES group, 29% sought treatment at public health centres, 13% at pharmacies and 58% at patent medicine dealers (p < 0.01). Very few of those in the richest SES group used public health centres (4%) instead choosing to go to pharmacies (44%) and patent medicine dealers (52%, p < 0.001). During consultations with a healthcare provider, the poorest compared to the richest were significantly more likely to discuss symptoms with the provider, be physically examined and rely on providers for diagnosis and treatment rather than request a specific medicine. Those from the poorest SES group were however, least likely to request or to receive an antimalarial (p < 0.001). The use of artemisinin combination therapy (ACT), the recommended treatment for uncomplicated malaria, was low across all SES groups. Conclusions: The quality of malaria treatment is sub-optimal for all febrile patients. Having greater interaction with the provider also did not translate to better quality care for the poor. The poor face a number of significant barriers to accessing quality treatment especially in relation to treatment seeking behaviour and type of treatment received. Strategies to address these inequities are fundamental to achieving universal coverage of effective malaria treatment and ensuring that the most vulnerable people are not left behind

The practice of 'doing' evaluation: Lessons learned from nine complex intervention trials in action

Background: There is increasing recognition among trialists of the challenges in understanding how particular 'real-life' contexts influence the delivery and receipt of complex health interventions. Evaluations of interventions to change health worker and/or patient behaviours in health service settings exemplify these challenges. When interpreting evaluation data, deviation from intended intervention implementation is accounted for through process evaluations of fidelity, reach, and intensity. However, no such systematic approach has been proposed to account for the way evaluation activities may deviate in practice from assumptions made when data are interpreted.Methods: A collective case study was conducted to explore experiences of undertaking evaluation activities in the real-life contexts of nine complex intervention trials seeking to improve appropriate diagnosis and treatment of malaria in varied health service settings. Multiple sources of data were used, including in-depth interviews with investigators, participant-observation of studies, and rounds of discussion and reflection.Results and discussion: From our experiences of the realities of conducting these evaluations, we identified six key 'lessons learned' about ways to become aware of and manage aspects of the fabric of trials involving the interface of researchers, fieldworkers, participants and data collection tools that may affect the intended production of data and interpretation of findings. These lessons included: foster a shared understanding across the study team of how individual practices contribute to the study goals; promote and facilitate within-team communications for ongoing reflection on the progress of the evaluation; establish processes for ongoing collaboration and dialogue between sub-study teams; the importance of a field research coordinator bridging everyday project management with scientific oversight; collect and review reflective field notes on the progress of the evaluation to aid interpretation of outcomes; and these approaches should help the identification of and reflection on possible overlaps between the evaluation and intervention.Conclusion: The lessons we have drawn point to the principle of reflexivity that, we argue, needs to become part of standard practice in the conduct of evaluations of complex interventions to promote more meaningful interpretations of the effects of an intervention and to better inform future implementation and decision-making. © 2014 Reynolds et al.; licensee BioMed Central Ltd

Exploring health providers' and community perceptions and experiences with malaria tests in South-East Nigeria: a critical step towards appropriate treatment.

BACKGROUND: The adoption of ACT as the first line treatment for uncomplicated malaria in Nigeria has concentrated attention on the role of testing in appropriate malaria treatment. There are calls at both national and global level for malaria treatment to be based on test result, but it is still unclear how testing can be incorporated into treatment-seeking and practices of health providers. This study explored community members and health providers' perceptions and experiences with malaria tests in south east Nigeria. METHODS: The study was conducted in urban and rural areas of Enugu state in south-eastern Nigeria. A total of 18 focus group discussions with 179 community members including sub-groups of primary caregivers, adult men and adult women aged 15 years and above. Twenty-six (26) In-depth interviews were held with public and private health providers involved in prescribing medicines at public and private health facilities in the study area. RESULTS: Both providers and community members were familiar with malaria tests and identified malaria tests as an important step to distinguish malaria from other illnesses with similar symptoms and as a means of delivering appropriate treatment. However, the logic of test-directed treatment was undermined by cost of test and a lack of testing facilities but above all concerns over the reliability of negative test results, with community members and providers observing inconsistencies between results and symptoms, and providers attributing inaccurate results to incompetencies of technicians. Recognition of malaria symptoms was deemed most important in determining the use of antimalarial drugs rather than the result of a malaria test. CONCLUSION: The results highlight important areas of intervention to promote appropriate malaria treatment. If tests are to play a role in patient management, demand and supply side interventions are needed to change people's attitude towards malaria test results

A strategy for reducing maternal and newborn deaths by 2015 and beyond.

BACKGROUND: Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030. DISCUSSION: The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact. SUMMARY: Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival

Paperikoneen online-pölymittauksen tuotekehitys

Tämän opinnäytetyön on teettänyt ACA Systems Oy. Työn kokeellinen osuus suoritet-tiin Stora Enso Oyj:n Varkauden tehtaalla, jossa mittauksia ja prosessin seurantaa toteu-tettiin kuukauden ajan. Työn tavoitteena oli tutkia ACA Systemsin kehittämän paperi-koneen online-pölymittauslaitteen DPA:n mittauskorrelaatiota todelliseen pölytasoon, reagointia erilaisiin prosessimuuttujiin ja tuotekehitysmahdollisuuksia. Tähän työkaluina käytettiin R.A. Emerson & Companyn mustakangasmenetelmää, paperikoneen pro-sessien mittausdataa, visuaalista seurantaa ja kokemusperäistä tietoa. Työn teoriaosiossa käsitellään päällystämättömän hienopaperin pölyävyyteen vaikuttavia tekijöitä Varkau-den paperiprosessin näkökulmasta. Paperikoneelle soveltuvasta online-pölymittauslaitteesta ei ole vielä DPA:n kaltaista kaupallista sovellusta. Paperin pölyävyys on hankala suure mitata, mutta koska pöly aiheuttaa paljon ongelmia ja lisäkustannuksia painokoneilla, niin kysyntää toimivalle sovellukselle, ja tarve tuotekehitykselle on olemassa. Seurannan aikana DPA reagoi selvästi teoriassakin pölytasoa nostaviin prosessimuutok-siin. DPA- ja Emerson-pölymittausmenetelmien välillä havaittiin selkeä tilastollinen korrelaatio. Pienillä ja kohtuullisilla pölytasoilla DPA:n ja Emersonin väliset mittausar-vojen erot olivat pieniä ja niiden kasvu oli lineaarista. Suureen pölymäärään DPA reagoi voimakkaasti, ja sen antama pölyarvo nousi moninkertaisesti Emersonin asteikkoon verrattuna. Tämä johtunee siitä, että kun DPA:n suodattimeen kertyy suuremmilla pöly-tasoilla tietty pölymäärä, niin se tukkii toimielimen suodattimen aiheuttaen nopeasti kasvavan voimakkaan paine-eron, joka on puolestaan verrannollinen DPA:n antamaan pölyarvoon. Kehittämällä DPA:n mittausaluetta ja toimintavarmuutta, siitä on mahdollista saada hyvä apuväline paperikoneen pölytason seurantaan. Laitetta voitaisiin hyödyntää erityi-sesti koeajoissa, jolloin päästäisiin kiinni prosessimuuttujien aiheuttamiin pölytasojen muutoksiin. Paperilaji- ja päiväkohtaisesta pölytason seurannasta on apua paperin pö-lyämättömyyden laadunhallinnassa. Myös reklamaatioiden todellisuutta liiallisesta pö-lyävyydestä voidaan arvioida tallennetun mittaustiedon perusteella. Työn kokeellisia tuloksia ja havaintoja tullaan hyödyntämään laitteen tuotekehityksessä. Työ sisältää luottamuksellista tausta-aineistoa.Al This final thesis has been commissioned by ACA Systems Oy. The experimental part was carried out at Stora Enso Oyj`s mill where the measurements and process monitor-ing were performed during one month. The aim was to inspected measurement correla-tion between a paper dust measuring device DPA developed by ACA Systems and actual dust levels. Other objectives were to find out how the device responds to process variables and what are the product development opportunities. In the investigation R. A. Emerson & Company`s black cloth method, processes measurement data of the paper machine, visual observation and empirical data were used. The theoretical section deals with causes of dusting in uncoated fine paper from the perspective of Varkaus mill. AS yet, here are no online measuring devices like DPA for paper machines. Dusting is a difficult quantity to measure and it caused a lot of problems and additional costs by printing machines. So there is need for a functioning application and product develop-ment. DPA reacts clearly to the same process changes that rise dust level even in theory during follow-up. A clear statistical correlation between DPA and Emerson dust measurement methods was found. The differences between DPA and Emerson were small at low and moderate levels of dust and their growth was linear. DPA reacted strongly to large amounts of dust and the dust value rose manifold compared with the scale of Emerson. This is probably due to the fact that DPA`s filter clogged up with dust at certain amount of dust. This caused a strong pressure difference, which is proportional to the DPA`s value of the dust. With the development of DPA`s measurement range and reliability it is possible to ob-tain a good tool for paper dust level monitoring. The device could be used specifically by test runs to got hands on the process variables what caused dust level changes. Paper Type and daily dust level monitoring will help by the quality control of dusting. Also the reality of excessive dusting reclamations can be estimated whit the help of basis measurement data. The experimental results and findings will be used in the device product development. This final thesis contains some confidential information

The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium

Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400–432,513). mRDTs were associated with significantly lower ACT prescription (range 8–69% versus 20–100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs

Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing : analysis of observational and randomised studies in public and private healthcare settings

OBJECTIVES To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia. DESIGN Analysis of nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study). SETTING Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda. PARTICIPANTS 522 480 children and adults with acute febrile illness. INTERVENTIONS Rapid diagnostic tests for malaria. MAIN OUTCOME MEASURES Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings. RESULTS Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole. CONCLUSIONS Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription. This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined