A cost-effectiveness analysis of provider and community interventions to improve the treatment of uncomplicated malaria in Nigeria: study protocol for a randomized controlled trial.

BACKGROUND: There is mounting evidence of poor adherence by health service personnel to clinical guidelines for malaria following a symptomatic diagnosis. In response to this, the World Health Organization (WHO) recommends that in all settings clinical suspicion of malaria should be confirmed by parasitological diagnosis using microscopy or Rapid Diagnostic Test (RDT). The Government of Nigeria plans to introduce RDTs in public health facilities over the coming year. In this context, we will evaluate the effectiveness and cost-effectiveness of two interventions designed to support the roll-out of RDTs and improve the rational use of ACTs. It is feared that without supporting interventions, non-adherence will remain a serious impediment to implementing malaria treatment guidelines. METHODS/DESIGN: A three-arm stratified cluster randomized trial is used to compare the effectiveness and cost-effectiveness of: (1) provider malaria training intervention versus expected standard practice in malaria diagnosis and treatment; (2) provider malaria training intervention plus school-based intervention versus expected standard practice; and (3) the combined provider plus school-based intervention versus provider intervention alone. RDTs will be introduced in all arms of the trial. The primary outcome is the proportion of patients attending facilities that report a fever or suspected malaria and receive treatment according to malaria guidelines. This will be measured by surveying patients (or caregivers) as they exit primary health centers, pharmacies, and patent medicine dealers. Cost-effectiveness will be presented in terms of the primary outcome and a range of secondary outcomes, including changes in provider and community knowledge. Costs will be estimated from both a societal and provider perspective using standard economic evaluation methodologies. TRIAL REGISTRATION: Clinicaltrials.gov NCT01350752

Current practice of epidemiology in Africa: highlights of the 3rd conference of the African epidemiological association and 1st conference of the Cameroon society of epidemiology, Yaoundé, Cameroon, 2014

As the study of disease occurrence and health indicators in human populations, Epidemiology is a dynamic field that evolves with time and geographical context. In order to update African health workers on current epidemiological practices and to draw awareness of early career epidemiologists on concepts and opportunities in the field, the 3rd African Epidemiology Association and the 1st Cameroon Society of Epidemiology Conference was organized in June 2-6, 2014 at the Yaoundé Mont Febe Hotel, in Cameroon. Under the theme«Practice of Epidemiology in Africa: Stakes, Challenges and Perspectives», the conference attracted close to five hundred guest and participants from all continents. The two main programs were the pre-conference course for capacity building of African Early Career epidemiologists, and the conference itself, providing a forum for scientific exchanges on recent epidemiological concepts, encouraging the use of epidemiological methods in studying large disease burden and neglected tropical diseases; and highlighting existing opportunities

Rethinking health systems in the context of urbanisation: challenges from four rapidly urbanising low-income and middle-income countries

The world is now predominantly urban; rapid and uncontrolled urbanisation continues across low-income and middle-income countries (LMICs). Health systems are struggling to respond to the challenges that urbanisation brings. While better-off urbanites can reap the benefits from the ‘urban advantage’, the poorest, particularly slum dwellers and the homeless, frequently experience worse health outcomes than their rural counterparts. In this position paper, we analyse the challenges urbanisation presents to health systems by drawing on examples from four LMICs: Nigeria, Ghana, Nepal and Bangladesh. Key challenges include: responding to the rising tide of non-communicable diseases and to the wider determinants of health, strengthening urban health governance to enable multisectoral responses, provision of accessible, quality primary healthcare and prevention from a plurality of providers. We consider how these challenges necessitate a rethink of our conceptualisation of health systems. We propose an urban health systems model that focuses on: multisectoral approaches that look beyond the health sector to act on the determinants of health; accountability to, and engagement with, urban residents through participatory decision making; and responses that recognise the plurality of health service providers. Within this model, we explicitly recognise the role of data and evidence to act as glue holding together this complex system and allowing incremental progress in equitable improvement in the health of urban populations

Pediatric Bacterial Meningitis Surveillance in Niger: Increased Importance of Neisseria meningitidis Serogroup C, and a Decrease in Streptococcus pneumoniae Following 13-Valent Pneumococcal Conjugate Vaccine Introduction

Background: Meningitis is endemic in Niger. Haemophilus influenzae type b (Hib) vaccine and the 13-valent pneumococcal conjugate vaccine (PCV13) were introduced in 2008 and 2014, respectively. Vaccination campaign against Neisseria meningitidis serogroup A was carried out in 2010–2011. We evaluated changes in pathogen distribution using data from hospital-based surveillance in Niger from 2010 through 2016. Methods: Cerebrospinal fluid (CSF) specimens from children <5 years old with suspected meningitis were tested to detect vaccine-preventable bacterial pathogens. Confirmatory identification and serotyping/grouping of Streptococcus pneumoniae, N. meningitidis, and H. influenzae were done. Antimicrobial susceptibility testing and whole genome sequencing were performed on S. pneumoniae isolates. Results: The surveillance included 2580 patients with suspected meningitis, of whom 80.8% (2085/2580) had CSF collected. Bacterial meningitis was confirmed in 273 patients: 48% (131/273) was N. meningitidis, 45% (123/273) S. pneumoniae, and 7% (19/273) H. influenzae. Streptococcus pneumoniae meningitis decreased from 34 in 2014, to 16 in 2016. PCV13 serotypes made up 88% (7/8) of S. pneumoniae meningitis prevaccination and 20% (5/20) postvaccination. Neisseria meningitidis serogroup C (NmC) was responsible for 59% (10/17) of serogrouped N. meningitidis meningitis. Hib caused 67% (2/3) of the H. influenzae meningitis isolates serotyped. Penicillin resistance was found in 16% (4/25) of S. pneumoniae isolates. Sequence type 217 was the most common lineage among S. pneumoniae isolates. Conclusions: Neisseria meningitidis and S. pneumoniae remain important causes of meningitis in children in Niger. The decline in the numbers of S. pneumoniae meningitis post-PCV13 is encouraging and should continue to be monitored. NmC is the predominant serogroup causing N. meningitidis meningitis

Inequities in incidence, morbidity and expenditures on prevention and treatment of malaria in southeast Nigeria

<p>Abstract</p> <p>Background</p> <p>Malaria places a great burden on households, but the extent to which this is tilted against the poor is unclear. However, the knowledge of the level of the burden of malaria amongst different population groups is vital for ensuring equitable control of malaria. This paper examined the inequities in occurrence, economic burden, prevention and treatment of malaria.</p> <p>Methods</p> <p>The study was undertaken in four malaria endemic villages in Enugu state, southeast Nigeria. Data was collected using interviewer-administered questionnaires. An asset-based index was used to categorize the households into socio-economic status (SES) quartiles: least poor; poor; very poor; and most poor. Chi-square analysis was used to determine the statistical significance of the SES differences in incidence, length of illness, ownership of treated nets, expenditures on treatment and prevention.</p> <p>Results</p> <p>All the SES quartiles had equal exposure to malaria. The pattern of health seeking for all the SES groups was almost similar, but in one of the villages the most poor, very poor and poor significantly used the services of patent medicine vendors and the least poor visited hospitals. The cost of treating malaria was similar across the SES quartiles. The average expenditure to treat an episode of malaria ranged from as low as 131 Naira ($1.09) to as high as 348 Naira ($2.9), while the transportation expenditure to receive treatment ranged from 26 Naira to 46 Naira (both less than $1). The level of expenditure to prevent malaria was low in the four villages, with less than 5% owning untreated nets and 10.4% with insecticide treated nets.</p> <p>Conclusion</p> <p>Malaria constitutes a burden to all SES groups, though the poorer socio-economic groups were more affected, because a greater proportion of their financial resources compared to their income are spent on treating the disease. The expenditures to treat malaria by the poorest households could lead to catastrophic health expenditures. Effective pro-payment health financing and health delivery methods for the treatment and prevention of malaria are needed to decrease the burden of the disease to the most-poor people.</p

Rural-Urban Differences in Maternal Responses to Childhood Fever in South East Nigeria

Childhood fevers due to malaria remain a major cause of morbidity and mortality among under-five children in Nigeria. The degree of vulnerability perceived by mothers will affect their perception of the severity and threat of their child's fever and the patterns of health care use. This study was undertaken to compare maternal responses to childhood fever in urban and rural areas of Enugu, south east Nigeria.Data was collected with pre-tested interviewer-administered questionnaires from 276 and 124 urban and rural households respectively. In each household, only one woman aged 15-49 years who had lived in each of the urban and rural communities for at least one year and had at least one child less than 5 years old was interviewed. Malaria was mentioned as the commonest cause of childhood fevers. Rural mothers were more likely to recognize danger signs and symptoms than urban mothers. Rural mothers use more of informal than formal health services, and there is more home management of the fever with urban than rural mothers. Chloroquine, ACT, SP and Paracetamol are the main drugs given at home for childhood fevers, but the rural mothers were more likely to use leftover drugs from previous treatment to treat the fevers than urban mothers. The urban respondents were also more likely to use a preventive measure. Urban mothers sought actions faster than rural mothers and the total cost of treatment was also higher in urban areas.Both urban and rural mothers are aware that malaria is the major cause of childhood fevers. Although rural mothers recognize childhood fever and danger signs better than urban mothers, the urban mothers' responses to fever seem to be better than that for rural mothers. These responses and differences may be important for geographical targeting by policy makers for malaria interventions

A systematic review of frameworks for the interrelationships of mental health evidence and policy in low- and middle-income countries

Background: The interrelationships between research evidence and policy-making are complex. Different theoretical frameworks exist to explain general evidence–policy interactions. One largely unexplored element of these interrelationships is how evidence interrelates with, and influences, policy/political agenda-setting. This review aims to identify the elements and processes of theories, frameworks and models on interrelationships of research evidence and health policy-making, with a focus on actionability and agenda-setting in the context of mental health in low- and middle-income countries (LMICs). Methods: A systematic review of theories was conducted based on the BeHeMOTh search method, using a tested and refined search strategy. Nine electronic databases and other relevant sources were searched for peer-reviewed and grey literature. Two reviewers screened the abstracts, reviewed full-text articles, extracted data and performed quality assessments. Analysis was based on a thematic analysis. The included papers had to present an actionable theoretical framework/model on evidence and policy interrelationships, such as knowledge translation or evidence-based policy, specifically target the agenda-setting process, focus on mental health, be from LMICs and published in English. Results: From 236 publications included in the full text analysis, no studies fully complied with our inclusion criteria. Widening the focus by leaving out ‘agenda-setting’, we included ten studies, four of which had unique conceptual frameworks focusing on mental health and LMICs but not agenda-setting. The four analysed frameworks confirmed research gaps from LMICs and mental health, and a lack of focus on agenda-setting. Frameworks and models from other health and policy areas provide interesting conceptual approaches and lessons with regards to agenda-setting. Conclusion: Our systematic review identified frameworks on evidence and policy interrelations that differ in their elements and processes. No framework fulfilled all inclusion criteria. Four actionable frameworks are applicable to mental health and LMICs, but none specifically target agenda-setting. We have identified agenda-setting as a research theory gap in the context of mental health knowledge translation in LMICs. Frameworks from other health/policy areas could offer lessons on agenda-setting and new approaches for creating policy impact for mental health and to tackle the translational gap in LMICs

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

“Even if You Know Everything You Can Forget”: Health Worker Perceptions of Mobile Phone Text-Messaging to Improve Malaria Case-Management in Kenya

This paper presents the results of a qualitative study to investigate the perceptions and experiences of health workers involved in a a cluster-randomized controlled trial of a novel intervention to improve health worker malaria case-management in 107 government health facilities in Kenya. The intervention involved sending text-messages about paediatric outpatient malaria case-management accompanied by “motivating” quotes to health workers’ mobile phones. Ten malaria messages were developed reflecting recommendations from the Kenyan national guidelines. Two messages were delivered per day for 5 working days and the process was repeated for 26 weeks (May to October 2009). The accompanying quotes were unique to each message. The intervention was delivered to 119 health workers and there were significant improvements in correct artemether-lumefantrine (AL) management both immediately after the intervention (November 2009) and 6 months later (May 2010). In-depth interviews with 24 health workers were undertaken to investigate the possible drivers of this change. The results suggest high acceptance of all components of the intervention, with the active delivery of information in an on the job setting, the ready availability of new and stored text messages and the perception of being kept ‘up to date’ as important factors influencing practice. Applying the construct of stages of change we infer that in this intervention the SMS messages were operating primarily at the action and maintenance stages of behaviour change achieving their effect by creating an enabling environment and providing a prompt to action for the implementation of case management practices that had already been accepted as the clinical norm by the health workers. Future trials testing the effectiveness of SMS reminders in creating an enabling environment for the establishment of new norms in clinical practice as well as in providing a prompt to action for the implementation of the new case-management guidelines are justified

Human resource management interventions to improve health workers' performance in low and middle income countries: a realist review

Contains fulltext : 80429.pdf (publisher's version ) (Open Access)BACKGROUND: Improving health workers' performance is vital for achieving the Millennium Development Goals. In the literature on human resource management (HRM) interventions to improve health workers' performance in Low and Middle Income Countries (LMIC), hardly any attention has been paid to the question how HRM interventions might bring about outcomes and in which contexts. Such information is, however, critical to assess the transferability of results. Our aim was to explore if realist review of published primary research provides better insight into the functioning of HRM interventions in LMIC. METHODOLOGY: A realist review not only asks whether an intervention has shown to be effective, but also through which mechanisms an intervention produces outcomes and which contextual factors appear to be of critical influence. Forty-eight published studies were reviewed. Results : The results show that HRM interventions can improve health workers' performance, but that different contexts produce different outcomes. Critical implementation aspects were involvement of local authorities, communities and management; adaptation to the local situation; and active involvement of local staff to identify and implement solutions to problems. Mechanisms that triggered change were increased knowledge and skills, feeling obliged to change and health workers' motivation. Mechanisms to contribute to motivation were health workers' awareness of local problems and staff empowerment, gaining acceptance of new information and creating a sense of belonging and respect. In addition, staff was motivated by visible improvements in quality of care and salary supplements. Only a limited variety of HRM interventions have been evaluated in the health sector in LMIC. Assumptions underlying HRM interventions are usually not made explicit, hampering our understanding of how HRM interventions work. CONCLUSION: Application of a realist perspective allows identifying which HRM interventions might improve performance, under which circumstances, and for which groups of health workers. To be better able to contribute to an understanding of how HRM interventions could improve health workers' performance, a combination of qualitative and quantitative research methods would be needed and the use of common indicators for evaluation and a common reporting format would be required