Presentation by Heidi Hopkins Cross-cutting analysis Lead, ACT Consortium Senior Lecturer in Malaria & Diagnostics at London School of Hygiene & Tropical Medicine

1. 1

2. Answering key questions on malaria drug delivery
Interventions to change providers’ practice:
A card game as interactive training
in Cameroon
Dr Heidi Hopkins on behalf of
ACT Consortium REACT study teams
LSHTM: Virginia Wiseman, Lindsay Mangham-Jefferies, Bonnie Cundill,
Clare Chandler, Neal Alexander, and Julia Langham
University of Yaoundé: Wilfred Mbacham, Olivia Achonduh, Akindeh Nji, et al.
University of Nigeria: Obinna Onwujekwe, Ogochukwu Ibe, Benjamin Uzochukwu, et al.

3. Research on Economics of ACTs
(REACT): Cameroon & Nigeria
Study objectives:
1) Understand quality of malaria case management in
different types of health facility
2) Design interventions to support the introduction of
malaria rapid diagnostic tests, with the National
Malaria Control Programmes
3) Implement interventions in selected study sites
4) Evaluate their effectiveness and cost-effectiveness

4. Study setting
Public health centres & posts
Pharmacies & drug stores
Enugu (urban)
Udi (rural)
Public & mission hospitals + health centres
Pharmacies & drug stores
Yaoundé (urban, Francophone)
Bamenda (urban & rural, Anglophone)
ENUGU STATE, NIGERIA CAMEROON

5. Policy context in Cameroon
• Malaria is endemic in Cameroon
– Antimalarials available from range of public and
private providers and medicine retailers
– ACTs became first-line treatment in 2004
• Parasitological testing is available at many
public and private facilities, but not medicine
retail outlets
• In August 2009, Cameroon government
announced intention to introduce RDTs

6. Formative research on malaria
diagnosis & treatment (2009-10)
Goal: Understand malaria case management in Yaoundé and
Bamenda
• Availability and use of parasitological testing
• Health workers’ practices when testing and treating febrile patients
• Provider & patient preferences for malaria testing and treatment
6Answering key questions on malaria drug delivery
• Chandler C et al (2012) ‘As a clinician, you are not managing lab results, you are managing the patient’:
how the enactment of malaria at health facilities in Cameroon compares with new WHO guidelines for
the use of RDTs. Social Science and Medicine 74(10):1528-35
• Mangham LJ, et al (2011) Malaria Prevalence and Treatment of Febrile Patients Attending Health
Facilities in Cameroon. Tropical Medicine and International Health 74(10):1528-35
Quantitative methods (2009):
• Patient exit survey
• Health worker survey
• Facility survey
Qualitative methods (2010):
• FGDs with health workers (public and mission)
• FGDs with community members

7. Formative research findings:
Provider practices in malaria
diagnosis & treatment
• ACT is often available
• Many providers know ACT is recommended
• Microscopy is often available, but under-utilized
• Malaria is over-diagnosed
– About one-third of febrile patients have malaria
• Treatment prescribed does not depend on the test
result
– About two-thirds of patients that did not have malaria received ACT

8. “We prescribe them drugs and to
boost their psychological
treatment we prescribe the test”
[Nurse; mission facility, Yaoundé]
How do providers perceive
malaria testing?
• Test results support treatment
decisions, but do not substitute
for clinical judgement
“Priority is always given to the
clinical (symptoms) despite the
results of the thick blood smear”
[Doctor, mission facility, Yaoundé]
• Malaria tests provide
psychological treatment
“When we do the malaria test
and it comes out negative, it does
not prevent the patient having
his malaria .... We continue with
the antimalarial treatment”
[Nurse, mission facility, Yaoundé]
8Answering key questions on malaria drug delivery
“Most of the times I will send the
patient for a malaria test just for
the psychology of the patient, just
to please the patient, ... but if I
have to decide, the lab test will not
count”
[Doctor, mission hospital, Bamenda]

9. Policy dialogue & formative research
underpinned intervention design
Formative Research:
Malaria testing is under-used
Malaria is over-diagnosed
Supporting interventions aimed to change provider behaviour:
1) Increase use of malaria testing
2) Encourage providers to treat based on test results
3) Improve provider-patient communication
Dialogue with Policy Makers:
Government plans to introduce
RDTs
9Answering key questions on malaria drug delivery
Need to address the gap between providers’ knowledge and practice
for RDT introduction to be cost-effective

10. Designing the intervention
• Literature review on supply-side interventions
• Discuss findings with stakeholders (NMCP, policy makers,
heads of public and mission facilities)
• Iterative process to design and refine intervention package
– Brainstorming workshops
– Expertise from artists
– Develop training materials: manuals, posters & card games
– Involve representatives from NMCP
– Presentations at stakeholder workshops
– Pilot 3-day training package with providers in Buea
• Finalize intervention materials
• Training of Trainers (NMCP representatives)
– on communication skills + training modules

11. Basic Training
Basic & Enhanced
Interventions
Control Basic Intervention Enhanced Intervention
* No intervention
(microscopy was
available)
* Supply RDTs
* 1-day basic training on
malaria testing &
treatment
* Peer-to-peer training
* Supply RDTs
* 1-day basic training on
malaria testing &
treatment
* 2-day enhanced training
on quality of care
* Peer-to-peer training
Enhanced Training
Case studies &
testimonials
6. Effect
Communication Picture
Scenarios
Problem
solving
Drama & role
play
4. Adapting to
change
Reflection &
Discussion3. Lecture on
malaria treatment
2. Practical on
how to use RDT
1. Lecture on
malaria diagnosis
5. Professionalism
Appropriate Tx
Card Game
11Answering key questions on malaria drug delivery

12. B C
A = Card game on
appropriate treatment
B = Card game on process
and quality of care
C= mRDT practice
A

13. Rules of the Game (3 - 5 players)
Step 1. Deal 3 cards per person, and place the remaining in a pile face down.
Step 2. The first player picks up one card from the pile and then determines if s/he
can give “appropriate treatment” using the correct combination of 3 cards.
If yes, s/he places the 3 cards on the table. If not, the turn ends.
Step 3. Play passes to the next player, and follows steps 2.
Step 4. Play continues until appropriate treatment has been given to five patients.
Appropriate Treatment Game

14. RDTs made
available at
health facility
HW knows how to do RDT
Patient
takes
medicine
as
advised
and
recovers
HW knows dosage & regimen
HW can interpret RDT
RDT available
HW has clinical guidelines
HW knows how to diagnose
malaria
Patient pays for
medicine
HW explains how to
take medicine
HW determines dose
of medicine
HW recommends
treatment
HW interprets test
correctly
HW conducts test
correctly
Patient accepts (&
pays for) test
Patient
asks for
test
Effect on Care
Provided to Patient
Intermediate effectsIntervention Expected
Output
Expected
Outcome
HW
offers
test
Medicine is
in correct
dose for
patient
Patient
knows how
to take
medicine
Patient is
satisfied with
the care
received
TREATMENT
CONSISTENT
WITH TEST
RESULT
RDTs supplied to facilities
HWs told ACT regimens
Provider
Training on
Malaria
Diagnosis &
Treatment
Intervention Process
HWs given treatment algorithm
HWs told how to interpret RDTs
HW practice using RDTs
HWs told benefits of testing
HWs told signs & symptoms
HWs attend training course
Patient receives
medicine
Data source for evaluation:
Patient Exit
Survey
Register of
Malaria Tests
Provider
Survey
Training
evaluation
Records of
RDT supply
PATIENT IS
TESTED
Provider
Training on
Improving
Quality of
Care
HWs improve communication
skills
HW recognise how their
behaviour affects care to patient
HWs reflect on professional
values
HWs understand need to change
practice
HWs attend training course
HW thinks it is important to
test and trusts test result
HW motivated to provide
quality care
HW communicates
effectively

15. Trial results
15Answering key questions on malaria drug delivery

16. Trial results
16Answering key questions on malaria drug delivery

17. Press release & news coverage

18. Cameroon REACT study: It “worked.” Why?
Interventions → no significant increase in proportion of patients
treated according to guidelines,
but enhanced training did substantially + significantly reduce
unnecessary use of antimalarials for patients with negative test.
Suggested explanations:
• An enhanced training programme, designed to translate
knowledge into prescribing practice and improve quality of care,
can significantly reduce the unnecessary use of antimalarial drugs.
• Basic training that focuses only on how to use RDTs and the
content of malaria treatment guidelines is not likely to bring about
behaviour change needed for national roll-out of RDTs.
Mbacham W, Mangham-Jefferies L, Cundill B, Achonduh O, Chandler C., Ambebila J,
Nkwescheu A, Forsah-Achu D, Ndiforchu V, Tchekountouo O, Akindeh-Nji M, Ongolo-Zogo P,
Wiseman V. (2014) Improved treatment for uncomplicated malaria according to guidelines in
Cameroon: a cluster randomised trial of the effectiveness of provider interventions. Lancet
Global Health Volume 2, Issue 6, Pages e346 - e358.

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Behaviour change in malaria &
fever case management
Thoughtful, “enhanced” RDT training programmes for health
workers and communities, designed with formative
research and consideration of the health care context, can
significantly improve some aspects of case management.
Multiple other factors in the wider context also affect the
actual impact of behaviour change efforts.
To maximise the impact of investment in malaria control, we
must look at not just local factors – must also address
broader systems and political issues.

20. Acknowledgements
• All patients, caregivers & health
workers that participated in the
study
• Cameroon National Malaria
Control Programme, and local
stakeholders
• Funding from Bill & Melinda
Gates Foundation to ACT
Consortium
• Colleagues from University of
Yaoundé & LSHTM
20Answering key questions on malaria drug delivery
Thank you for your kind attention!
www.actconsortium.org