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1
Answering key questions on malaria drug delivery
Interventions to change providers’ practice:
A card game as interactive t...
Research on Economics of ACTs
(REACT): Cameroon & Nigeria
Study objectives:
1) Understand quality of malaria case manageme...
Study setting
Public health centres & posts
Pharmacies & drug stores
Enugu (urban)
Udi (rural)
Public & mission hospitals ...
Policy context in Cameroon
• Malaria is endemic in Cameroon
– Antimalarials available from range of public and
private pro...
Formative research on malaria
diagnosis & treatment (2009-10)
Goal: Understand malaria case management in Yaoundé and
Bame...
Formative research findings:
Provider practices in malaria
diagnosis & treatment
• ACT is often available
• Many providers...
“We prescribe them drugs and to
boost their psychological
treatment we prescribe the test”
[Nurse; mission facility, Yaoun...
Policy dialogue & formative research
underpinned intervention design
Formative Research:
Malaria testing is under-used
Mal...
Designing the intervention
• Literature review on supply-side interventions
• Discuss findings with stakeholders (NMCP, po...
Basic Training
Basic & Enhanced
Interventions
Control Basic Intervention Enhanced Intervention
* No intervention
(microsco...
B C
A = Card game on
appropriate treatment
B = Card game on process
and quality of care
C= mRDT practice
A
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. Th...
RDTs made
available at
health facility
HW knows how to do RDT
Patient
takes
medicine
as
advised
and
recovers
HW knows dosa...
Trial results
15Answering key questions on malaria drug delivery
Trial results
16Answering key questions on malaria drug delivery
Press release & news coverage
Cameroon REACT study: It “worked.” Why?
Interventions → no significant increase in proportion of patients
treated accordin...
19
Behaviour change in malaria &
fever case management
Thoughtful, “enhanced” RDT training programmes for health
workers a...
Acknowledgements
• All patients, caregivers & health
workers that participated in the
study
• Cameroon National Malaria
Co...
Interventions to change providers' practice in cameroon h hopkins
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Interventions to change providers' practice in cameroon h hopkins

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

Published in: Healthcare
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Interventions to change providers' practice in cameroon h hopkins

  1. 1. 1
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 12. B C A = Card game on appropriate treatment B = Card game on process and quality of care C= mRDT practice A
  13. 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. 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. 15. Trial results 15Answering key questions on malaria drug delivery
  16. 16. Trial results 16Answering key questions on malaria drug delivery
  17. 17. Press release & news coverage
  18. 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.
  19. 19. 19 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. 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

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