interventions to change providers' practice in cameroon h hopkins

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 teamsLSHTM: Virginia Wiseman, Lindsay Mangham-Jefferies, Bonnie Cundill, Clare Chandler, Neal Alexander, and Julia LanghamUniversity of Yaoundé: Wilfred Mbacham, Olivia Achonduh, Akindeh Nji, et al.University of Nigeria: Obinna Onwujekwe, Ogochukwu Ibe, Benjamin Uzochukwu, et al.

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

Study setting

Public health centres & postsPharmacies & drug stores

Enugu (urban)Udi (rural)

Public & mission hospitals + health centresPharmacies & drug stores

Yaoundé (urban, Francophone)Bamenda (urban & rural, Anglophone)

ENUGU STATE, NIGERIA CAMEROON

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

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

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

“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]


“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]

Policy dialogue & formative researchunderpinned 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


Need to address the gap between providers’ knowledge and practice for RDT introduction to be cost-effective

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

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


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. 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

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

Trial results


Press release & news coverage

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

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.

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


Thank you for your kind attention!

www.actconsortium.org

interventions to change providers' practice in cameroon h hopkins

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