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

HHopkins, KJ Bruxvoort, ME Cairns, CIR Chandler, B Leurent, EK Ansah, F Baiden, KA Baltzell, A Björkman, HED Burchett, SE Clarke, DD DiLiberto, K Elfving, C Goodman, KS Hansen, SP Kachur, S Lal, DG Lalloo, T Leslie, P Magnussen, see L Mangham Jefferies, A Mårtensson, I Mayan, AK Mbonye, MI Msellem, OE Onwujekwe, S Owusu-Agyei, H Reyburn, MW Rowland, D Shakely, LS Vestergaard, J Webster, VL Wiseman, S Yeung, D Schellenberg, SG Staedke, CJM Whitty.

BMJ 2017;356:j1054 | DOI: 10.1136/bmj.j1054


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: 522480 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.


Click here for article | PDF

Examining intervention design: lessons from the development of eight related malaria health care intervention studies

CIR Chandler, H Burchett, L Boyle, O Achonduh, A Mbonye, D DiLiberto, H Reyburn, O Onwujekwe, A Haaland, A Roca-Feltrer, F Baiden, WF Mbacham, R Ndyomugyenyi, F Nankya, Methocarbamol canada L Mangham-Jefferies, S Clarke, H Mbakilwa, J Reynolds, S Lal, T Leslie, C Maiteki-Sebuguzi, J Webster, P Magnussen, E Ansah, KS Hansen, E Hutchinson, B Cundill, K Barnes, S Yeung, D Schellenberg, SG Staedke, V Wiseman, DG Lalloo, CJM Whitty.

Health System & Reform 2016 | DOI:10.1080/23288604.2016.1179086


Rigorous evidence of ‘what works’ to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This paper presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (i) intended pathways of change and (ii) how their intervention would be implemented.

The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical, but the result of micro and macro social, political and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques, to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.

Click here for article | PDF

Incorporating demand and supply constraints into economic evaluations in low-income and middle-income countries

A Vassall, L Mangham-Jefferies, GB Gomez, C Pitt, N Foster.

Health Economics 2016, 25(S1):95-115 | DOI:10.1002/hec.3306


Global guidelines for new technologies are based on cost and efficacy data from a limited number of trial locations. Country-level decision makers need to consider whether cost-effectiveness analysis used to inform global guidelines are sufficient for their situation or whether to use models that adjust cost-effectiveness results taking into account setting-specific epidemiological and cost heterogeneity. However, demand and supply constraints will also impact cost-effectiveness by influencing the standard of care and the use and implementation of any new technology. These constraints may also vary substantially by setting. We present two case studies of economic evaluations of the introduction of new diagnostics for malaria and tuberculosis control. These case studies are used to analyse how the scope of economic evaluations of each technology expanded to account for and then address demand and supply constraints over time. We use these case studies to inform a conceptual framework that can be used to explore the characteristics of intervention complexity and the influence of demand and supply constraints. Finally, we describe a number of feasible steps that researchers who wish to apply our framework in cost-effectiveness analyses.

Click here for article | PDF

A qualitative study on health workers’ and community members’ perceived sources, role of information and communication on malaria treatment prevention and control in southeast Nigeria

JC Umeano-Enemuoh, B Uzochukwu, N Ezumah, L Mangham-Jefferies, V Wiseman, O Onwujekwe.

BMC Infectious Diseases 2015, 15:437 | DOI:10.1186/s12879-015-1187-2


Background: It has been widely acknowledged that well-planned and executed communication programmes can contribute to achieving malaria prevention and treatment goals. This however requires a good understanding of current sources and roles of information used by both health workers and communities. The study aimed at determining health workers’ and community members’ sources, value and use of information on malaria prevention and treatment in Nigeria.

Methods: Qualitative data was collected from six selected communities (three urban and three rural) in Enugu state, southeast Nigeria. A total of 18 Focus Group Discussions (FGDs) with 179 community members and 26 in-depth interviews (IDIs) with health workers in public and private health facilities were used to collect data on where people receive treatment for malaria and access information on malaria. The FGDS and IDIs also provided data on the values, uses and effects of information and communication on malaria treatment seeking and provision of services.

Results: The findings revealed that the major sources of information on malaria for health workers and community members were advertisements in the mass media, workshops and seminars organized by donor agencies, facility supervision, posters, other health workers, television and radio adverts. Community involvement in the design and delivery of information on malaria control was seen as a strong strategy for improving both consumer and provider knowledge. Information from the different sources catalyzed appropriate provision and consumption of malaria treatment amongst health workers and community members.

Conclusion: Health workers and consumers receive information on malaria prevention and treatment from multiple sources of communication and information, which they find useful. Harnessing these information sources to encourage consistent and accurate messages around malaria prevention and treatment is a necessary first step in the design and implementation of malaria communication and behaviour change interventions and ultimately for the sustained control of malaria.

Click here for article | PDF

Effectiveness of provider and community interventions to improve treatment of uncomplicated malaria in Nigeria: a cluster randomized control trial

O Onwujekwe, L Mangham-Jefferies, B Cundill, N Alexander, J Langham, O Ibe, B Uzochukwu, V Wiseman.

PLoS ONE 2015, 10(8) e0133832 | DOI:10.1371/journal.pone.0133832


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.

Click here for article | PDF

Erratum: Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review

L Mangham-Jefferies, C Pitt, S Cousens, A Mills, J Schellenberg

BMC Pregnancy and Childbirth 2015, 15:64 | DOI: 10.1186/s12884-015-0476-5


During the publication process of this article [1] a number of errors were unfortunately introduced into the references included in figure three, and were not noticed until after the final version had been published.

Click here for article | PDF

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

OP Ibe, L Mangham-Jefferies, B Cundill, V Wiseman, BS Uzochukwu, OE Onwujekwe.

International Journal for Equity in Health 2015, 14:19 | DOI: 10.1186/s12939-015-0150-6


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.

Click here for article | PDF

Mind the Gap: knowledge and practice of providers treating uncomplicated malaria at health facilities and medicine retailers in Cameroon and Nigeria

L Mangham-Jefferies, K Hanson, W Mbacham, O Onwujekwe, V Wiseman

Health Policy & Planning 2014, 30(9):1129-1141 | DOI: 10.1093/heapol/czu118


Background: Artemisinin combination therapy (ACT) has been the first-line treatment for uncomplicated malaria in Cameroon since 2004 and Nigeria since 2005, though many febrile patients receive less effective antimalarials. Patients often rely on providers to select treatment, and interventions are needed to improve providers’ practice and encourage them to adhere to clinical guidelines.

Methods: Providers’ adherence to malaria treatment guidelines was examined using data collected in Cameroon and Nigeria at public and mission facilities, pharmacies and drug stores. Providers’ choice of antimalarial was investigated separately for each country. Multilevel logistic regression was used to determine whether providers were more likely to choose ACT if they knew it was the first-line antimalarial. Multiple imputation was used to impute missing data that arose when linking exit survey responses to details of the provider responsible for selecting treatment.

Results: There was a gap between providers’ knowledge and their practice in both countries, as providers’ decision to supply ACT was not significantly associated with knowledge of the first-line antimalarial. Providers were, however, more likely to supply ACT if it was the type of antimalarial they prefer. Other factors were country-specific, and indicated providers can be influenced by what they perceived their patients prefer or could afford, as well as information about their symptoms, previous treatment, the type of outlet and availability of ACT.

Conclusions: Public health interventions to improve the treatment of uncomplicated malaria should strive to change what providers prefer, rather than focus on what they know. Interventions to improve adherence to malaria treatment guidelines should emphasize that ACT is the recommended antimalarial, and it should be used for all patients with uncomplicated malaria. Interventions should also be tailored to the local setting, as there were differences between the two countries in providers’ choice of antimalarial, and who or what influenced their practice.

Click here for article | PDF

How do Health Extension Workers in Ethiopia allocate their time?

L Mangham-Jefferies, B Mathewos, J Russell, A Bekele.

Human Resources for Health 2014, 12:61 | DOI: 10.1186/1478-4491-12-61


Background: Governments are increasingly reliant on community health workers to undertake health promotion and provide essential curative care. In 2003, the Government of Ethiopia launched the Health Extension Programme and introduced a new cadre, health extension workers (HEWs), to improve access to care in rural communities. In 2013, to inform the government’s plans for HEWs to take on an enhanced role in community-based newborn care, a time and motion study was conducted to understand the range of HEW responsibilities and how they allocate their time across health and non-health activities.

Methods: The study was administered in 69 rural kebeles in the Southern Nations Nationalities and People’s Region and Oromia Region that were intervention areas of a trial to evaluate a package of community-based interventions for newborns. Over 4 consecutive weeks, HEWs completed a diary and recorded all activities undertaken during each working day. HEWs were also surveyed to collect data on seasonal activities and details of the health post and kebele in which they work. The average proportion of productive time (excluding breaks) that HEWs spent on an activity, at a location, or with a recipient each week, was calculated.

Results: The self-reported diary was completed by 131 HEWs. Over the course of a week, HEWs divided their time between the health post (51%) and the community (37%), with the remaining 11% of their time spent elsewhere. Curative health activities represented 16% of HEWs’ time each week and 43% of their time was spent on health promotion and prevention. The remaining time included travel, training and supervision, administration, and community meetings. HEWs spent the majority (70%) of their time with individuals, families, and community members.

Conclusions: HEWs have wide-ranging responsibilities for community-based health promotion and curative care. Their workload is diverse and they spend time on activities relating to family health, disease prevention and control, hygiene and sanitation, as well as other community-based activities. Reproductive, maternal, newborn, and child health activities represent a major component of the HEW’s work and, as such, they can have a critically important role in improving the health outcomes of mothers and children in Ethiopia.

Click here for article | PDF

Economic evaluation of a cluster-randomized trial of interventions to improve health workers’ practice in diagnosing and treating uncomplicated malaria in Cameroon

L Mangham-Jefferies, V Wiseman, OA Achonduh, TL Drake, B Cundill, O Onwujekwe, W Mbacham.

Value in Health 2014, 17(8):783-791 | DOI: 10.1016/j.jval.2014.07.010


Background: Malaria rapid diagnostic tests (RDTs) are a valid alternative to malaria testing with microscopy and are recommended for the testing of febrile patients before prescribing an antimalarial. There is a need for interventions to support the uptake of RDTs by health workers.

Objective: To evaluate the cost-effectiveness of introducing RDTs with basic or enhanced training in health facilities in which microscopy was available, compared with current practice.

Methods: A three-arm cluster randomized trial was conducted in 46 facilities in central and northwest Cameroon. Basic training had a practical session on RDTs and lectures on malaria treatment guidelines. Enhanced training included small-group activities designed to change health workers’ practice and reduce the consumption of antimalarials among test-negative patients. The primary outcome was the proportion of febrile patients correctly treated: febrile patients should be tested for malaria, artemisinin combination therapy should be prescribed for confirmed cases, and no antimalarial should be prescribed for patients who are test-negative. Individual patient data were obtained from facility records and an exit survey. Costs were estimated from a societal perspective using project reports and patient exit data. The analysis used bivariate multilevel modeling and adjusted for imbalance in baseline covariates.

Results: Incremental cost per febrile patient correctly treated was $8.40 for the basic arm and $3.71 for the enhanced arm. On scale-up, it was estimated that RDTs with enhanced training would save $0.75 per additional febrile patient correctly treated.

Conclusions: Introducing RDTs with enhanced training was more cost-effective than RDTs with basic training when each was compared with current practice.

Click here for article | PDF