The development of effective behaviour change interventions to support the use of malaria rapid diagnostic tests by Tanzanian clinicians

Clare I R Chandler, Judith Meta, Célia Ponzo, Fortunata Nasuwa, John Kessy, Hilda Mbakilwa, Ane Haaland, Hugh Reyburn, Clare I R Chandler, Judith Meta, Célia Ponzo, Fortunata Nasuwa, John Kessy, Hilda Mbakilwa, Ane Haaland, Hugh Reyburn

Abstract

Background: Parasitological confirmation is now recommended for all cases of suspected malaria. The roll-out of rapid diagnostic tests (RDTs) is hoped to enable this goal in low resource settings through point of care testing. However, simply making RDTs available has not led to high uptake of the tests or adherence to results by clinicians, with malaria continuing to be overdiagnosed in many settings. We undertook to design an evidence-based intervention package that would be sufficient to support the introduction of RDTs at dispensaries in Tanzania, to be evaluated through the Targeting Artemisinin Combination Therapy (TACT) cluster randomised controlled trial.

Methods: We describe five steps in our intervention design: formative research, review of existing evidence and theory, a workshop to define the intervention approach and content and results of formative research, engagement with behaviour change theory and literature, detailed design of intervention materials and piloting and pretesting of intervention materials. This involved fieldwork with a total of 19 health workers and 212 community members in northeast Tanzania.

Results: The formative research suggested that RDTs were a potential source of conflict in the health worker-patient interaction, but that health workers used various techniques to resolve this, including provision of antimalarial drugs for RDT-negative patients. Our reviews showed that evidence was mixed regarding the effectiveness of different methods and theories to support change in prescribing practice. Our design process is presented, drawing from this collective evidence. We describe the final TACT intervention package (including interactive small group workshops, feedback text messages, motivational text messages and patient information leaflets and posters) in terms of its programme theory and implementation theory.

Conclusions: Our study suggests that evidence-based design of complex interventions is possible. The use of formative research to understand malaria overdiagnosis in context was central to the design of the intervention as well as empirical research to test materials and methods prior to implementation. The TACT interventions may be appropriate for other settings where clinicians face similar challenges with malaria diagnostics.

Trial registration: NCT01292707.

Figures

Figure 1
Figure 1
Flow diagram of the process of designing the TACT intervention package.
Figure 2
Figure 2
TACT Logic model.

References

    1. World Health Organisation. Guidelines for the Treatment of Malaria. 2. Geneva; 2010. Available online at .
    1. D’Acremont V, Lengeler C, Genton B. Reduction in the proportion of fevers associated with Plasmodium falciparum parasitaemia in Africa: a systematic review. Malar J. 2010;9:240.
    1. Rao VB, Schellenberg D, Ghani AC. Overcoming health systems barriers to successful malaria treatment. Trends Parasitol. 2013;29:164–180.
    1. Bell D, Wongsrichanalai C, Barnwell JW. Ensuring quality and access for malaria diagnosis: how can it be achieved? Nat Rev Microbiol. 2006;4:682–695.
    1. Odaga J, Lokong JA, Donegan S, Garner P, Sinclair D. Rapid diagnostic tests versus clinical diagnosis for managing people with fever in malaria endemic settings (Review) Cochrane Database Syst Rev. 2014;4
    1. D’Acremont V, Kahama-Maro J, Swai N, Mtasiwa D, Genton B, Lengeler C. Reduction of anti-malarial consumption after rapid diagnostic tests implementation in Dar es Salaam: a before-after and cluster randomized controlled study. Malar J. 2011;10:107.
    1. Williams HA, Causer L, Metta E, Malila A, O’Reilly T, Abdulla S, Kachur SP, Bloland PB. Dispensary level pilot implementation of rapid diagnostic tests: an evaluation of RDT acceptance and usage by providers and patients–Tanzania, 2005. Malar J. 2008;7:239.
    1. Masanja MI, McMorrow M, Kahigwa E, Kachur SP, McElroy PD. Health workers’ use of malaria rapid diagnostic tests (RDTs) to guide clinical decision making in rural dispensaries, Tanzania. Am J Trop Med Hyg. 2010;83:1238–1241.
    1. Bruxvoort K, Kalolella A, Nchimbi H, Festo C, Taylor M, Thomson R, Cairns M, Thwing J, Kleinschmidt I, Goodman C, Kachur SP. Getting antimalarials on target: impact of national roll-out of malaria rapid diagnostic tests on health facility treatment in three regions of Tanzania. Trop Med Int Health. 2013;18:1269–1282.
    1. Chandler CIR, Jones C, Boniface G, Juma K, Reyburn H, Whitty CJ. Guidelines and mindlines: why do clinical staff over-diagnose malaria in Tanzania? A qualitative study. Malar J. 2008;7:53.
    1. Chandler CIR, Mwangi R, Mbakilwa H, Olomi R, Whitty CJM, Reyburn H. Malaria overdiagnosis: is patient pressure the problem? Health Policy Plan. 2008;23:170–178.
    1. Chandler CIR, Whitty CJ, Ansah EK. How can malaria rapid diagnostic tests achieve their potential? A qualitative study of a trial at health facilities in Ghana. Malar J. 2010;9:95.
    1. Baiden F, Owusu-Agyei S, Okyere E, Tivura M, Adjei G, Chandramohan D, Webster J. Acceptability of rapid diagnostic test-based management of Malaria among caregivers of under-five children in rural Ghana. PLoS ONE. 2012;7:e45556.
    1. Stambach A. “Here in Africa, we teach; students listen”: lessons about culture from Tanzania. J Curric Superv. 1994;9:368–385.
    1. Montgomery CM, Mwengee W, Kong’ong’o M, Pool R. ‘To help them is to educate them’: power and pedagogy in the prevention and treatment of malaria in Tanzania. Trop Med Int Health. 2006;11:1661–1669.
    1. Mann KV. Theoretical perspectives in medical education: past experience and future possibilities. Med Educ. 2011;45:60–68.
    1. Vavrus F. The cultural politics of constructivist pedagogies: teacher education reform in the United Republic of Tanzania. Int J Educ Dev. 2009;29:303–311.
    1. Michie S, Fixsen D, Grimshaw JM, Eccles MP. Specifying and reporting complex behaviour change interventions: the need for a scientific method. Implement Sci. 2009;4:40.
    1. Mmbando BP, Vestergaard LS, Kitua AY, Lemnge MM, Theander TG, Lusingu JP. A progressive declining in the burden of malaria in north-eastern Tanzania. Malar J. 2010;9:216.
    1. Chandler CIR, Reynolds J, Palmer J, Hutchinson E. ACT Consortium Guidance: Qualitative Methods Training Materials. 2009. Available at .
    1. Haaland A, Molyneux CS, Marsh V. Quality information in field research: Training manual on practical communication skills for field researchers and project personnel. WHO/TDR; 2006. Available online .
    1. MRC. Developing and Evaluating Complex Interventions: new guidance. London: Medical Research Council; 2008. Available online at
    1. Painter JE, Borba CP, Hynes M, Mays D, Glanz K. The use of theory in health behavior research from 2000 to 2005: a systematic review. Ann Behav Med. 2008;35:358–362.
    1. Grol RP, Bosch MC, Hulscher ME, Eccles MP, Wensing M. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q. 2007;85:93–138.
    1. National Institute for Health and Clinical Excellence. Behaviour Change at Population, Community and Individual Levels. London: NICE Public Health Guidance; 2007.
    1. Aboud FE. Virtual special issue introduction: health behaviour change. Soc Sci Med. 2010;71:1897–1900.
    1. Noar SM, Zimmerman RS. Health behavior theory and cumulative knowledge regarding health behaviors: are we moving in the right direction? Health Educ Res. 2005;20:275–290.
    1. Eccles MP, Grimshaw JM, MacLennan G, Bonetti D, Glidewell L, Pitts NB, Steen N, Thomas R, Walker A, Johnston M. Explaining clinical behaviors using multiple theoretical models. Implement Sci. 2012;7:99.
    1. Yoder PS. Negotiating relevance: belief, knowledge, and practice in international health projects. Med Anthropol Q. 1997;11:131–146.
    1. Rowe AK, de Savigny D, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet. 2005;366:1026–1035.
    1. Arhinful D, Das A, Heggenhougen K, Higginbotham N, Iyun F, Quick J, Ross-Degnan D. How to Use Applied Qualitative Methods to Design Drug Use Interventions, Working Draft. 1996. (Social Scientists Working Group: International Network for the Rational Use of Drugs). Available online at .
    1. Cornwall A, Jewkes R. What is participatory research? Soc Sci Med. 1995;41:1667–1676.
    1. Newton L, Newton D, Clark J, Kenny T, Moseley D, Purves I, Wilson R. Patient information leaflets: producing understandable PILs. J Inf Sci. 1998;24:167–181.
    1. Haaland A. Reporting with Pictures. A concept paper for researchers and health policy decision-makers. Geneva: UNDP/WOrld Bank/WHO Special Programme for Research and Training in Tropical Diseases; 2001.
    1. Gal I, Prigat A. Why organizations continue to create patient information leaflets with readability and usability problems: an exploratory study. Health Educ Res. 2005;20:485–493.
    1. Haaland A, Moloney J, Mshana C. Multilateral Initiative on Malaria Conference. Nairobi; 2009. Instructions on use of AMs which give users visual logical reasons to finish course, may influence adherence understanding of connection between taking full course of treatment and clearance of malaria parasites in Tanzania and Uganda (poster)
    1. Fussell D, Haaland A. Communicating with Pictures in Nepal. Kathmandu: UNICEF Nepal and National Development Service (NDS), Kirtipur University; 1976.
    1. Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006;61:173–190.
    1. Hoffmann T, Worrall L. Designing effective written health education materials: considerations for health professionals. Disabil Rehabil. 2004;26:1166–1173.
    1. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2000;51:1087–1110.
    1. Dickinson D, Raynor DK, Duman M. Patient information leaflets for medicines: using consumer testing to determine the most effective design. Patient Educ Couns. 2001;43:147–159.
    1. Haaland A. Pretesting communication materials with special emphasis on child health and nutrition education: a manual for trainers and supervisors. Rangoon, Burma: UNICEF; 1984.
    1. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995;153:1423–1431.
    1. Grimshaw J, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman A, O’Brien M. In: Getting Research Findings into Practice. 2. Haines A, Donald A, editor. London: BMJ Books; 2002. Changing provider behaviour: an overview of systematic reviews of interventions to promote implementation of research findings by healthcare professionals; pp. 29–68.
    1. Grol RP, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362:1225–1230.
    1. Ross-Degnan D, Laing R, Santoso B, Ofori-Adjei D, Lamoureux C, Hogerzeil H. Presented at the International Conference on Improving Use of Medicines. Chiang Mai, Thailand; 1997. Improving pharmaceutical use in primary care in developing counties: a critical review of experience and lack of experience.
    1. le Grand A, Hogerzeil HV, Haaijer-Ruskamp FM. Intervention research in rational use of drugs: a review. Health Policy Plan. 1999;14:89–102.
    1. World Health Organisation. Interventions and strategies to improve the use of antimicrobials in developing countries. Geneva: Drug Management Program; 2001.
    1. Mann KV, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2009;14:595–621.
    1. Wenger E. Communities of Practice. Learning, Meaning, and Identity. New York: Cambridge University Press; 1998.
    1. Scho¨n D. The reflective practitioner. San Francisco: Jossey-Bass; 1983.
    1. Kjeldmand D, Holmstrom I, Rosenqvist U. Balint training makes GPs thrive better in their job. Patient Educ Couns. 2004;55:230–235.
    1. Kjeldmand D, Holmstrom I. Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners. Ann Fam Med. 2008;6:138–145.
    1. Kolb D. Experiential learning: experience as the source of learning and development. New Jersey: Prentice-Hall; 1984.
    1. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302:1284–1293.
    1. Haaland A, Sopiene R, Kuksa L, Skrastina I, Biraua E, Skerbiene A, Gajauskiene V, Kaupiene J, Bielskiene V. EACH (European Association for Communication in Health) conference. Verona, Italy; 2010. Using guided self-observation and reflection Increase motivation to learn communication skills (poster)
    1. Zurovac D, Sudoi RK, Akhwale WS, Ndiritu M, Hamer DH, Rowe AK, Snow RW. The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: a cluster randomised trial. Lancet. 2011;378:795–803.
    1. Asiimwe C, Kyabayinze DJ, Kyalisiima Z, Nabakooza J, Bajabaite M, Counihan H, Tibenderana JK. Early experiences on the feasibility, acceptability, and use of malaria rapid diagnostic tests at peripheral health centres in Uganda-insights into some barriers and facilitators. Implement Sci. 2012;7:5.
    1. Baltzell K, Elfving K, Shakely D, Ali AS, Msellem M, Gulati S, Martensson A. Febrile illness management in children under five years of age: a qualitative pilot study on primary health care workers’ practices in Zanzibar. Malar J. 2013;12:37.
    1. Yeung S, Chandler CIR, Tabernero P, Rada O, de Souza M, Boravan M, Nguon C. American Society of Tropical Medicine & Hygiene. Philadelphia; 2011. Rapid Diagnostic Tests in the Cambodian private sector: How (well) are they being used in practice?
    1. Comoe CC, Ouattara AF, Raso G, Tanner M, Utzinger J, Koudou BG. Willingness to use a rapid diagnostic test for malaria in a rural area of central Cote d’Ivoire. BMC Public Health. 2012;12:1089.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe