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Community Pharmacists’ Knowledge, Practices and Attitudes towards the Medication Use Review in Qatar

Author(s) Ahmed Babiker1, Louise Carson2, Ahmed Awaisu3.
Affiliation(s) 1Pharmacy & Drug Control Department, Supreme Council of Health, Doha, Qatar, 2School of Pharmacy, Queen's University Belfast, Belfast, United Kingdom, 3College of Pharmacy, Qatar University, Doha, Qatar.
Country - ies of focus Qatar
Relevant to the conference tracks Advocacy and Communication
Summary Medication use review (MUR) is a service provision with accredited pharmacists undertaking structured adherence-centered reviews with patients on multiple medications, particularly those receiving medications for long-term conditions. The overall goal of MUR is to maximize an individual patient’s benefit from their medication regimen and prevent drug-related problems. MUR service is not yet established in community pharmacies in Qatar and nothing is known about pharmacists' knowledge, attitude, and practice pertaining to this service.
Background In Qatar, most patients currently receive their medications from the 8 public hospitals under Hamad Medical Corporation (HMC). In spite of being secondary and tertiary hospitals, most patients prefer to obtain their care including outpatient pharmacy services from these hospitals. Owing to this preference and attitude, there is unwarranted overcrowding in most hospitals and their outpatient pharmacies within HMC. One of the goals of Qatar’s National Health Strategies 2011-2016 is to improve the health services to international standards. Under this premise, Qatar envisions to provide world-class health care standard services and the best healthcare in the Middle East region (NHS 2011-2016). Within this goal, there is a community pharmacy strategy project aiming to adopt and implement international community pharmacy services and best practices as benchmark. Medication use review (MUR,) is one of these services. MUR service is not yet established in community pharmacies in Qatar and nothing is known about pharmacists' knowledge, attitude, and practice pertaining to this service. To our knowledge, the current study is the first one carried out to investigate the potential impact of implementing MUR services.
Objectives The overall aim of this research was to evaluate the perception of community pharmacists towards establishing MUR service as an extended role in patient care. The specific objectives of the study are to: 1) Assess the availability of facilities to support MUR implementation in community pharmacies in Qatar; 2) Evaluate pharmacist's self-perceived competence in providing MUR service; 3) Assess the knowledge of community pharmacists on MUR; 4) Assess the practices of the community pharmacists pertaining to MUR.
Methodology A cross-sectional study using self-administered questionnaires as a research tool was conducted among community pharmacists in Qatar from December 2012 to January 2013. The survey evaluated the pharmacists' self-perceived competence and attitudes towards providing MUR services in Qatar. The study involved pharmacists practicing in the private community pharmacy setting. There are approximately a total of 500 community pharmacists practicing in Qatar. In order to achieve a confidence level of 95% and 5% margin of error, a random sample of 220 community pharmacists currently practicing as community pharmacists in different cities and different pharmacies, including chains and independent pharmacies, in Qatar were selected to participate in the study. Inclusion criteria for potential respondents was: 1) being licensed as a practicing pharmacist in Qatar; 2) Currently working as a community pharmacist and; 3) working in a community pharmacy in Qatar for at least 12 months. The research instrument was developed via review of the literature pertaining to MUR, consultation with experienced researchers, experts, and licensed community pharmacists involved in the service. The data collected were analyzed using IBM Statistical Package for Social Science (IBM SPSS® Statistics) version 20 for analysis. Both descriptive and inferential statistics were used for data analysis. The study was approved by the Institutional Review Board of the Supreme Council of Health, Qatar.
Results One hundred and twenty-three community pharmacists responded to the survey, but 116 were included in the analysis (useable rate 94%; 116/123). The mean total knowledge score was 71.4% ± 14.7%. Although, nearly all of the participants (97%) were able to identify the scope of MUR in relation to chronic illnesses and in enhancing the quality use of medicines, only 43.4% knew that acute conditions are not the principal focus of MUR services. Over 80% of the community pharmacists were able to identify patients of priority for inclusion in an MUR program. At least 95% of the participants acknowledged that provision of MUR services is a great opportunity for the extended role of community pharmacists and that MUR makes excellent use of the pharmacist's professional skills in the community. Participants generally reported concerns about time, dedicated consultation areas, and support staff being significant barriers towards MUR. A large proportion of the participants (95%) indicated that training and education should be conducted for community pharmacists before implementing MUR program.
Conclusion The current findings suggest that community pharmacists in Qatar had sufficient knowledge about the concept of MUR and its scope, but there were still important areas of deficiencies and misconception of the practice that warrant education and training. The findings have important implications for policy and practice, particularly pertaining to the implementation of MUR services as an extended role of pharmacists and as part of Qatar's National Health Strategy 2011-2016 agenda to move primary health care forward in Qatar.

Best Practices for Building an Integrated National Health Information System: Rwanda.

Author(s) Caricia Catalani1, Angela Hoth2, Dawn Seymour3, Tyler Nelson 4, Felix Kayigamba 5, Richard Gakuba6
Affiliation(s) 1Innovative Support to Emergency, Disease, & Disaster (InSTEDD) & University of California, Berkeley, School of Public Health, San Francisco, United States, 2Innovative Support to Emergency, Disease, & Disaster (InSTEDD), Berkeley, United States, 3Rwanda Health Information Exchange, Regenstrief Institute, Kigali, Rwanda, 4Maternal Health & RapidSMS, The Access Project, Kigali, Rwanda, 5The Access Project, Kigali, Rwanda, 6 Rwanda Health Information Exchange , Kigali, Rwanda
Country - ies of focus Rwanda
Relevant to the conference tracks Innovation and Technologies
Summary The Rwanda Health Information Exchange (RHIE) is among the world’s first efforts to establish an integrated national health information system in a low-resource setting. Global decision-makers and implementers can benefit from both RHIE's open source tools and knowledge of leading and managing innovation for integration. This study assesses best practices in the design, development, and deployment of RHIE from the perspective of key stakeholders. Themes from the analysis of semi-structured interviews with funders, leaders, and implementers include recommendations on governance of country-owned initiatives, technological design and development, and deployment in a low-resource setting.
Background RHIE is a cloud-based system that supports quality of care and continuity of care over time, across geographies, and across different care delivery sites. RHIE’s vision is to improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different information systems used nationwide. In 2010, RHIE was designed and developed under the leadership of Rwanda’s Ministry of Health by the Open Health Information Exchange (OpenHIE), a global open-source technology community including partners at PEPFAR, Canadian International Research Development Center, Rockefeller Foundation, Regenstrief Institute, InSTEDD, Jembi Health Systems, IntraHealth, and others. RHIE’s national rollout began in 2012 and entailed working across sites with minimal infrastructure and among providers with little computer experience to configure hardware, install software, build local capacity, and manage technical support . Today, and as scale-up continues, RHIE facilitates the movement of health information across Rwanda with the primary aim of improving maternal and child health and the treatment and prevention of HIV/AIDS.
Objectives The Open Health Information Exchange builds free and open-source tools to enable other national leaders, policymakers, and implementers to improve the integration of health data and systems through the establishment of health information exchanges. Today, the partnership is collaborating with national leaders from six countries, providing technical support required to spearhead this effort. However, more than just tools and technical support, decision-makers need practical insights into the process of leading and managing innovation of this kind. As such, this study aims to describe the best practices in design, development, and deployment of a health information exchange, based on the RHIE experience. Researchers conducted key stakeholder interviews among RHIE funders, leaders, and implementers with a range of expertise from computer engineering to health systems management to clinical care. From their critical reflections of the RHIE initiative, its three years of history, and its pathways forward, stakeholders provide recommendations on approaches to governance of country-owned initiatives, strategies for technological design and development, and tactics for managing deployment of technological innovation in low-resource settings.
Methodology Qualitative semi-structured interviews were conducted with RHIE key stakeholders. Stakeholders included Ministry of Health leaders & implementers, project managers & strategists, technology architecture designers & developers, and funders & other institutional partners. Semi-structured interviews guided a conversational interview, providing the interviewers with key points of discussion without requiring strict adherence to a set order of questioning or phrasing of the questions. As such, interviewees provide descriptions of their experiences, ideas, and critiques in an open and guided discussion. Interview were conducted by two trained interviewers via phone, audio-recorded, and documented through detailed notes. Interview duration ranged from 45-75 minutes. Analysis was conducted using Dedoose Mixed Methods Analysis Software, a cloud-based research and analysis application. A modified grounded theory approach was used in the analysis of qualitative data. This approach facilitated the detailed and systematic examination of data regularities in the relationships between and within codes, and for variations and contrasts within codes. Major themes emerged from the codes and a descriptive framework formed.
Results Key stakeholder interviews included 14 participants from 7 organizations and 4 countries. Several key themes emerged across the major phases, spanning partnership building, design, development, deployment, and evaluation. First, eHealth is a new field without established guidelines for management and leadership and, as such, most found it challenging to partner without clearly articulated governance rules. Terms of governance, they argued, provide guidance for decision-making, roles and responsibilities, accountability, and transparency. The RHIE experience confirmed for most that country-ownership of the initiative should be established early and embedded into the partnership’s governance structures.Second, most partners commented on the difficulty of collaboration when key contributors were spread across several countries and time-zones. They explained that in a low-resource setting, it is often necessary to look for eHealth integration expertise and capacity from people based in other countries. Cross-cultural, cross-national, and cross-disciplinary communication was immensely difficult, although building an integrated system required a well-integrated team. Stakeholders found that it was critical to have a shared commitment to regular communication and ample budget for in-person meetings.Third, experts were adamant that an eHealth integration initiative should start by looking at existing, tested, and ideally open-source tools that might serve as customizable building blocks for their own solution. While identifying these tools, most argued that the team must create a shared standard of assessment so that they can transparently evaluate tools in a world where business interests may sway these decisions. Many stakeholders shared the opinion that eHealth solutions must be simple, tested, and even boring, although “the siren song is to do something new, bold, and innovative.”Finally, most partners found that the health and human development objectives of the project were obfuscated by the technological objectives of the project. RHIE contributors spent the vast majority of their efforts on designing and developing the technology, often without a shared vision of how the system would ultimately impact health services, morbidity, and mortality. One expert argued that it should have been the opposite and that “in a sociotechnical system, the technical should be 10% and the rest of the money and time should be spent focusing on implementing.”
Conclusion The health systems integration experts involved in RHIE shared a common sense of the challenges and opportunities inherent in partnering, designing, developing, and deploying a health information exchange. Several best practices emerge from these findings: establish rules of governance to guide the partnership; plan for regular and in-person communications to facilitate collaboration among diverse contributors; build on existing, tested, and open-source technologies before considering anything new; and, create a shared strategic and practical vision for how a new eHealth tool will impact health. As the OpenHIE expands beyond Rwanda and into new country implementations, these findings can be used to guide policy-makers, implementers, and other experts. Worldwide, country leaders are struggling to take advantage of the digitization of health information while managing innovation within health centers and protecting patient privacy. In an era of big data, health information exchange is one way to integrate and manage health information across disparate systems. Health information exchange tools and best practices may improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different health information devices, tools, and systems emerging worldwide.

Performance of Community Health Workers in Community Case Management: Uganda

Author(s) Agnes Nanyonjo1, Edmound Kertho2, Seyi Soremekun3, Frida Kastenge 4, Guus TenAsbroek 5, James Tibenderana6, Karin Kallander7
Affiliation(s) 1Technical, Uganda Country Office, Malaria Consortium, Kampala, Uganda, 2Technical, Uganda Country Oficce, Malaria Consortium, Kampala, Uganda, 3Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom, 4Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom, 5Population Health, London School of Hygiene and Tropical Medicine, Amsterdam, Netherlands, 6Technical, Africa Region Ofiice, Malaria Consortium, Kampala, Uganda, 7Technical, Africa Region Office, Malaria Consortium, Kampala, Uganda.
Country - ies of focus Uganda
Relevant to the conference tracks Health Workforce
Summary Integrated community case management is key child survival strategy in resource poor settings. There is paucity of data on performance of community health workers in this strategy and how this performance can be measured. We report on a study that evaluated the performance of community health workers using case vignettes. Overall community health workers perform well with respect to treatment. However omissions in terms of probing for danger signs and other illness symptoms and provision of general health education required by the treatment guidelines deter community health worker performance.
Background Integrated community case management for malaria, pneumonia and diarrhoea (iCCM) is one of the key interventions tailored towards curbing child mortality in low income countries. In iCCM lay community health workers (CHWs) use a given algorithm provided in a job aid to ask about illness symptoms, assess signs, classify and treat disease or refer severely ill children. They treat malaria with artemether lumefantrine combination, pneumonia with amoxycillin and diarrhoea with oral rehydration salts (ORS) and zinc. They are also required to offer health education regarding disease prevention. Although measurement of performance in itself poses key challenges in terms of choice of method used, assessment and understanding of the performance of CHWs is crucial to ensure high quality care of the sick children.
Objectives The objective of the study was to assess the performance of CHWs while managing children with solitary disease such as malaria alone or mixed infections such as malaria and pneumonia by using case vignettes.
Methodology The study was conducted among a sample of 360 CHWs who had been practicing iCCM for at least three to eight months in eight districts in Midwestern Uganda. CHWs were given four case vignettes; one after the other. Using probing questions the CHWs were asked to describe the actions they would take from the time they encountered the sick child and his/her caregiver to the time they finished the consultation. The CHWs were allowed to use their job aid during the evaluation. One case vignette emulated a 6 months old child with an uncomplicated malaria classification presenting with fever, poor appetite and no danger signs; requiring a malaria rapid diagnostic test, malaria treatment and health education. Another vignette depicted a 3 year old child with diarrhoea and no blood in stool; requiring zinc, ORS and health education. The third vignette was about a child with both cough fast breathing and fever and a history of stiff feet early that morning depicting a child with pneumonia and complicated malaria requiring referral and pre-referral treatment due to the danger sign. The last case was about a child with fever and cough, essentially with uncomplicated malaria but no pneumonia. Each appropriate action, i.e. questions the CHW should have asked, test CHW should have performed and treatment and health education CHW should have given basing on the guidelines, was assigned a weight of one. The average performance score for each CHW was generated on a scale of 0-100. Scores were also sub-analyzed per case managed as well as association with socio-demographic factors, such as sex, literacy and district of the CHWs.
Results Out of all actions that should have been taken for each case, the overall mean performance score of the CHWs was 41.5 (SD 8.6). The mean performance score based on case scenarios was 46.6 (SD 16.3) for the uncomplicated malaria case, 59.3 (SD 15.6) for the case of uncomplicated malaria with cough, 36.5 (SD 13.6) for the diarrhoea case, and 23.5 (SD 14.4) for the case with pneumonia and complicated malaria and. Overall, CHWs ability to state the correct treatment and dose for the simulated case was high, with 93.3% sating the correct treatment for a child case with malaria alone; 94.4% stating the appropriate treatment for a child case with diarrhoea, and 84.4% being able to suggest referral for a child case with a history of a danger sign. However, the problematic areas in the management algorithm that appeared to decrease the overall mean performance score included: a) failure to ask about dangers signs and symptoms that are not mentioned by the caregiver. Overall only 1% of the CHWs remembered to probe for the presence of any danger signs and other symptoms not automatically volunteered by the care taker in at least one of the case scenarios; b) Failure to assess for key illness symptoms. In the pneumonia and complicated malaria case only 22.7% of CHWs mentioned that they would assess the respiratory rate of the child; c) Failure to give pre-referral treatment. Only 28.1% and 9.7% CHWs mentioned that they would give pre-referral treatment for malaria and pneumonia, respectively; d) Failure to give instructions on how to administer the drug, especially in the diarrhoea case scenario where only 40% mentioned at least one instruction they would give to the caretaker regarding how to mix and give ORS; e) Failure to provide general health education and information on when to take the child to the health facility for further treatment. Twenty percent of CHWs did not give caretakers any of the recommended advice. Performance levels were positively associated with the district of the CHWs (p<0.001) and to the increasing number of patients the CHW had seen in the last week (p=0.015).
Conclusion If the case scenarios where a reflection of a real life situation our data suggest that majority of children seen by CHWs would get the appropriate curative treatment or action required. However they would not be able to benefit optimally from their visit to the CHWs due to omitted actions, such as provision of pre-referral treatment, health education and counseling, and demonstration to caregivers on how to give the first dose. Supportive supervision and refresher training of CHWs should which emphasizes strict adherence to treatment algorithms, and which offers strengthening of interpersonal communication skills should be implemented.

Princeton’s University Global Health Program: Research and teaching at the nexus of science, policy and social science

Author(s) Kristina Graff1, Peter Locke2
Affiliation(s) 1Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, United States, 2Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, United States, 3.
Country - ies of focus Global
Relevant to the conference tracks Education and Research
Summary Princeton University’s Global Health Research and Teaching Program is anchored in the philosophy that complex problems demand a comprehensive and integrated approach, in which players from a range of academic and technical areas collaborate to analyze global health problems and explore innovative solutions. Princeton’s Global Health Program generates the scholarship fundamental to health improvements at the nexus of science, policy and social science, and educates students who will become leaders in these fields. Its defining elements are a cross-disciplinary approach, hands-on field research and a focus on the policy dimensions of global health.
What challenges does your project address and why is it of importance? Global health challenges go far beyond clinical issues. These problems are rooted in economic, social and political forces, geographical and logistical hurdles as well as the dynamic impacts of globalization and governance. Solutions to global health problems demand an interdisciplinary response –one that integrates the expertise and perspectives of a range of sectors and specialties. A holistic approach to global health looks beyond what medicine alone can achieve and addresses all the elements that contribute to improved wellbeing, ranging from population and system-based interventions to an understanding of how broad public health initiatives affect individual lives.
Princeton University’s Global Health Program is anchored in the philosophy that complex problems demand a comprehensive and integrated approach, in which players from a range of academic and technical areas collaborate to analyze global health problems and explore innovative solutions. Princeton’s Global Health Program generates the scholarship fundamental to health improvements at the nexus of science, policy and social science, and educates students who will become leaders in these fields. Its defining elements are a cross-disciplinary approach, hands-on field research and a focus on the policy dimensions of global health.
How have you addressed these challenges? Do you see a solution? Princeton’s Global Health Program operates integrated research and teaching initiatives that span the breadth of faculty expertise. The global health program supports a multi-disciplinary research agenda and curriculum bridging engineering, the humanities, and the social and natural sciences.The University sponsors innovative and exploratory research, which is scaled up to draw external grants. Faculty lead projects that engage undergraduates, graduates and postdoctoral researchers. They extend into the classroom and into students’ research and internships.The global health program also supports students’ internships and research in laboratories and field sites around the globe, academic and public events, and student participation in external conferences. This program model simultaneously fuels research and teaching in key areas of global health.A key program focus is on high-quality, hands-on learning. Students conduct research and internships in 20+ countries, based at research centers, NGOs and grassroots organizations, academic institutions, hospitals and clinics. Junior researchers mentor many student projects, providing training in topics such as technical methods for research and analysis, to the ethics and principles of sound and responsible global health research. These field experiences are life changing for many students and form the basis of their future pursuits in domestic and global health.A final critical factor in the success of Princeton’s global health program is a strong and longstanding partnership with the institutions where students and faculty conduct research. Solid institutional relationships allow for regular exchanges, high-quality research, expanded opportunities for collaborative projects and more efficient administration. Two key governing principles for the program’s collaborations are reciprocity and on-site advising by Princeton researchers based in the field. Princeton hosts faculty members and graduate students from partner institutions for varying periods of time. Postdoctoral fellows have proven highly effective as on-site research coordinators and advisors.

By centering its research and teaching activities on interdisciplinary and integrated principles, Princeton’s global health program facilitates cross-departmental engagement of faculty and prepares students to address the increasingly complex slate of global health challenges.

How do you know whether you have made a difference? The Princeton Global Health Program tracks the impact of its research and teaching programs over time, and it also devotes ongoing attention to ensuring that its international partnerships are mutually beneficial. For research we monitor how the work is scaled up into larger programs, published in academic and other journals, and translated into policy and practice changes. We do this through reporting by recipients of internal grants and through tracking global health faculty member’s work.For teaching we follow the threads of students’ academic progress over multiple years and then track their career trajectories once they graduate. We do this through a combination of quantitative measures (number and proportion of global health students who pursue related graduate study and careers) and qualitative data (asking students over time how their experience in Princeton’s global health program shaped their understanding of global health issues and the evolution of their careers). We also link current students to program alumni, in order to create an informal network for advising and guidance.For international partnerships we work with our collaborating institutions to identify mutually beneficial projects at the start of our cooperative efforts. We also commit to a true exchange, whereby our partner institutions can send faculty or graduate students to Princeton for periods of research or study. We communicate frequently to keep things running smoothly, set agreements about use of data and publications resulting from the collaboration, send as many field-based researchers to our partner sites as possible, and conduct periodic site visits for monitoring and relationship management.
Have you or the project mobilized others and if so, who, why and how? The international partnerships have resulted in a range of studies, projects and grants to address global health challenges around the world. Some of these have been the result of student projects that were designed to address pressing issues facing a particular partner institution. Princeton’s participants were called upon to address the economic, social, cultural and logistical factors affecting health care access and overall wellbeing. One example is Princeton’s global health program partnership with Wellbody Alliance, a community-based healthcare organization in rural Sierra Leone. Under the supervision of a global health program postdoctoral fellow, Princeton students conduct summer field research focused on helping Wellbody to better understand community needs and evaluate the impact of its services.Based on a student’s project analyzing barriers to tuberculosis (TB) treatment adherence, Wellbody applied for and received a grant from the World Health Organization’s STOP-TB Partnership to implement an innovative district-wide home-based TB screening and treatment system. As part of this project, Wellbody Alliance has hired and trained 150 community health workers, upgraded laboratory and administrative capacity, and secured additional medication needed to treat hundreds of new TB patients. All patients diagnosed with TB in Kono District are now assigned a Wellbody Alliance community health worker who visits patients in their homes to administer medication and evaluate their progress. Additionally, community health workers offer early testing and treatment to high-risk individuals, saving lives and preventing others from becoming infected.In the summer of 2013, students returned to support and evaluate the implementation of the program by accompanying supervisors and health workers as they carried out their duties in the community. Their findings will be essential to identifying and overcoming unexpected challenges in the field and to facilitating the renewal of the WHO grant beyond the first year.
When your donor funding runs out how will your idea continue to live? In the research dimension, the University’s initial investment in global health research is being translated into support from external donors whose primary agenda is to further these lines of inquiry. The research projects will then ultimately become a self-sustaining entity. The program also maintains endowed funds so that there will always be avenues to seed innovative ideas and projects until they can be scaled up for broader external funding. In the teaching dimension, the philosophy of Princeton’s global health program is present in the University’s core educational curriculum. Therefore the program and its guiding principles will remain at the center of all pedagogical initiatives as ongoing and standard academic offerings.In its international collaborations, these costs will ultimately be moved from the category of “special initiatives” over to a standard part of normal program operations, so that they become part and parcel of global health partnerships – both at Princeton and within its partner institutions. When the partnerships prove to be mutually beneficial they can then merit a spot as an essential element of both collaborators’ regular operating budgets.

Why Educational Interventions Fail in Changing Treatment Practices in Rural Hospitals: Evidence from Sri Lanka.

Author(s) Lalith Senarathna1, Cynthia Hunter2, Andrew Dawson3, Michael Dibley 4
Affiliation(s) 1South Asian Clinical Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka, 2Sydney School of Public Health, University of Sydney, Sydney, Australia, 3National Poisons Register & Clinical Toxicology, Royal Prince Alfred Hospital, Sydney , Sydney, Australia, 4Sydney School of Public Health, University of Sydney, Sydney, Australia.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Health Systems
Summary Non-adherence to education interventions is a barrier to improving hospital treatment. This qualitative exploration reveals that education interventions are capable of improving knowledge, but success of the intervention in rural hospitals depends on social dynamics of hospital and influences from the community. In these hospitals introducing new practices was easier than changing established practices. Treatments by clinicians were easily improved than practices with non-clinical staff involvements. Interventions for specific practices will be useful in improving adherence. Similarly, parallel community awareness programs to discuss changes of hospital practices will improve this situation.
Background Lack of continuous educational programs for health care workers has created a gap between standard patient treatment guidelines and actual practice in hospitals. This gap is a significance barrier in improving patient care in rural hospitals in low and middle income countries (LMICs) like Sri Lanka where rural primary care hospitals act as initial access point to health care for majority of the population. Although different educational strategies had been in use to promote clinical guidelines aimed at closing this gap for a range of disease in rural hospitals, non-adherence to educational interventions is a major issue. Reasons for this poor adherence to educational interventions in rural hospitals in LMIC settings have not been systematically studied. This lack of evidence has created difficulties in designing educational interventions to improve hospital treatment practices.
Objectives The objective of this study was to explore reasons for non-adherence to the recommendations from education intervention in rural hospitals in Sri Lanka.
Methodology This study was a qualitative exploration related to a completed cluster randomised controlled trial (Trail Registration Number ISRCTN73983810) conducted in 46 rural primary care hospitals in North Central Province of Sri Lanka to promote poisoning treatment guidelines using an outreach education approach. This study showed that recommended treatments which were to be initiated by clinicians were well adopted while other treatments with non-clinical staff involvement did not change. Practices that were not changed following the educational intervention were used to explore the reasons for non-adherence to recommendations from education interventions.
Focus group discussions were conducted with doctors, nurses and non-clinical staff members in selected interventional hospitals. A sampling framework developed using hospital capacity and staff numbers were used to select 8 hospitals from the intervention group for the data collection. Thematic analysis was conducted using transcribed records according to the principles of grounded theory.
Results This exploration showed that outreach education intervention was capable of improving knowledge of treatment guidelines and creating a positive attitude among hospital staff members. But this attitude and knowledge alone did not change the practices as recommended during the education interventions. There were other significant internal and external influences which played a major role in treatment decisions such as social dynamics within hospital and where the influence from the communities were more prominent. In rural hospitals where there is limited staff availability, even non-clinical staff perform assisting roles in patient treatments. Hence, changing long established practices for which both clinical and non-clinical staff contribute cannot be changed using interventions designed only for clinical staff. Introducing new practises or treatments are relatively easier than changing long established inappropriate practices.
In these rural hospitals, treatment decisions are shaped to meet community expectations which are, at times, not aligned with the recommendations from clinical guidelines or interventions. Hospital staff including doctors are reluctant to neglect requests from the community in fear of becoming unpopular. During the group discussions, doctors stated that that community awareness programs parallel to hospital education interventions are essential when promoting updated treatment practices in rural hospitals.
Conclusion In rural Sri Lankan hospitals, only education interventions do not improve treatment practices. Social dynamics of the hospital and expectations of the community influence treatment decisions. Hence, these factors should be considered in designing education interventions in rural hospitals, not only in Sri Lanka, but also similar settings in other low and middle income countries. Furthermore targeted interventions aimed at selected hospital staff categories or specific treatment practices would be more appropriate than common interventions for all staff. Similarly, awareness programs to educate community about changes in village hospitals and updates of treatment practices would facilitate improvements in the hospitals.

Integrating neuro-psychiatric disorders at the level of primary health care centres: Guinea

Author(s) Abdoulaye SOW1, Oury SY2, Amatigui DIALLO3, Abdoulaye KOULIBALY4, Mouctar DIALLO5, Binta BAH6.
Affiliation(s) 1Mangment, Medical fraternity Guinea, Conakkry, Guinea, 2Physian, Medical fraternity Guinea, Conakry, Guinea, 3Physian, Medical fraternity Guinea, Conakry, Guinea, 4Physian, Medical fraternity Guinea, Conakry,Guinea, 5Physian, Medical fraternity Guinea, Conakry, Guinea, 6research, Medical fraternity Guinea, Conakry, Guinea.
Country - ies of focus Guinea
Relevant to the conference tracks Chronic Diseases
Summary Mental, neurological, and substance use disorders make a substantial contribution to the global burden of disease. According to the World Health Report 2000 neuropsychiatric disorders (a component of mental health) are the second cause of disability-adjusted life years (DALYs), behind the infectious and parasitic diseases. Under the theme “Stop exclusion, Dare to care”, the year 2001 was dedicated by the WHO as the "Year of mental health”. Since ancient times, epilepsy has remained a controversial subject for many world populations. This is because mental illness has been perceived as socio-anthropological for many societies.
What challenges does your project address and why is it of importance? Primary health care strategy aims to make accessible to as many people as possible healthcare according to people’s needs, at an affordable cost and taking into account a country's given resources. Equity and social justice are the basic principles of this strategy.
According to the World Health Report 2002, neuropsychiatric disorders account for 13 % of the global burden of disabilities adjusted life years (DALYs). In Guinea, while significant progress has been made in primary health care programmes, little improvement has been measured in the field of mental health. The psychiatrist ratio per capita is one of the lowest in the world. A similar gap in the number of neurologists prevails throughout the country.
In order to address this gap, the Guinea Medical Fraternity (a Guinean association of doctors) opted for the integration of neuropsychiatric consultation into the daily work of the general practioners working in its health centers.
At the opening of its health centers in the 90's, one missing element was the lack of data about the number of patients who sought consultation for mental health problems. At that time, no information was available due to the lack of qualified human resources and poor access to medicines. To tackle this challenge, Guinea Medical Fraternity initiated the project SaMoa, and used 'action research.'
How have you addressed these challenges? Do you see a solution? The model of care employed is based on the three-dimensional approach used in outpatient mental health management: medical, socio-psychological and the community. These three dimensions are combined for almost all patients in our centers, without following neither a chronological nor a hierarchical order.
For the two groups of diseases described in this abstract, epilepsy and mental health disorders, a care package is offered to the patient. This includes: identification of fixed and advanced strategy for the patient, medical treatment (with antipsychotics and/or anticonvulsants), follow-up and psychosocial support (individual interview, with family members, home visits), family and community reintegration through discussion groups and reintegration workshops (graphical expression, apprenticeships) and finally social support interventions (such as supporting the recovery of a lost job or supporting patients in rebuilding a couple in crisis).
In order to ensure continuity of care, a number of materials have been developed.
These include:
• Personal health record (first visit and follow up)
• Home visit notebook
• Reintegration notebook (describing the patient personal project)
• Group workshops notebook.
• Monthly collection sheet.
• Monthly report
Regular inter-professional encounters have been established in order to promote synergies and complementarity among caregivers and has been used to foster continuous staff training. This framework is supported by:
• A joint consultation between a generalist and a specialist (neuropsychiatrist ) at the beginning of the project
• A daily joint consultation between doctors and social workers
• A weekly team meeting between doctors, social workers and community volunteers, to discuss specific cases
• A monthly coordination meeting, which brings together the heads of unit of each health center and the officials of the NGO.
How do you know whether you have made a difference? From January 2000 to June 2013, 7079 mental health problems were diagnosed among which 47 % were psychoses, 33% were epilepsy cases and the remaining 20% represented by depression, dementia, neurosis, social problems and cerebral motor deficiencies.
Among patients put under treatment, two main molecules were used for psychosis (different forms of Haloperidol and Akineton as corrector) and for epilepsy, four essential generic drugs (carbamazepine, phenobarbital, phenytoin and sodium valproate). We found a positive impact for both patients and their families, health care providers as well as for health centres.
For the patient, the impact is assessed by how much healthcare management has improved by integrating the socio-cultural context of the patient and his/her family, how much the intervention has strengthened patient-provider relationship and contributed to better adherence and how much the intervention has facilitated patients social reintegration and has strengthened their economic capacity.
At the level of health centers and providers: the impact is felt at many levels
 Improved patient-provider relationship (beyond mentally ill patients).
Indeed, GP’s trained to adopt a more holistic bio-psycho-social approach with psychiatric patients and spontaneously applied a similar approach vis-à-vis other patients, spending more time, listening and discussing with them and paying more attention to their psychosomatic problems.
 Improved relationships between health centers and the communities they serve.
Communities started to see healthcare providers and the health centres as partners and contributed to the development of the relationship.
 Improved relationships between primary health centers and referral hospitals.
Given the fact that the care package provided by the programme is not available in district hospitals, the project has reversed the usual pattern of the health pyramid that usually sees PHC centers referring their patients to a hospital. In this case, the opposite took place, hospitals sending their patients to the lower level of care.
 Implementation of several community initiatives around the health centres.
The momentum created by the project has allowed the emergence of community-led initiatives such as economic interest groups among intervention communities, involvement of young people in the village around health promotion activities and the establishment of patient support groups.
 Health centre as a training and internships for medical students in public health and community health workers. Successful health centres are coveted by academics whose students are engaged in the internships and the development of dissertations.
Have you or the project mobilized others and if so, who, why and how? The project involved several actors in different and various socio-medical fields.
In Guinea, networking is not integrated into the system. Each association operates in isolation and tries to protect its field of competencies as a private territory. Initiatives are confined to a limited territory or to a given intervention and do not benefit neither the beneficiaries nor field social workers. To break this single thought mindset, our project has created an inter-professional approach mobilizing a supportive and dynamic network of various health workers, social workers and human rights advocates in order to improve the management of heavy neuropsychiatric disorders.
Among the objectives, this initiative attempted also to demedicalize some health problems, to push healthcare providers to pay more attention to social problems and to involve other social stakeholders in medical work.
As an illustration, health centres provide care (medical consultations, nursing services and drugs) to all populations. Social centres provide services (psycho -social support, legal support, rehabilitation, social and professional reintegration) to the same populations. The interaction of these two levels of intervention can only be beneficial for patients, providers and medical-social structures.
Our methodology involves the organization of platforms for dialogue between actors, field visits, referrals of patients or target groups and the organization of joint actions.
The platforms are organized around a theme: clinical, social, results or best practice.
Field visits take place upon request in order to assess the social and/or medical situation of an identified patient, or to meet with an association that wants to share its experience and best practices or seek advice.
Social workers refer their clients to a healthcare professional for a medical condition and the healthcare professional refers their patients to social workers in order to be more effective not only in medical care but also to delegate certain activities (counseling, search of lost to follow up) in order to deal with other aspects.
Joint actions are put in place to identify, plan and agree upon a synergic mode of implementing activities that improve the quality of services offered.
When your donor funding runs out how will your idea continue to live? The project initially depended on single funding, but since its activities are integrated into health centres, it has become routine and no longer dependent on external funding. Yet, the fact that we are in the process of replicating and scaling up the programme in several other health centres, funding will be needed in order to train staff, provide a starting stock of essential generic drugs, conduct reintegration workshops and provide supportive teaching materials.

Performance of Community Health Workers in Community Case Management: Uganda.

Author(s) Agnes Nanyonjo1, Edmound Kertho2, Seyi Soremekun3, Karin Källander 4, inSCAlE Studygroup 5.
Affiliation(s) 1Techinical, Malaria Consortium, Kampala, Uganda, 2Technical, Malaria Consortium, Kampala, Uganda, 3Department of Population Health, London School of Tropical Medicine and Hygiene, London, United Kingdom, 4Technical, Malaria Consortium, Kampala, Uganda, 5Technical, Malaria Consortium, London, United Kingdom.
Country - ies of focus Uganda
Relevant to the conference tracks Advocacy and Communication
Summary Integrated community case management is a key child survival strategy in resource poor settings. There is a paucity of data on the performance of community health workers and how this performance can be assessed. We report on a study that assessed the performance of community health workers using various case vignettes.
Background Integrated community case management for malaria, pneumonia and diarrhoea (iCCM) is one of the key interventions tailored towards curbing child mortality in low income countries. In iCCM, lay community health workers (CHWs) use a given algorithm provided as a job aid to ask about illness symptoms, assess signs, classify and treat disease or refer severely ill children. They treat malaria with artemether lumefantrine combination, pneumonia with amoxycillin and diarrhoea with oral rehydration salts (ORS) and zinc. They are also required to offer health education regarding disease prevention. Although measurement of performance in itself poses key challenges in terms of the method of choice, assessment and understanding of the performance of CHWs is crucial to ensure high quality care of the sick children.
Objectives The objective of the study was to assess the performance of CHWs while managing children with solitary disease such as malaria alone or mixed infections such as malaria and pneumonia by using case vignettes.
Methodology The study was conducted among a sample of 360 CHWs who had been practicing iCCM for at least three to eight months in eight districts in Midwestern Uganda. CHWs were given three case vignettes; one after the other. Using probing questions the CHWs were asked to describe the actions they would take from the time they encountered the sick child and his/her caregiver, to the time they finished the consultation. The CHWs were allowed to use their job aid during the evaluation. One case vignette emulated a 6 months old child with an uncomplicated malaria classification presenting with fever, poor appetite and no danger signs; requiring a malaria rapid diagnostic test, malaria treatment and health education. Another vignette depicted a 3 year old child with diarrhoea and no blood in stool; requiring zinc, ORS and health education. The third vignette was about a child with both cough and fever and a history of stiff feet depicting a child with complicated malaria and pneumonia requiring referral and pre-referral treatment due to the danger signs. The last case was about a child with fever and cough essentially with uncomplicated malaria but no pneumonia. Each appropriate action based on the guidelines (i.e. questions the CHW should have asked, tests the CHW should have performed and treatment and health education CHW should have given) was assigned a weight of one. The average performance score for each CHW was generated on a scale of 0-100. Scores were also sub-analyzed per case managed, as well as for association with socio-demographic factors, such as sex, literacy and district of the CHWs.
Results Out of all actions that should have been taken for each case, the overall mean performance score of the CHWs was 41.5 (SD 8.6). The mean performance score based on case scenarios was 46.6 (SD 16.3) for uncomplicated malaria cases, 59.3 (SD 15.6) for the cases of uncomplicated malaria with cough, 36.5 (SD 13.6) for the diarrhoea cases, and 23.5 (SD 14.4) for the cases with complicated malaria and pneumonia. Overall, CHW's ability to state the correct treatment and dose for the simulated cases was high, with 93.3% stating the correct treatment for a child with malaria alone, 94.4% stating the appropriate treatment for a case with diarrhoea, and 84.4% being able to refer a case with a history of danger signs. However, the problematic areas in the management algorithm that appeared to decrease the overall mean performance score included: a) failure to ask about dangers signs and symptoms that are not mentioned by the caregiver. Overall only 1% of the CHWs remembered to probe for the presence of any danger signs and other symptoms not automatically volunteered by the care taker in at least one of the case scenarios; b) Failure to assess for key illness symptoms. In the complicated malaria and pneumonia case only 22.7% of CHWs mentioned that they would assess the respiratory rate of the child; c) Failure to give pre-referral treatment. Only 28.1% and 9.7% CHWs mentioned that they would give pre-referral treatment for malaria and pneumonia respectively; d) Failure to give instructions on how to administer the drug, especially in the diarrhoea case scenario where only 40% mentioned at least one instruction they would give to the caretaker regarding how to mix and give ORS; e) Failure to provide general health education and information on when to take the child to the health facility for further treatment. Twenty percent of CHWs did not give caretakers any of the recommended advice. Performance levels were positively associated with the district of the CHWs (p<0.001) and to the increasing number of patients the CHW had seen in the last week (p=0.015).
Conclusion If the case scenarios were a reflection of a real life situation, our data suggests that the majority of children seen by CHWs would get the appropriate curative treatment or action required. However they would not be able to benefit optimally from their visit to CHWs due to omitted actions, such as provision of pre-referral treatment, health education, counselling and demonstration to caregivers on how to give the first dose. Supportive supervision and refresher training of CHWs, which emphasizes strict adherence to treatment algorithms, and which offers strengthening of interpersonal communication skills, should be implemented.

Integrating artistic programs in diabetes education and self management in Madagascar.

Author(s) Tojosoa Rajaonarison1, Haja Ramamonjisoa2, Tiziana Assal3, Jean-Philippe Assal4, Georges Ramahandridona5.
Affiliation(s) 1Art-therapy, Madagascar Diabetes Association, Antananarivo, Madagascar, 2Therapeutic Education, Madagascar Diabetes Association, Antananarivo, Madagascar, 3Art-therapy, Foundation for Research and Training in Patient Education, Geneva, Switzerland, 4Therapeutic Education, Foundation for Research and Training in Patient Education, Geneva,Switzerland, 5Medical, Madagascar Diabetes Association, Antananarivo, Madagascar.
Country - ies of focus Madagascar
Relevant to the conference tracks Chronic Diseases
Summary The Malagasy perception of diabetes is negative. Patient with diabetes often do not accept their treatment and their family members reject them. Heath caregivers need to be closer to patients and to promote a good collaboration with them.
Our Diabetic Association has organized up to 12 painting workshops from 2010 to 2013 with 141 patients. They are centered on patients’ problems and needs. Each workshop provides painting exercises associated with specific moments: blood sugar measurements, diet discussion, and hypoglycaemia. Health caregivers provide flashes of therapeutic education during this time. Workshops also provide psychological and social balance enabling patients to be more responsible for their health
What challenges does your project address and why is it of importance? Painting workshops are a tool to promote therapeutic patient education for all types of diabetics. Organized by A.MA.DIA. (Association Malgache contre le Diabète à Antananarivo), they have brought many changes in our participants’ lives: patients are finally able to express themselves more freely, they discover their personal creativity, they are more involved in social activity, they feel less isolated. This process has a strong effect on the coping ability of each patient. Adherence of treatment increases, medical appointments are better respected and the doctor–patient relationship improves. As a consequence, there is a general improvement of patients and care providers’ attitudes. They all feel more empowered in their daily activities. After the workshops patients feel that their family members understand them better.
How have you addressed these challenges? Do you see a solution? The A.MA.DIA has faced many problems over the years including crowded outpatient clinics, lack of enough fully trained personnel, difficulties in continuing education as well as being faced with false copies of medication: diabetic oral agent, antihypertensive drugs, and antibiotics. This situation has forced us to develop specific courses to teach patients to detect the copies of false drugs that patients may have bought cheaply at a local market.
Hypoglymia in children and young adults is another serious problem.
During the workshops with children, the blood sugar is tested and explanations are given about corrective snacks.
Another aspect is the timidity of patients in the presence of the care providers. The consequence is that patients suffer from a lack of psychological support.
Painting workshops reinforce continuing education as well as the self-reliability of patients.
They develop self-confidence and autonomy.
How do you know whether you have made a difference? The various activities we described, linked to therapeutic education, did not exist 4 years ago. Since their creation and development, there is an increasing demand for participation among patients as well as their families.
There is a weekly connection through skype between A.M.A.DIA and the Geneva center, and a monthly video sessions with the participation of experts who are at the disposal of the team of l’AMADIA Hospital. Those meetings allow joint discussions, lectures, supervision, continuing evaluation and support.
The experts have writen some observations about our workshops of Art-Therapy : “The thing that strikes all those who have observed the AMADIA workshops is the extraordinary enthusiasm and commitment of the caregivers and patients. Caregivers experiment continuously new ways of helping patients using art, working with different groups of participants: families, young diabetics, aged people as well as mixed groups."
The example of AMADIA shows that art can be integrated in a global system of care where emotional expression and medical care can be simultaneously present.
Have you or the project mobilized others and if so, who, why and how? Among the various approaches we have developed, we obtained help from the World Diabetes Foundation and the order of St. Jean France and Switzerland. This allowed the improvement of our Hospital AMADIA and the widening of detection campaigns throughout the country. We also have the benefit of monthly Video sessions with Geneva with the help Orange Madagascar and the Foundation for Research and Training for Patient Education in Geneva.
When your donor funding runs out how will your idea continue to live? We think that financial support from donors is of vital importance for the continuity of the painting workshops. Madagascar is a very low income country and so are the majority of our patients. Many people cannot even afford the cost of their daily pills.
However, psychological support is necessary for people living with diabetes. It is fully recognized that painting equipment colors, paper, brushes are expensive. This is why this type of practice should be supported.

Patient Age, Sex, Education and Income level determine Mobile Phone use in HIV Care.

Author(s) Naieya Madhvani1, Michele Santacatterina2, Ziad El-Khatib3.
Affiliation(s) 1Project completed at IHCAR Department of Public Health Science., Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden., Currently Leicester, UK. Previously Stockholm, Sweden., United Kingdom, 2Unit of Biostatistics, Department of Environmental Medicine., Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden., Stockholm, Sweden., Sweden, 3HCAR Department of Public Health Science., Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden., Ottawa, Canada., Canada.
Country - ies of focus South Africa
Relevant to the conference tracks Innovation and Technologies
Summary Despite years of goal making and action taking, Human Immunodeficiency Virus (HIV) remains a major global health issue. Challenges include retaining patients in care and optimising adherence to Anti-retroviral Therapy (ART). Mobile phones are one possible solution to these challenges. The main aim of our study was to identify patient demographic groups least likely to use mobile phones as reminder tools in HIV care.
Background During the last thirty years the number of HIV cases in South Africa has dramatically increased. In the 2012 World AIDS Day Report it was reported that 5.6 million people were living with HIV in South Africa – the highest absolute number of HIV cases for any country globally. Despite these bleak statistics, South Africa has one of the highest ART coverage levels in low- and middle-income countries. This underlines the relative success of ART roll out in South Africa.Even with this relative success there are a number of challenges associated with HIV care both worldwide and within South Africa. These include: 1) retaining patients in care and 2) optimising adherence to ART. One possible solution is using mobile phones as reminder tools. Importantly mobile phone use relative to other electronic devices is high in South Africa. According to a study of consumer behaviour by Neilsen.com, there are a reported 29 million people mobile phones users relative to a mere 5 million landline users in South Africa. This is a strong reason for choosing South Africa as the setting for fulfilling the general aim of this study.
Objectives The overarching aim of this study was to explore and answer the following question: Which patient demographic groups are least likely to use mobile phones as reminder tools in HIV care, in Soweto, South Africa? Specific objectives included 1) to identify the types of reminders used and the frequency of use of such reminders 2) to assess whether using more reminders improves i) retention in care and ii) adherence to ART, 3) to identify patient demographic groups least likely to use mobile phones as reminders for i) attending clinic appointments relating to appointment reminders (ARs) and ii) taking medication on time relating to medication reminders (MRs).
Methodology The data for this study comes from a cross-sectional study carried out at the Chris Hani Baragwanath Hospital, Soweto, in the outskirts of Johannesburg, South Africa, during March to September 2008. The study was performed at two clinics, one, a Non-Governmental Organisation (NGO) clinic and another a public health clinic. Patients were recruited through posters. An English interview questionnaire was developed and translated into Sesotho and isiZulu. The questionnaire was first piloted and then edited. The final version included 59 questions (210 items). Some questions asked for basic demographic information whilst other questions focused on specific areas of HIV care such as: failure to attend clinic appointments, reminders for attending appointments, ART adherence over the last weekend and reminders for taking medication. Information was collected on demographic characteristics, reminders used for attending clinic appointments, failing to attend appointments, reminders for taking medication and failing to take medication. Firstly, basic descriptive analysis was performed to characterise the study population and obtain frequencies for i) ARs and ii) MRs. Secondly, logistic regression analysis was performed to identify the relationship between a number of variables and the use of ARs and MRs.
Results With regards to ARs: the majority of patients reported using a clinic register card with the appointment date written on it (N=543; 61.5%). Other popular reminder tools were diary/appointment book (N=192; 21.7%) and memory (N=183; 20.7%). A relatively small percentage reported using a mobile phone (N=93; 10.5%) and a similar percentage said they used a close friend/relative (N=86; 9.7%). Few patients reported using a partner (N=36; 4.1%), friend at work (N=2; 0.2%) or other reminder device (N=14; 1.6%). Patient groups significantly associated with being less likely to use mobile phones, as clinic ARs, in the final model were: a) patients 45 years or older (P=0.001), b) women (P=0.015) and c) patients with only primary or no schooling level. (P=0.034).With regards to MRs: the most popular reminder tool was the mobile phone (N=431; 48.8%). A similar percentage of patients reported relying on their memory (N=429; 48.6%). Approximately one fifth of patients used a close friend/relative (N=173; 19.6%) or other reminder device (N=176; 19.9%). A relatively small number of participants used their partner to remember to take medication (N=68; 7.7%). Less than one percent of patients reported using a pill box (N=7; 0.8%), a diary/appointment book (N=5; 0.6%) or a friend at work (N=6; 0.7%).
Conclusion Our study found that people infected with HIV in Soweto, South Africa use a variety of reminder tools in HIV care and that specific demographic groups (those of older age, women, with lower educational attainment and lower income) were less likely to use mobile phones as reminders in HIV care.With the results from this study we highlighted a number of further questions and provided various study suggestions. As per the World Health Organizations (WHO) report on Mobile Health (mHealth) these can be combined into a number of recommendations for the advancement of mHealth in South Africa.1) We suggest exploring further and gaining knowledge on why HIV patients don’t use mobile phones in Soweto, South Africa and then second to investigate additional patient variables associated with using/not using mobile phones.2) Given the high penetration of mobile phones within South Africa and the finding that almost 50% of patients in our study used mobile phones as reminder tools for taking medication, there is a strong argument for making mHealth a bigger priority within South Africa.3) There is still much to be researched but the most conclusive evidence will come from larger scale studies that incorporate a larger sample of the general population and which focus on cost-effectiveness analysis.

4) By combining evidence-based knowledge regarding the clinical and cost-effectiveness of mHealth in HIV care together with prioritising mHealth on the South African health agenda we hope and anticipate that policy makers will have enough to formally prioritise mHealth on the national health agenda and specifically develop mHealth focussed policy.

Identifying and addressing structural quality gaps in primary health care in Tanzania

Author(s) Dominick Mboya1, Flora Kessy2, Christopher Mshana3, Alexander Schulze 4, Christian Lengeler 5
Affiliation(s) 1Research, Ifakara Health Institute, Dar es Salaam, Tanzania, 2Dar es Salaam Campus College, Mzumbe University, Dar es Salaam, Tanzania, 3Research, Ifakara Health Institute, Dar es Salaam, Tanzania, 4Novartis Foundation for Sustainable Development, Novartis Company, Basel, Switzerland, 5Health Interventions Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.
Country - ies of focus Tanzania
Relevant to the conference tracks Advocacy and Communication
Summary The abstract presents the findings from assessments that used an electronic Tool to Improve Quality of Health Care (e-TIQH) within regular supportive supervision of primary health care facilities in Tanzania. The e-TIQH uses a comprehensive approach to assess the quality of primary healthcare provision at facility level, disseminates the results, and uses the results for evidence-based planning and budgeting. Improvements in some indicators are attributed both to targeted interventions after the assessments and proper planning and budgeting at district level. The tool has huge potential for scaling up by informing the planning process and making resource allocation more efficient.
Background Regular supportive supervision is a crucial element to improving the performance and quality of health facilities. To make supervision more effective, a situation analysis needs to be conducted and identified problems need to be discussed and addressed with all involved. In order to facilitate this process, an electronic Tool to Improve Quality of Health Care (e-TIQH) was introduced on a pilot basis in the Kilombero and Ulanga Districts, Morogoro Region in Tanzania. This assessment tool uses a performance based approach to identify and address the quality gaps in health facilities (mainly primary health care) in a comprehensive manner. The focus lies on primary healthcare since this is the entry point into the formal health system for most patients. Moreover, most health conditions are managed at this level. The services available at health facilities are compared with the expectations on these services, as defined by the national standards of care and community preferences. The e-TIQH approach has recently been scaled up to seven additional councils in the country (Kilosa, Gairo, Rufiji, Bagamoyo, Iringa Municipal, Mvomero and Morogoro Rural) covering 420 health facilities.
Objectives The electronic Tool to Improve Quality of Health Care (e-TIQH) was introduced with the objective of making supportive supervision of primary health care services more manageable, efficient and sustainable through reducing time and costs and by removing technical challenges in entering, cleaning and analyzing the collected data.
Methodology e-TIQH is embedded in a comprehensive approach that is to be applied in the frame of supportive supervision activities at district level. This approach is comprised of three steps:
• Assessing the quality of primary healthcare provision at facility level
• Disseminating the results of the assessments including identified quality gaps, root causes and improvements to both healthcare providers and district health authorities
• Evidence-based planning and budgeting according to the assessment findings. A comprehensive assessment of the quality of health care provision in all health facilities in the project districts is done annually. The tool assesses performance in six areas:(1) physical environment and equipment, (2) job expectations, (3) professional knowledge and skills, (4) management and administration of the facility, (5) staff motivation and (6) clients’ satisfaction. After data entry at the facility, the data are uploaded via an internet connection, and the backend of the tool generates automatically statistical reports based on predefined, standardized data analysis. This also means that the results are immediately available and easily accessible to allow for timely feedback to providers and health system managers. The following results can be viewed by health facility, district or region:
• Each of the six quality dimensions
• Disease specific care (TB, HIV/AIDS, fever (malaria) in adults, Integrated Management of Childhood Illnesses (IMCI) and maternal health
• Ownership category of health facilities (faith-based, public, private or institutional)
• Historical trends.The main results of each assessment round are disseminated among the healthcare providers and district health authorities. Moreover, they are used as a basis for evidence-based planning and budgeting of health interventions in the district through the so-called Comprehensive Council Health Plans (CCHPs).
Results At baseline, weak performance prevailed with regard to staff motivation, job expectations, and professional knowledge, skills and attitudes of health care personnel. Shortage of trained staff, lack of essential equipment and non-adherence to basic principles of infection prevention and control measures were important issues across all districts. Similarly, low performance prevailed with regard to management of TB/HIV across all districts. A comparison of the baseline and follow-up assessments in Kilombero and Ulanga Districts showed quick improvements in job expectations and professional knowledge skills and attitudes as a result of targeted on-the-job training and supply of treatment guidelines to health facilities. The results indicate that districts can reach scores of 80% or beyond. However, it seems rather hard for the districts to go higher given the limited resources at the district level and lack of qualified staff. While Kilombero and Ulanga, after 5 years of quality assessments, have reached a good level of above 75%, Kilosa/Gairo, after only two assessment rounds, still lags behind. However, the example of Kilosa/Gairo illustrates a general trend one observes in all districts so far and relatively quick improvements can be made in the quality areas of job expectations and client satisfaction. Even the most challenging dimension, staff motivation, can be improved, though on a relatively low level. Through appropriate feedback following the assessments, small changes at health facility level (e.g. provision of incentives to staff on night shift) can be rapidly initiated which results to improvement in quality of care. These changes can then lead to higher client satisfaction. Yet, most changes with regard to physical environment and staff motivation in terms of promotions and salary increment depend a lot on resources made available at district level and therefore often take more time. Professional knowledge and facility management/administration can be partially addressed through on-the-job training.In terms of disease specific care offered in the assessed primary healthcare services, results reveal that the two districts which have been benefiting from the e-TIQH exercises for a longer time have higher scores, especially for malaria/fever and TB care, but also for child and maternal healthcare. Generally, weaknesses remain with regard to HIV/AIDS and partially maternal healthcare (Rufiji, Iringa).
Conclusion e-TIQH helps to identify the major quality gaps across districts, regions and the country. For the first time it provides a realistic, structured and informed picture of the quality of health care situation, including performance in child and maternal health, malaria, HIV/AIDS and TB related care. Furthermore, it offers the opportunity for productive interactions between health system managers and health care providers. By providing immediate results and feedback to providers and health governing structures, the e-TIQH approach facilitates immediate, mid- and long term planning to address the identified gaps. Thus, it has huge potential for scaling up by informing the planning process and making resource allocation efficient in view of achieving the health-related Millennium Development Goals.