El Frente Nacional es un fenómeno multidimensional

The aim of the REACT project was to improve the diagnosis and treatment of

uncomplicated malaria in Cameroon and Nigeria. The project commenced in 2009 and continued until 2013. REACT was financed by the ACT Consortium, which was supported through a grant from the Bill & Melinda Gates Foundation to the London School of Hygiene and Tropical Medicine (www.actconsortium.org).

REACT was founded on the principle that the project should respond to policy priorities in each country and take an evidence-based approach. This required close collaboration with the National Malaria Control Programme in Cameroon and the Enugu State Malaria

92 Control Programme in Nigeria. Extensive formative research was also critical to identify priorities and design interventions tailored to each study setting.

REACT was implemented in four phases:

1. Formative research to understand how malaria was diagnosed and treated at different types of facility.

2. Design interventions to support the introduction of malaria rapid diagnostic tests and improve providers’ adherence to malaria treatment guidelines.

3. Implement interventions and evaluate their effectiveness and cost-effectiveness. 4. Disseminate research findings.

The formative research involved quantitative and qualitative research in all four study sites. Patient exit surveys were conducted at different types of health facility to determine the proportion of febrile patients tested for malaria, and the proportion of febrile patients who received an ACT, the first-line antimalarial. The patient exit surveys were

accompanied by provider and facility surveys. Survey results highlighted the limited availability of malaria testing, and treatment practices that did not adhere to the malaria treatment guidelines (Research Papers I and II) [6, 7]. The findings led to additional research:

 Secondary analysis of the survey data to examine the providers’ knowledge, preference and practice for treating uncomplicated malaria (Research Papers III and IV) [8, 9].

 Focus group discussions with community members and in-depth interventions with providers in Nigeria to explore the potential for malaria rapid diagnostic testing [10].

 Focus group discussions with health workers at public and mission facilities in Cameroon to explore their perceptions of malaria testing and the reasons why

93 antimalarials were prescribed to patients who tested negative for malaria

(Appendix B) [11].

The findings from the formative research in Cameroon and Nigeria were shared with representatives from their respective Malaria Control Programmes in 2010, shortly after the WHO had published revised malaria treatment guidelines that confirmed RDTs are a valid alternative to malaria microscopy [12]. In these discussions it was agreed REACT should design interventions to support the introduction of malaria RDTs and address problems with providers’ practice. However, the interventions needed to be tailored to the country context since the formative research had demonstrated substantial differences between the two countries.

In Nigeria, the State Malaria Control Programme (SMCP) indicated they wanted REACT to intervene in primary health facilities, private sector pharmacies and drug stores, as these types of facilities are often the first point of contact individuals seeking treatment for febrile illness. The formative research showed that malaria treatment was often

presumptive since access to malaria testing was extremely limited, and there were major problems with the type of antimalarial supplied, with less than a quarter of febrile patients receiving an ACT. The formative research also highlighted the extent to which patients and caregivers at pharmacies and drug stores asked for a specific medicine.

As a result it was agreed that an intervention in Nigeria would need to address the knowledge and practice of providers, and also the knowledge and preferences of those seeking treatment. Following discussions between the SMCP and the REACT team, it was agreed that RDTs would be introduced in all facilities and medicine retail outlets

participating in the trial and the project would evaluate the effectiveness of a provider training intervention that sought to improve the knowledge and practice of providers and the combined effectiveness of a provider and community intervention, with the latter engaging school teachers and school-children to raise awareness about malaria testing

94 with RDTs and also that ACT is the recommended treatment for confirmed cases of

uncomplicated malaria [13]. Interventions were designed and evaluated in Nigeria, though I have not included this research in my thesis.

My thesis does, however, include research undertaken to evaluate the cost-effectiveness of the interventions implemented in Cameroon since the study was closely aligned to my interests on providers’ knowledge, preference and practice and I had a lead role in economic evaluation. The remainder of this section explains the rationale and design of the REACT study in Cameroon, and includes a copy of the published trial protocol [14]. The National Malaria Control Programme (NMCP) in Cameroon indicated they wanted REACT to focus on introducing RDTs at public and mission health facilities. Having found that malaria testing was underused and it was common for febrile patients who tested negative to be prescribed an antimalarial, it was agreed that the intervention would need to encourage providers to test for malaria before prescribing treatment and to ensure that the treatment prescribed should be based on the test result [6]. Also for the intervention to be accepted by the NMCP, it was important for the intervention to be relatively inexpensive, easy to replicate on a larger scale and tested in a setting as close to the ‘real- world’ as possible. On this basis financial incentives were ruled out since the NMCP had indicated they had concerns about their affordability and sustainability over the longer term. Similarly, it was agreed that the project would not intervene to control the supply of ACT and that the process by which RDTs were supplied to facilities would need to be agreed by the NMCP.

A training intervention was considered since the literature review had shown training can improve providers’ practice, though we were also aware training was not identified as a significant predictor in either the primary analysis (Research Paper II) or the secondary analysis on the relationship between providers’ knowledge and practice (Research Paper IV). On the other hand, there was evidence that providers’ stated preference (Research

95 Paper III) may depend on the source and method of communication and literature review had emphasized the importance of considering not only the content and length of the training but also the difference between passive and active learning. It was finally agreed two different training interventions would be evaluated.

Figure 2 summarizes the development of REACT in Cameroon. It illustrates the key steps that followed formative research, including the selection and design of interventions, implementation and evaluation. For example, it shows how the literature review on interventions to improve providers’ ability to diagnose and treat uncomplicated malaria informed the selection of interventions.

96 Figure 2. Development of REACT in Cameroon

Engage Experts

* Drama & Artwork * Advice on clinical

content

Finalize Study Design

3 arm cluster randomized trial

Implement Interventions

* Trained trainers.

* Held REACT training & In-facility training * Participants completed pre-post test & feedback form

Evaluate Cluster Randomized Trial

% of patients that received treatment according to guidelines (i.e. tested & treatment based on test result)

Economic Evaluation

Compare basic and enhanced interventions with current practice

Literature Review

Interventions to improve providers’ ability to treat malaria

NMCP