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Operations Research

Infectious Diseases

Mother carrying child on her back seeks advice on malaria drugs

Seeking advice on malaria drugs from the private sector. Photo by Waverly Rennie


Adherence to antiretroviral (ARV) therapy in Rwanda
This study will document and identify barriers to adherence to ARV therapy among HIV+ patients using ARVs who come for medical care to King Faycal Hospital.

Analysis of workforce needs for the scaling up of HIV care in Rwanda
This three-phase study applied the methodology used by QAP in Zambia to assess Rwanda's workforce needs for scaling up HIV care to the entire country.

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Antiretroviral therapy outcomes in Rwanda
QAP has been asked by the Rwanda Ministry of Health to evaluate the outcomes of all people currently receiving ARV therapy in Rwanda. This study will include documentation of the impact on CD4, viral load, and hospitalizations, using 2002 data from the six major sites that have been providing ARV in Rwanda to date.

Follow-up of HIV+ mother and child pairs in Jamaica
This study assessed Jamaica’s pilot program to prevent mother-to-child transmission of HIV/AIDS (PMTCT). The pilot sought to identify and counsel HIV-positive, pregnant women in high-risk areas and/or practicing high-risk activities. Counseling encouraged them to reduce risky behavior, increase family planning, and accept PMTCT practices. The pilot was largely successful in improving mothers’ knowledge: Almost all indicated that HIV could be transmitted through breast-feeding and that antiretrovirals (ARVs) could prevent transmission, and 90% reported receiving nutritional counseling. The study tested 29 infants whose mothers had taken ARVs, and 26 (90%) were HIV-negative; of 21 infants whose mothers had not taken ARVs, 16 (76%) were HIV-negative (the differences are too small to be statistically significant). Of 12 infants who were breast-fed, 6 (50%) were HIV-negative; of 36 who were not breast-fed, 8 (22%) were HIV-negative (significant at p<0.001). Recommendations include: improving follow-up to help HIV-positive women select and perform the feeding option that would best minimize transmission risk for their situation; incorporating the private health sector in PMTCT efforts; and more community education to reduce stigma, which causes women to avoid settings where they could find guidance and support.

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Follow-up of HIV-positive mother and child pairs in Jamaica

Functional analysis of PMTCT program in Soweto, South Africa
This study of a "best practice" model has just commenced and will identify elements of the Soweto PMTCT program that have a potential for scaling up to other sites in South Africa.

Impact of stigma on HIV/AIDS care providers' attitudes
This ongoing study examines provider and patient attitudes toward the stigma associated with HIV+ status through focus groups with providers and people living with HIV/AIDS (PLWHA). Provider interviews are being conducted in 13 sites throughout Rwanda. In-depth interviews are also being conducted with service providers, and record review is used to assess quality of care provided. This study is being carried out in Rwanda, Tanzania, and Haiti.

Programmatic evidence on HIV and infant feeding
As a technical collaboration with UNICEF, QAP undertook a review of evidence of programmatic experience related to infant feeding and preventing transmission of HIV from mothers to their children (PMTCT), summarizing the most important experiences and evidence from around the world. This report represents the first attempt of its kind to collect and analyze a wide range of worldwide program experience on the topic, which will assist the international health community in updating and adapting the international guidelines on HIV and infant feeding guidelines. These revised guidelines will inform national policy decisions and the implementation of new recommendations at the local level. Undertaken with UNICEF, and with close cooperation of WHO, findings underscore the multiple challenges faced by programs related to training, counseling, logistics, community support, and behavior change, and highlight the continuing confusion of healthcare workers and communities alike about the best infant feeding options for mothers with HIV. (See information on downloading the report and the source documents upon which the review was based.)

Use of job aids to improve infant feeding counseling in PMTCT in Tanzania
This study pilot-tested job aids and take-home materials designed to improve the quality of infant feeding counseling within PMTCT services and enhance mothers' understanding of safe and appropriate feeding practices. Nurse-counselors at one facility that provides PMTCT counseling were trained to use an array of job aids and take-home brochures to counsel expectant mothers.  The counseling materials included longer materials that were retained by counselors and brief brochures that counselors used in discussion with mothers and then offered to mothers to keep.  The experiences, attitudes, and behaviors of those mothers were compared in this study to those of mothers counseled at other PMTCT sites without the materials.  The study found that mothers who had been exposed to the materials were better informed and more able to sustain their feeding choices.

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Testing a PMTCT Infant-feeding Counseling Program in Tanzania

Workload and staff to scale-up PMTCT and ARV programs in Zambia
This recently completed study, carried out by QAP subcontractor Initiatives Inc., examined the human resource requirements for HIV/AIDS services in Zambia. The study was conducted to assist the Government of Zambia to determine whether it will have the staff to scale up voluntary counseling and testing (VCT), prevention of mother-to-child transmission of HIV (PMTCT), and antiretroviral (ARV) therapy as planned. Using direct observation, facility record review, and interviews with providers, data were obtained over a 2-4 day period per site for VCT and PMTCT at 3 government hospitals, 5 government clinics, and 3 NGO facilities (VCT only), and for ARV at demonstration sites in 2 government hospitals, 2 private facilities, and one NGO facility. The data included interviews with 102 providers (including doctors, nurses, and volunteers), 320 direct client observations, 42 observations of laboratory services, and 25 observations of ARV dispensing sites (largely pharmacies). Cost figures were calculated for alternative assumptions about scale-up. One such alternative assumes that all residents of Zambia are tested and counseled appropriately once per year at an efficiency equal to the best observed site and the current mix of types of providers, and that 20% of HIV persons will require ARV therapy. These assumptions imply that to accomplish this, Zambia would require a minimum of 958 additional counselors, 302 additional doctors, and 119 additional pharmacy technicians at an annual salary cost of $11.6 million (USD), not counting training or other costs.

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The Zambia HIV/AIDS Workforce Study: Preparing for Scale-up

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Development of a job aid to improve quality of malaria rapid diagnostic tests
WHO has requested QAP assistance to design and field test a job aid to help semi-literate or non-literate health workers correctly use and interpret malaria rapid diagnostic tests. The job aid will be bfield tested in the Philippines and Laos.

Malaria rapid diagnostic kits
As a complement to a CDC study in Malawi, QAP developed and implemented a research protocol for testing and modifying job aids (instructional inserts) that accompanied two Malaria Rapid Diagnostic Kits. The study used quality design techniques to improve the job aids and to make recommendations for product design changes. The technique involved observing kits being used, noting problems, redesigning the instructions, having users test them while under observation, and redesigning them again. In an initial test prior to the modification of the instructional inserts, only 3 of 19 (15%) providers used the two kits without making errors. Eight of the providers had received training in the use of the kits, and two of these (25%) were error free. After the instructions were revised, 85% (17 of 20) used the kits without error. The study demonstrated that large improvements can be achieved in the instructions by using the redesign process and that improved inserts can be more effective than training.

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Using Quality Design to Improve Malaria Rapid Diagnostic Tests in Malawi

Developing and Testing a Generic Job Aid for Malaria Rapid Diagnostic Tests (RDTs)

Neighbor-to-neighbor education to improve malaria treatment by private drug outlets
This study tested interventions to increase the compliance of private drug outlets in selling anti-malarial drugs for children beyond what was achieved in the Vendor-to-Vendor study summarized below. The intervention tested was a public education campaign that included recruiting and training one advocate in each village who spread information and brochures via a reach-one-teach-five diffusion strategy and a radio campaign. An evaluation of a sample of households seeking to purchase anti-malarials for a child from private drug outlets found that 57 percent of households exposed to the education campaign obtained acceptable medicines and doses, compared to only 31 percent of households not exposed. Another interesting finding was the messiness of the marketplace for anti-malarials. Over 100 different substances were offered for sale by the drug outlets studied, only a few of which were appropriate. Many inappropriate substances mimicked the packaging of approved drugs, thus increasing confusion and inappropriate treatment.

Vendor-to-vendor education to improve malaria treatment by private drug outlets
Although many patients obtain anti-malarial drugs from small private drug outlets in Kenya, earlier studies indicated that 87% of shopkeepers had never received training in appropriate use of anti-malarial drugs and that 60% gave instructions or dosages to customers. This study tested whether a low-cost education strategy in one district of Kenya would increase private drug outlet knowledge of and compliance with national malaria guidelines. Local wholesalers (mobile vendors and counter attendants at wholesale outlets) were given a one-day training in malaria drug standards and equipped with customized job aids (posters) to give to the retail drug outlets that were their customers. Mystery shoppers visited 101 intervention outlets that received the job aids from wholesalers and 151 control outlets that did not receive the job aids, asking for treatment for their child under two distinct scenarios that required decision-making by the shopkeeper. In response, the mystery shoppers were sold over 70 different anti-malarials (only 5 are government approved), and over 30 anti-pyretics. In the intervention outlets, the shoppers came away with an approved anti-malarial and were told the correct dosage 17% (27/157) of the time compared to 1.5% (3/202) in the control outlets.

In the intervention outlets, 35% of shopkeepers answered all 10 knowledge questions correctly compared to only 4% in the controls. The intervention cost was about $17 per outlet reached, or about $0.10 per additional case correctly treated.

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Vendor to Vendor Education to Improve Malaria Treatment by Drug Outlets in Kenya


Treating Tuberculosis in the Private Sector: Cambodia. In 2004, QAP undertook a national assessment of private sector tuberculosis (TB) services in Cambodia to improve understanding of private sector practices and the sector’s willingness to participate in efforts to improve TB services. Over 500 respondents, including doctors, pharmacists, drug sellers, and TB patients participated. In addition, mystery shoppers visited private pharmacists and drug sellers so that the surveyed groups’ reports could be compared to actual experiences. The study uncovered many aspects of private sector TB services that are undermining the Cambodian Government’s efforts to increase detection and cure rates. About half of TB patients surveyed initially went to a government facility and the other half to a private facility or provider/vendor. Private doctors generally reported—and patients affirmed—charging between US$ 1 and US$ 3 for a consultation, with higher rates in urban areas. A third of private doctors said they dispense TB drugs, another third reported that they refer to a pharmacy for drug purchases, and a quarter refers to government facilities where TB drugs are free. While a high percentage of private doctors reported that patients can afford a week’s or a month’s worth of TB drugs, they usually prescribe a week’s worth or less, raising concerns of antimicrobial resistance. Pharmacists confirmed these low prescription dosages but said that clients can afford a month’s or even three months’ worth and that almost a quarter ask for brand name TB drugs.

Over 90% of private doctors work at a government facility as well as having a private practice; nearly half had had refresher training, and half of them had had refresher training that included directly observed therapy, short course (DOTS). While their diagnosing and treatment practices were good or better, their follow-up practices were very poor. Interestingly, over 90% of patients said they wanted DOTS treatment, but only 12% of doctors said it is a good treatment.

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Treating Tuberculosis in the Private Sector: Cambodia


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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development (USAID) under Contract Number GPH-C-00-02-00004-00.