A comparison of smartphone and paper data-collection tools in the Burden of Obstructive Lung Disease (BOLD) study in Gezira state, Sudan.

INTRODUCTION: Data collection using paper-based questionnaires can be time consuming and return errors affect data accuracy, completeness, and information quality in health surveys. We compared smartphone and paper-based data collection systems in the Burden of Obstructive Lung Disease (BOLD) study in rural Sudan. METHODS: This exploratory pilot study was designed to run in parallel with the cross-sectional household survey. The Open Data Kit was used to programme questionnaires in Arabic into smartphones. We included 100 study participants (83% women; median age = 41.5 ± 16.4 years) from the BOLD study from 3 rural villages in East-Gezira and Kamleen localities of Gezira state, Sudan. Questionnaire data were collected using smartphone and paper-based technologies simultaneously. We used Kappa statistics and inter-rater class coefficient to test agreement between the two methods. RESULTS: Symptoms reported included cough (24%), phlegm (15%), wheezing (17%), and shortness of breath (18%). One in five were or had been cigarette smokers. The two data collection methods varied between perfect to slight agreement across the 204 variables evaluated (Kappa varied between 1.00 and 0.02 and inter-rater coefficient between 1.00 and -0.12). Errors were most commonly seen with paper questionnaires (83% of errors seen) vs smartphones (17% of errors seen) administered questionnaires with questions with complex skip-patterns being a major source of errors in paper questionnaires. Automated checks and validations in smartphone-administered questionnaires avoided skip-pattern related errors. Incomplete and inconsistent records were more likely seen on paper questionnaires. CONCLUSION: Compared to paper-based data collection, smartphone technology worked well for data collection in the study, which was conducted in a challenging rural environment in Sudan. This approach provided timely, quality data with fewer errors and inconsistencies compared to paper-based data collection. We recommend this method for future BOLD studies and other population-based studies in similar settings.

Community prevalence of chronic respiratory symptoms in rural Malawi: Implications for policy.

BACKGROUND: No community prevalence studies have been done on chronic respiratory symptoms of cough, wheezing and shortness of breath in adult rural populations in Malawi. Case detection rates of tuberculosis (TB) and chronic airways disease are low in resource-poor primary health care facilities. OBJECTIVE: To understand the prevalence of chronic respiratory symptoms and recorded diagnoses of TB in rural Malawian adults in order to improve case detection and management of these diseases. METHODS: A population proportional, cross-sectional study was conducted to determine the proportion of the population with chronic respiratory symptoms that had a diagnosis of tuberculosis or chronic airways disease in two rural communities in Malawi. Households were randomly selected using Google Earth Pro software. Smart phones loaded with Open Data Kit Essential software were used for data collection. Interviews were conducted with 15795 people aged 15 years and above to enquire about symptoms of chronic cough, wheeze and shortness of breath. RESULTS: Overall 3554 (22.5%) participants reported at least one of these respiratory symptoms. Cough was reported by 2933, of whom 1623 (55.3%) reported cough only and 1310 (44.7%) combined with wheeze and/or shortness of breath. Only 4.6% (164/3554) of participants with chronic respiratory symptoms had one or more of the following diagnoses in their health passports (patient held medical records): TB, asthma, bronchitis and chronic obstructive pulmonary disease). CONCLUSIONS: The high prevalence of chronic respiratory symptoms coupled with limited recorded diagnoses in patient-held medical records in these rural communities suggests a high chronic respiratory disease burden and unmet health need.

The effect of engaging unpaid informal providers on case detection and treatment initiation rates for TB and HIV in rural Malawi (Triage Plus): A cluster randomised health system intervention trial.

BACKGROUND: The poor face barriers in accessing services for tuberculosis (TB) and Human Immuno-deficiency Virus (HIV) disease. A cluster randomised trial was conducted to investigate the effectiveness of engaging unpaid informal providers (IPs) to promote access in a rural district. The intervention consisted of training unpaid IPs in TB and HIV disease recognition, sputum specimen collection, appropriate referrals, and raising community awareness. METHODS: In total, six clusters were defined in the study areas. Through a pair-matched cluster randomization process, three clusters (average cluster population = 200,714) were allocated to receive the intervention in the Early arm. Eleven months later the intervention was rolled out to the remaining three clusters (average cluster population = 209,564)-the Delayed arm. Treatment initiation rates for TB and Anti-Retroviral Therapy (ART) were the primary outcome measures. Secondary outcome measures included testing rates for TB and HIV. We report the results of the comparisons between the Early and Delayed arms over the 23 month trial period. Data were obtained from patient registers. Poisson regression models with robust standard errors were used to express the effectiveness of the intervention as incidence rate ratios (IRR). RESULTS: The Early and Delayed clusters were well matched in terms of baseline monthly mean counts and incidence rate ratios for TB and ART treatment initiation. However there were fewer testing and treatment initiation facilities in the Early clusters (TB treatment n = 2, TB testing n = 7, ART initiation n = 3, HIV testing n = 20) than in the Delayed clusters (TB treatment n = 4, TB testing n = 9, ART initiation n = 6, HIV testing n = 18). Overall there were more HIV testing and treatment centres than TB testing and treatment centres. The IRR was 1.18 (95% CI: 0.903-1.533; p = 0.112) for TB treatment initiation and 1.347 (CI:1.00-1.694; p = 0.049) for ART initiation in the first 12 months and the IRR were 0.552 (95% CI:0.397-0.767; p<0.001) and 0.924 (95% CI: 0.369-2.309, p = 0.863) for TB and ART treatment initiations respectively for the last 11 months. The IRR were 1.152 (95% CI:1.009-1.359, p = 0.003) and 1.61 (95% CI:1.385-1.869, p<0.001) for TB and HIV testing uptake respectively in the first 12 months. The IRR was 0.659 (95% CI:0.441-0.983; p = 0.023) for TB testing uptake for the last 11 months. CONCLUSIONS: We conclude that engagement of unpaid IPs increased TB and HIV testing rates and also increased ART initiation. However, for these providers to be effective in promoting TB treatment initiation, numbers of sites offering TB testing and treatment initiation in rural areas should be increased. TRIAL REGISTRATION: ClinicalTrials.gov NCT02127983.

Informal Health Provider and Practical Approach to Lung Health interventions to improve the detection of chronic airways disease and tuberculosis at primary care level in Malawi: study protocol for a randomised controlled trial.

BACKGROUND: In developing countries like Malawi, further investigation is rare after patients with chronic cough test negative for tuberculosis. Chronic airways disease has presentations that overlap with tuberculosis. However, chronic airways disease is often unrecognised due to a lack of diagnostic services. Within developing countries, referral systems at primary health care level are weak and patients turn to unskilled informal health providers to seek health care. Delayed diagnosis and treatment of these diseases facilitates increased severity and tuberculosis transmission. The World Health Organisation developed the Practical Approach to Lung Health strategy which has been shown to improve the management of both tuberculosis and chronic airways disease. The guidelines address the need for integrated guidelines for tuberculosis and chronic airways disease. Engaging with informal health providers has been shown to be effective in improving health services uptake. However, it is not known whether engaging community informal health providers would have a positive impact in the implementation of the Practical Approach to Lung Health strategy. We will use a cluster randomised controlled trial to determine the effect of using the two interventions to improve case detection and treatment of patients with tuberculosis and chronic airways disease. METHODS: A three-arm cluster randomised trial design will be used. A primary health centre catchment population will form a cluster, which will be randomly allocated to one of the arms. The first arm personnel will receive the Practical Approach to Lung Health strategy intervention. In addition to this strategy, the second arm personnel will receive training of informal health providers. The third arm is the control. The effect of interventions will be evaluated by community surveys. Data regarding the diagnosis and management of chronic cough will be gathered from primary health centres. DISCUSSION: This trial seeks to determine the effect of Informal Health Provider and Practical Approach to Lung Health interventions on the detection and management of chronic airways disease and tuberculosis at primary care level in Malawi. TRIAL REGISTRATION: The unique identification number for the registry is PACTR201411000910192--21 November 2014.

A systematic assessment of the concept and practice of public-private mix for tuberculosis care and control.

INTRODUCTION: The STOP TB Partnership aims to improve global tuberculosis (TB) control through expanding access to the directly observed treatment short course (DOTS) strategy. One approach to this is 'Engaging all Care Providers', which evolved from 'Public-Private Mix (PPM) DOTS'. The overall aim of this study was to systematically assess whether and to what degree the STOP TB Partnership's four global objectives of engaging all care providers are met through existing PPM interventions. These four objectives are; 1) Increase TB case detection; 2) Improve TB treatment outcomes; 3) Enhance access and equity; 4) Reduce financial burden on patients. The specific objectives of this assessment were to 1) Understand what PPM means to the STOP TB Partnership's PPM Subgroup and to National Tuberculosis Programme managers; 2) Scope the nature of existing country-level PPM interventions and 3) Review PPM practice against the global PPM objectives. METHODS: We undertook a systematic, multi-facetted assessment. The methods included interviews with National Tuberculosis Programme managers from high burden countries, clarification of key issues with the STOP TB Partnership PPM secretariat and a review of publicly accessible reports and published articles on PPM projects. Both the literature review and interviews with the National Tuberculosis Programme managers yielded data on project characteristics; PPM models at country level; National Tuberculosis Programme partners; and mechanisms for engagement. Matrices were developed from the literature review and the interviews to show the relationship between services and service providers for different PPM projects. Data from the literature were assessed against each of the four global PPM objectives. RESULTS: Twelve National Tuberculosis Programme managers from high burden countries were interviewed about the scope of PPM partnerships. Understanding of PPM and types of engaged providers varied considerably; 'private-for-profit qualified clinical providers' were the dominant category. The literature review yielded information on 22 projects in which 'private-for-profit qualified clinical providers' were again the dominant category. The contributions made by 'private-for-profit qualified clinical providers' and 'Non Governmental Organisation qualified clinical providers', were assessed against the four global PPM objectives. Reporting on tuberculosis case detection and treatment outcomes was generally good and demonstrated important PPM contributions in these areas. Reporting on equity, access and reduced patient costs was often lacking or inconclusive. CONCLUSIONS: PPM has improved case detection and treatment outcomes among patients seeking care with private providers. Evidence on reducing patient costs is inconclusive, and there is scope for increasing equity in access to care by systematically engaging those providers who are the primary agents for poor people seeking health care. Guidelines outlining which types of providers best contribute to achieving the four global objectives, along with the resources required by National Tuberculosis Programs for such engagement is needed.

Can public-private collaboration promote tuberculosis case detection among the poor and vulnerable?

Private-public mix (PPM) DOTS is widely advocated as a DOTS adaptation for promoting progress towards the international tuberculosis (TB) control targets of detecting 70% of TB cases and successfully treating 85% of these. Private health care plays a central role in health-care provision in many developing countries that have a high burden of TB. It is therefore encouraging that PPM projects are being set up in various countries around the world to explore possible interaction between the national TB programmes and other partners in the fight against TB. The objective of this review was to use the published literature to assess the range of providers included in PPMs for their ability to provide case-detection services for the vulnerable. From a case-detection perspective, we identify the essential elements of a pro-poor PPM model, namely, cost-effectiveness from a patient perspective, accessibility, acceptability and quality. The review revealed that a very large part of the total spectrum of potential PPM-participating partners has not yet been explored; current models focus on private-for-profit health-care providers and non-governmental organizations. We conclude that it is important to think critically about the type of private providers who are best suited to meeting the needs of the poor, and that more should be done to document the socioeconomic status of patients accessing services through PPM pilots.