Costs and Cost-Effectiveness of a Mobile Phone Text-Message Reminder Programmes to Improve Health Workers' Adherence to Malaria Guidelines in Kenya

Background

Simple interventions for improving health workers'' adherence to malaria case-management guidelines are urgently required across Africa. A recent trial in Kenya showed that text-message reminders sent to health workers'' mobile phones improved management of pediatric outpatients by 25 percentage points. In this paper we examine costs and cost-effectiveness of this intervention.

Methods/Findings

We evaluate costs and cost-effectiveness in 2010 USD under three implementation scenarios: (1) as implemented under study conditions in study areas; (2) if the intervention was routinely implemented by the Ministry of Health (MoH) in the same areas; and (3) if the intervention was scaled up nationally. Under study conditions, intervention costs were 19,342 USD, of which 45% were for developing and pretesting text-messages, 12% for developing text-message distribution system, 29% for collecting health workers'' phone numbers, and 13% were costs of sending text-messages and monitoring of the system. If the intervention was implemented in the same areas by the MoH, the costs would be 28% lower (13,920 USD) due to lower costs of collecting health workers'' numbers. The cost of national scale-up would be 97,350 USD, and the majority of these costs (66%) would be for sending text-messages. The cost per additional child correctly managed was 0.50 USD under study conditions, 0.36 USD if implemented by the MoH in the same area, and estimated at only 0.03 USD if implemented nationally. Even if the effect size was only 5% or the cost on the national scale was 400% higher than estimated, the cost per additional child correctly managed would be only 0.16 USD.

Conclusions

A simple text-messaging intervention improving health worker adherence to malaria guidelines is effective and inexpensive. Further research is justified to optimize delivery of the intervention and expand targets beyond children and malaria disease.     

Improving immunisation: coverage in a province in Papua New Guinea

The effect on immunisation coverage of applying guiding principles to the management of primary health care services in a province in Papua New Guinea is described. These principles were: (a) Each health centre should have a defined geographical area of responsibility. (b) Each health centre should be responsible for a defined population. (c) Each health centre should have defined target groups for immunisation and child health clinic enrolment. (d) An accurate and meaningful reporting system is essential. (e) Each health centre should receive regular feedback on its achievements. Immunisation coverage in the province, as judged by the proportion of children under 1 year of age receiving their second dose of triple antigen, improved from 57-67% in 1980-2 to 89-94% in 1983-4.Immunisation is the most cost effective preventive activity undertaken in child health care. The application of these guiding principles would be relevant in the United Kingdom.     

The Impact of Text Message Reminders on Adherence to Antimalarial Treatment in Northern Ghana: A Randomized Trial

Background

Low rates of adherence to artemisinin-based combination therapy (ACT) regimens increase the risk of treatment failure and may lead to drug resistance, threatening the sustainability of current anti-malarial efforts. We assessed the impact of text message reminders on adherence to ACT regimens.

Methods

Health workers at hospitals, clinics, pharmacies, and other stationary ACT distributors in Tamale, Ghana provided flyers advertising free mobile health information to individuals receiving malaria treatment. The messaging system automatically randomized self-enrolled individuals to the control group or the treatment group with equal probability; those in the treatment group were further randomly assigned to receive a simple text message reminder or the simple reminder plus an additional statement about adherence in 12-hour intervals. The main outcome was self-reported adherence based on follow-up interviews occurring three days after treatment initiation. We estimated the impact of the messages on treatment completion using logistic regression.

Results

1140 individuals enrolled in both the study and the text reminder system. Among individuals in the control group, 61.5% took the full course of treatment. The simple text message reminders increased the odds of adherence (adjusted OR 1.45, 95% CI [1.03 to 2.04], p-value 0.028). Receiving an additional message did not result in a significant change in adherence (adjusted OR 0.77, 95% CI [0.50 to 1.20], p-value 0.252).

Conclusion

The results of this study suggest that a simple text message reminder can increase adherence to antimalarial treatment and that additional information included in messages does not have a significant impact on completion of ACT treatment. Further research is needed to develop the most effective text message content and frequency.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01722734","term_id":"NCT01722734"}}NCT01722734     

Perceptions and Acceptability of Short Message Services Technology to Improve Treatment Adherence amongst Tuberculosis Patients in Peru: A Focus Group Study

Background

Tuberculosis (TB) is global health concern and a leading infectious cause of mortality. Reversing TB incidence and disease-related mortality is a major global health priority. Infectious disease mortality is directly linked to failure to adhere to treatments. Using technology to send reminders by short message services have been shown to improve treatment adherence. However, few studies have examined tuberculosis patient perceptions and attitudes towards using SMS technology to increase treatment adherence. In this study, we sought to investigate perceptions related to feasibility and acceptability of using text messaging to improve treatment adherence among adults who were receiving treatment for TB in Callao, Peru.

Methods

We conducted focus group qualitative interviews with current TB positive and non-contagious participants to understand the attitudes, perceptions, and feasibility of using short message service (SMS) reminders to improve TB treatment adherence. Subjects receiving care through the National TB Program were recruited through public health centers in Ventanilla, Callao, Peru. In four focus groups, we interviewed 16 patients. All interviews were recorded and transcribed verbatim. Thematic network analysis and codebook techniques were used to analyze data.

Results

Three major themes emerged from the data: limits on health literacy and information posed challenges to successful TB treatment adherence, treatment motivation at times facilitated adherence to TB treatment, and acceptability of SMS including positive perceptions of SMS to improve TB treatment adherence. The majority of patients shared considerations about how to effectively and confidentially administer an SMS intervention with TB positive participants.

Conclusion

The overall perceptions of the use of SMS were positive and indicated that SMS technology may be an efficient way to transmit motivational texts on treatment, health education information, and simple reminders to increase treatment adherence for low-income TB patients living in Peru.     

Knowledge,Attitudes, and Practices Concerning Malaria in Pregnancy: Results from a Qualitative Study in Madang,Papua New Guinea

Background

Malaria is the leading cause of illness and death in Papua New Guinea (PNG). Infection during pregnancy with falciparum or vivax malaria, as occurs in PNG, has health implications for mother and child, causing complications such as maternal anemia, low birth weight and miscarriage. This article explores knowledge, attitudes and practices concerning malaria during pregnancy and it’s prevention in Madang, PNG, a high prevalence area.

Methods

As part of a qualitative study in Madang, exploring MiP, participatory techniques (free-listing and sorting) were conducted along with focus group discussions, in-depth interviews (with pregnant women, health staff and other community members) and observations in the local community and health facilities.

Results

The main themes explored were attitudes towards and knowledge of MiP, its risks, and prevention. Although there was a general awareness of the term “malaria”, it was often conflated with general sickness or with pregnancy-related symptoms. Moreover, many preventive methods for MiP were related to practices of general healthy living. Indeed, varied messages from health staff about the risks of MiP were observed. In addition to ideas about the seriousness and risk of MiP, other factors influenced the uptake of interventions: availability and perceived comfort of sleeping under insecticide-treated mosquito nets were important determinants of usage, and women’s heavy workload influenced Chloroquine adherence.

Conclusion

The non-specific symptoms of MiP and its resultant conflation with symptoms of pregnancy that are perceived as normal have implications for MiP prevention and control. However, in Madang, PNG, this was compounded by the inadequacy of health staff’s message about MiP.     

Reorganization of a nutrition unit in Papua New Guinea.

Adequate nutrition is a medical priority. It has been estimated that more than half the children in the Chimbu District of Papua New Guinea are malnourished. A practical scheme combat poor nutrition there was based on emphasizing the value of breast-feeding and of locally grown foods. The daily menu given was the same, with three meals each day. The scheme''s underlying principles can be adapted for any developing country or for migrant and other minority groups in a developed country.     

Factors Influencing Antiretroviral Adherence and Virological Outcomes in People Living with HIV in the Highlands of Papua New Guinea

Adherence to antiretroviral therapy (ART) is paramount for virological suppression and positive treatment outcomes. ART has been rapidly scaled up in Papua New Guinea (PNG) in recent years, however clinical monitoring of HIV+ individuals on ART is limited. A cross-sectional study was conducted at two major sexual health clinics in high HIV prevalence provinces in the Highlands Region of PNG to assess ART adherence, factors affecting adherence and the relationship between ART adherence and virological outcomes. Ninety-five HIV+ individuals were recruited and administered a questionnaire to gather demographic and ART adherence information whilst clinical data and pill counts were extracted from patient charts and blood was collected for viral load testing. Bivariate analysis was performed to identify independent predictors of ART adherence. Fourteen percent (n = 12) of participants showed evidence of virological failure. Although the majority of participants self-reported excellent ART adherence in the last seven days (78.9%, 75/91), pill count measurements indicated only 40% (34/84) with >95% adherence in the last month. Taking other medications while on ART (p = 0.01) and taking ART for ≥1 year (p = 0.037) were positively associated with adherence by self-report and pill count, respectively. Participants who had never heard of drug resistance were more likely to show virological failure (p = 0.033). Misconception on routes of HIV transmission still persists in the studied population. These findings indicate that non-adherence to ART is high in this region of PNG and continued education and strategies to improve adherence are required to ensure the efficacy of ART and prevent HIV drug resistance.     

Bloody time revisited: New observations on time in a Papua New Guinea Village

In a 1982 paper I argued that perceptions of time scarcity in Kragur Village, Papua New Guinea, in the mid‐1970s were best understood as a reaction to new forms of authority characteristic of the growth of capitalism and calls for greater time order were grounded largely in its perceived ritual significance. More than forty years later, villagers are much more familiar with Western time, but less likely to perceive time as scarce. As in the 1970s, aspiring leaders still press for greater time order. Millenarian illusions informed advocacy of time order in the 1970s. Although today these illusions are, if not extinct, then dormant, unquestioned assumptions mirroring Western capitalist views of time inspire many of today's advocates. Yet, lacking the authority to impose new forms of time order, they have little effect on the rhythms of village life, and economic incentives to abandon comparative indifference to time remain weak.     

Preying on those close to home: witchcraft violence in a Papua New Guinea Village

Recent attacks on suspected witches in Telefomin led to several deaths and the flight of families in fear of their lives. This violence has much in common with similar events elsewhere in PNG, but there are important differences as well: accusations do not have a misogynist cast (all the targets were men), and the witchcraft is attributed to non‐indigenous sources. As in many PNG instances, the police failed to prosecute homicides arising from witchcraft accusations, a fact that has led to widespread local concern. In this paper I present the Telefol cases with a focus on the relation of perpetrators to their victims and to the community at large. I argue that certain aspects of the regional economy combined with a generic witchcraft discourse and the ineffectiveness of the state have fostered a lethal crisis in the relation between villagers and male youth.     

Insect trypanosomatids in Papua New Guinea: high endemism and diversity

The extreme biological diversity of Oceanian archipelagos has long stimulated research in ecology and evolution. However, parasitic protists in this geographic area remained neglected and no molecular analyses have been carried out to understand the evolutionary patterns and relationships with their hosts. Papua New Guinea (PNG) is a biodiversity hotspot containing over 5% of the world's biodiversity in less than 0.5% of the total land area. In the current work, we examined insect heteropteran hosts collected in PNG for the presence of trypanosomatid parasites. The diversity of insect flagellates was analysed, to our knowledge for the first time, east of Wallace's Line, one of the most distinct biogeographic boundaries of the world. Out of 907 investigated specimens from 138 species and 23 families of the true bugs collected in eight localities, 135 (15%) were infected by at least one trypanosomatid species. High species diversity of captured hosts correlated with high diversity of detected trypanosomatids. Of 46 trypanosomatid Typing Units documented in PNG, only eight were known from other geographic locations, while 38 TUs (~83%) have not been previously encountered. The widespread trypanosomatid TUs were found in both widely distributed and endemic/sub-endemic insects. Approximately one-third of the endemic trypanosomatid TUs were found in widely distributed hosts, while the remaining species were confined to endemic and sub-endemic insects. The TUs from PNG form clades with conspicuous host-parasite coevolutionary patterns, as well as those with a remarkable lack of this trait. In addition, our analysis revealed new members of the subfamilies Leishmaniinae and Strigomonadinae, potentially representing new genera of trypanosomatids.     

Genetic distance: probing the origin of a Papua New Guinea isolate

In an attempt to elucidate the origin of an isolated peripheral Highland, Papua New Guinea population (the Karimui), HLA, blood group and serum protein markers were investigated. Due to the paucity of published HLA marker data, genetic distances using non-HLA markers were constructed between populations surrounding the Karimui and compared in 3-dimensions by multidimensional scaling analysis. Genetically, the Karimui is most closely associated with Highland populations to the east and northeast. In a attempt to develop a more global view of relationships, distances constructed from HLA marker data between 2 close Highland populations, 2 Coastal Papua New Guinea populations and 4 Australian aborigine populations were compared. The Karimui associated most closely with the Highland populations and equidistantly and at opposite poles from both the Coastal Papuan and aborigine populations. A paradigm of the composition of the founder group and the early population dynamics is developed from genetic, linguistic and anthropologic data.     

Improving Maternal and Newborn Health: Effectiveness of a Community Health Worker Program in Rural Kenya

Background

Volunteer community health workers (CHWs) form an important element of many health systems, and in Kenya these volunteers are the foundation for promoting behavior change through health education, earlier case identification, and timely referral to trained health care providers. This study examines the effectiveness of a community health worker project conducted in rural Kenya that sought to promote improved knowledge of maternal newborn health and to increase deliveries under skilled attendance.

Methods

The study utilized a quasi-experimental nonequivalent design that examined relevant demographic items and knowledge about maternal and newborn health combined with a comprehensive retrospective birth history of women’s children using oral interviews of women who were exposed to health messages delivered by CHWs and those who were not exposed. The project trained CHWs in three geographically distinct areas.

Results

Mean knowledge scores were higher in those women who reported being exposed to the health messages from CHWs, Eburru 32.3 versus 29.2, Kinale 21.8 vs 20.7, Nyakio 26.6 vs 23.8. The number of women delivering under skilled attendance was higher for those mothers who reported exposure to one or more health messages, compared to those who did not. The percentage of facility deliveries for women exposed to health messages by CHWs versus non-exposed was: Eburru 46% versus 19%; Kinale 94% versus 73%: and Nyakio 80% versus 78%.

Conclusion

The delivery of health messages by CHWs increased knowledge of maternal and newborn care among women in the local community and encouraged deliveries under skilled attendance.     

Introduction: The Politics of Order in Contemporary Papua New Guinea

ABSTRACT

This collection of articles seeks to demonstrate that the concept of order – the intensive and extensive coordination of human action across space and time – is useful for answering some of the most pressing theoretical and practical questions in contemporary Papua New Guinea (PNG) today. Building on existing work in this field [Benda-Beckmann, K., and F. Pirie. 2007. “Introduction.” In Order and Disorder: Anthropological Perspectives, 1–15. New York: Berghahn Books] in this special issue we ask: How do people create enduring, stable, and routinised life in contemporary Melanesia today? We position our work as the next step in a growing movement to study contemporary institutions in PNG as order-making projects, rather than attempting to divide them into legitimate projects like ‘government’ and false or ineffective ones like ‘cargo cults’.     

In the shadow of industry: a study of culturization in Papua New Guinea

The activities of extractive industry have recently been framed by a language of corporate social responsibility that relies on a system of legibility and objectification. This process reifies ‘cultural units’, abstracting them from the rules of kinship, migration, and exchange that ensure social and economic security. I refer to this process and the ideology of ‘development’ that accompanies it as culturization and examine it in the context of oil extraction in Papua New Guinea's Kutubu region. Drawing on debates on the indigenization and politicization of ‘culture’, I present culturization as a process that relies on rules of inheritance and property to impose a structure of difference in contexts of extractive industry that ignores the intricacies of sociality that ultimately give life meaning. The aim of the paper is to both illustrate the consequences of this process and consider cognate ideas of ‘culture’ vis‐à‐vis ‘sociality’ to emphasize their mutual theoretical importance to contemporary anthropological inquiry.     

Litter production and seasonality of mangroves in Papua New Guinea

Productivity, as measured by litter trapping, of a mangrove dominated by Rhizophora stylosa Griff. at Motupore Island (lat. 9° 31′34′?S; long. 147° 17$\text{\$}\text{?}$02‘ E) was 1430 g dry weight m^?2 year^?1. This is a high figure when compared with other studied mangrove sites. Phenological data were obtained for R. stylosa, R. apiculata Blume and Sonneratia alba Smith. All species have a major leaf fall in the wet season. Flowering in both Rhizophora species is greatest during the wet season, but S. alba peaks during the dry season. Leaf emergence data were only available for R. stylosa and these appeared to be trimodal. Correlations were calculated for each component with rainfall, wind run, maximum temperature and minimum temperature. Some significant correlations were obtained with rainfall and maximum temperature. These correlations are discussed and it is suggested that the seasonality of mangrove phenologies needs to be considered in terms of whole tree physiology rather than isolated environmental factors.     

Finding Money: Business and Charity in Auhelawa,Papua New Guinea

There is a growing consensus that money and the market principle have not led to a great transformation into modernity. Rather, market exchange is everywhere socially embedded. But what does this embedding consist of, structural limits, tactics of resistance, or moral boundaries? Auhelawa (Normanby Island, Papua New Guinea) have incorporated money into their local economy in a variety of ways which keep the logic of the market in check. The comparison between two modes of accumulation – business and charity – sheds light on the precise nature of embeddedness. Local entrepreneurs describe themselves as navigating dilemmas which arise from contradictions between accumulation and reciprocity. Church congregations, however, appear to have transcended this conflict by representing their charitable contributions of money as love-gifts which are not subject to reciprocity. While charity, like business, is an embedded form of accumulation, I argue that it creates links to an alternative hierarchy of values, and thus contains the potential to create a great transformation of its own.     

Quality of Antimalarial Drugs and Antibiotics in Papua New Guinea: A Survey of the Health Facility Supply Chain

Background

Poor-quality life-saving medicines are a major public health threat, particularly in settings with a weak regulatory environment. Insufficient amounts of active pharmaceutical ingredients (API) endanger patient safety and may contribute to the development of drug resistance. In the case of malaria, concerns relate to implications for the efficacy of artemisinin-based combination therapies (ACT). In Papua New Guinea (PNG), Plasmodium falciparum and P. vivax are both endemic and health facilities are the main source of treatment. ACT has been introduced as first-line treatment but other drugs, such as primaquine for the treatment of P. vivax hypnozoites, are widely available. This study investigated the quality of antimalarial drugs and selected antibiotics at all levels of the health facility supply chain in PNG.

Methods and Findings

Medicines were obtained from randomly sampled health facilities and selected warehouses and hospitals across PNG and analysed for API content using validated high performance liquid chromatography (HPLC). Of 360 tablet/capsule samples from 60 providers, 9.7% (95% CI 6.9, 13.3) contained less, and 0.6% more, API than pharmacopoeial reference ranges, including 29/37 (78.4%) primaquine, 3/70 (4.3%) amodiaquine, and one sample each of quinine, artemether, sulphadoxine-pyrimethamine and amoxicillin. According to the package label, 86.5% of poor-quality samples originated from India. Poor-quality medicines were found in 48.3% of providers at all levels of the supply chain. Drug quality was unrelated to storage conditions.

Conclusions

This study documents the presence of poor-quality medicines, particularly primaquine, throughout PNG. Primaquine is the only available transmission-blocking antimalarial, likely to become important to prevent the spread of artemisinin-resistant P. falciparum and eliminating P. vivax hypnozoites. The availability of poor-quality medicines reflects the lack of adequate quality control and regulatory mechanisms. Measures to stop the availability of poor-quality medicines should include limiting procurement to WHO prequalified products and implementing routine quality testing.