Comparative Assessment of Exclusive Breastfeeding Rates From 24-Hour Recall and Since Birth Methods in Southwestern Pennsylvania Using Ecological Momentary Assessment.

BACKGROUND: Accurate measurement of exclusive breastfeeding is important in maternal and child health research. Exclusive breastfeeding is often measured using the 24-hour recall or the since birth method for the first 6 months. These methods can produce different estimates, introducing problems in interpreting breastfeeding behavior and making accurate comparisons across settings or countries. RESEARCH AIM: Our aim was to compare the exclusive breastfeeding rates between the 24-hour recall and since birth methods among a diverse cohort of birthing people using the ecological momentary assessments method. In addition, we compared the exclusive breastfeeding rates between the two methods across race and other maternal characteristics. METHODS: This study is a secondary analysis using data from the Postpartum Mothers Mobile Study (PMOMS), a prospective longitudinal study which recruited participants during pregnancy and followed them for 12 months after delivery. Participants completed surveys in real-time via ecological momentary assessment. Individual exclusive breastfeeding rates from months 1-6 were computed using 24-hour recall and since birth methods for 284 participants. We calculated the percentage point difference between the two methods across child age and maternal characteristics. We used a two-sample test of proportions to determine if the differences observed in the proportions were significant. RESULTS: Exclusive breastfeeding rates from the 24-hour recall were higher than the since birth rates across all ages and maternal characteristics. The difference between the two methods at 3 months was 25.7 percentage points and at 6 months was a 17.2 percentage points. Irrespective of the method used to measure exclusive breastfeeding, White participants had higher exclusive breastfeeding rates than Black participants. CONCLUSION: The 24-hour recall and the since birth methods of assessing exclusive breastfeeding provided substantially different estimates. These findings highlight the importance of specificity in measuring and reporting exclusive breastfeeding.

Stress, social support, and racial differences: Dominant drivers of exclusive breastfeeding.

Exclusive breastfeeding is recommended for 6 months; however, many childbearing people wean their infants before 6 months. Psychosocial factors such as stress, social support and race are significant determinants of breastfeeding; however, few studies have longitudinally explored the effect of perceived stress and various forms of social support on exclusive breastfeeding. We used quantitative methodologies to examine exclusive breastfeeding, perceived stress and social support among 251 participants from the Postpartum Mothers Mobile Study. Participants between 18 and 44 years were recruited during pregnancy (irrespective of parity) and completed surveys in real-time via Ecological Momentary Assessment up to 12 months postpartum from December 2017 to August 2021. We measured perceived stress with the adapted Perceived Stress Scale and perceived social support with the Multi-dimensional Social Support Scale. Received social support was measured using a single question on breastfeeding support. We conducted a mixed-effects logistic regression to determine the effect of stress, race and social support on exclusive breastfeeding over 6 months. We examined the moderation effect of perceived social support and breastfeeding support in the relationship between perceived stress and exclusive breastfeeding. Black, compared with White, participants were less likely to breastfeed exclusively for 6 months. Participants who reported higher perceived stress were less likely to breastfeed exclusively for 6 months. Perceived social support moderated the relationship between perceived stress and exclusive breastfeeding (odds ratio: 0.01, 95% confidence interval: 0.001-0.072). However, breastfeeding support directly increased the likelihood of exclusive breastfeeding over 6 months. Perceived stress is negatively associated with exclusive breastfeeding. Birthing people who intend to breastfeed may benefit from perinatal support programs that include components to buffer stress.

The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions.

INTRODUCTION: Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes. METHODS: We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices. RESULTS: The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings. CONCLUSION: The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.

Barriers, facilitators, and recommendations for childhood immunisation in Nigeria: perspectives from caregivers, community leaders, and healthcare workers.

Introduction: vaccination is one of the most successful and cost-effective public health interventions, significantly reducing childhood morbidity and mortality. In 2019, Nigeria had almost 2.5 million unvaccinated children. This study highlights barriers, facilitators, and recommendations for childhood immunisation uptake from various stakeholder perspectives. Methods: the study team conducted ten focus groups with mothers/caregivers and community leaders and nine semi-structured interviews with healthcare workers who provide routine immunisation services in Lagos State primary healthcare facilities. We performed a descriptive thematic analysis of the focus groups and semi-structured interviews. Results: study participants included 44 mothers/caregivers and 24 community leaders, and 19 primary healthcare workers in the State. Study participants reported barriers, facilitators, and recommendations for childhood immunisation uptake. Barriers include poor geographical and financial constraints to access healthcare services, inconducive health facility attributes, negative attitudes of health facility staff, vaccination misperceptions, and adverse events following immunisation. Facilitators include free immunisation service policy, optimal vaccine and device supply chain system, adequate knowledge of immunisation benefits and efficacy, vaccination outreaches, and provision of incentives to caregivers. Participants also made recommendations for implementation, including more awareness creation, use of community resources, employing more healthcare workers, frequent and optimal immunisation services and planning, and instituting a reminder system and defaulter tracking. Conclusion: our results can inform the development of interventions to improve childhood immunisation uptake. In addition, study findings can be employed to improve adult immunisation acceptance and uptake and other services provided within the primary healthcare setting.

The Socioecological Model as a framework for exploring factors influencing childhood immunization uptake in Lagos state, Nigeria.

BACKGROUND: Nigeria is one of the ten countries globally that account for 62% of under- and unvaccinated children worldwide. Despite several governmental and non-governmental agencies' interventions, Nigeria has yet to achieve significant gains in childhood immunization coverage. This study identifies intrapersonal, interpersonal, organizational, community, and policy-level factors that influence childhood immunization uptake from various stakeholders' perspectives using the Socioecological Model (SEM). METHODS: Using the Socioecological Model as a guiding framework, we conducted ten focus group sessions with mothers/caregivers and community leaders residing in Lagos state and nine semi-structured interviews with healthcare workers who provide routine immunization services in Lagos state primary healthcare facilities. We performed a qualitative analysis of focus groups and semi-structured interviews using deductive coding methods. RESULTS: The study sample included 44 mothers/caregivers and 24 community leaders residing in Lagos State, Nigeria, and 19 healthcare workers (routine immunization focal persons) working in the primary healthcare setting in Lagos state. Study participants discussed factors at each level of the SEM that influence childhood immunization uptake, including intrapersonal (caregivers' immunization knowledge, caregivers' welfare and love of child/ren), interpersonal (role of individual relationships and social networks), organizational (geographical and financial access to health facilities, health facilities attributes, staff coverage, and healthcare worker attributes), community (community outreaches and community resources), and policy-level (free immunization services and provision of child immunization cards). Several factors were intertwined, such as healthcare workers' education of caregivers on immunization and caregivers' knowledge of vaccination. CONCLUSIONS: The reciprocity of the findings across the Socioecological Model levels emphasizes the importance of developing multi-pronged interventions that operate at multiple levels of the SEM. Our results can inform the design of culturally appropriate and effective interventions to address Nigeria's suboptimal immunization coverage.

Integrated community case management: planning for sustainability in five African countries.

BACKGROUND: The World Health Organization (WHO) launched an initiative to plan for the sustainability of integrated community case management (iCCM) programmes supported by the Rapid Access Expansion (RAcE) Programme in five African countries in 2016. WHO contracted experts to facilitate sustainability planning among Ministries of Health, WHO, nongovernmental organisation grantees, and other stakeholders. METHODS: We designed an iterative and unique process for each RAcE project area which involved creating a sustainability framework to guide planning; convening meetings to identify and prioritise elements of the framework; forming technical working groups to build country ownership; and, ultimately, creating roadmaps to guide efforts to fully transfer ownership of the iCCM programmes to host countries. For this analysis, we compared priorities identified in roadmaps across RAcE project sites, examined progress against roadmaps via transition plans, and produced recommendations for short-term actions based on roadmap priorities that were unaddressed or needed further attention. RESULTS: This article describes the sustainability planning process, roadmap priorities, progress against roadmaps, and recommendations made for each project area. We found a few patterns among the prioritised roadmap elements. Overall, every project area identified priorities related to policy and coordination of external stakeholders including funders; supply chain management; service delivery and referral system; and communication and social mobilisation, indicating that these factors have persisted despite iCCM programme maturity, and are also of concern to new programmes. We also found that a facilitated process to identify and document programme priorities in roadmaps, along with deliberately planning for transition from an external implementer to a national system could support the sustainability of iCCM programmes by facilitating teams of stakeholders to accomplish explicit tasks related to transitioning the programme. CONCLUSIONS: Certain common elements are of concern for sustaining iCCM programmes across countries, among them political leadership, supply chain management, data processes, human resources, and community engagement. Adapting and using a sustainability planning approach created an inclusive and comprehensive dialogue about systemic factors that influence the sustainability of iCCM services and facilitated changes to health systems in each country.

Misuse of Artemisinin Combination Therapies by Clients of Medicine Retailers Suspected to Have Malaria Without Prior Parasitological Confirmation in Nigeria.

BACKGROUND: Prompt and effective case detection and treatment are vital components of the malaria case management strategy as malaria-endemic countries implement the testing, treating and tracking policy. The implementation of this policy in public and formal private sectors continue to receive great attention while the informal private retail sector (mostly the patent and propriety medicine vendors [PPMVs]) where about 60% of patients with fever in Nigeria seek treatment is yet to be fully integrated. The PPMVs sell artemisinin combination therapies (ACTs) without prior testing and are highly patronized. Without prior testing, malaria is likely to be over-treated. The need to expand access to diagnosis in the huge informal private health sector among PPMVs is currently being explored to ensure that clients that patronize retail drug stores are tested before sales of ACTs. METHODS: A cross-sectional multistage study was conducted among 1279 adult clients, 20 years and above, who purchased malaria medicines from 119 selected PPMVs in five administrative areas (States) of Nigeria, namely: Adamawa, Cross River, Enugu, Lagos and Kaduna, as well as the Federal Capital Territory, Abuja. Exit interviews using a standard case report questionnaire was conducted after the purchase of the antimalarial medicine and thick/thin blood smears from the clients' finger-prick were prepared to confirm malaria by expert microscopy. RESULTS: Of the 1279 clients who purchased malaria medicines from the PPMV outlets, 107 (8.4%) were confirmed to have malaria parasites. The malaria prevalence in the various study areas ranged from 3.5% to 16%. A high proportion of clients in the various study sites who had no need for malaria medicines (84%-96.5%) purchased and used antimalarial medicines from the PPMVs. This indicated a high level of over-treatment and misuse of antimalarials. Common symptoms that are widely used as indicators for malaria such as, fever, headache, and tiredness were not significantly associated with malaria. Nausea/vomiting, poor appetite, chills, bitter taste in the mouth and dark urine were symptoms that were significantly associated with malaria among the adult clients (P<.05) but not fever (P=.06). CONCLUSION: Misuse of ACTs following overtreatment of malaria based on clinical diagnosis occurs when suspected cases of malaria are not prior confirmed with a test. Non-testing before sales of malaria medicines by PPMVs will perpetuate ACT misuse with the patients not benefiting due to poor treatment outcomes, waste of medicines and financial loss from out-of-pocket payment for unneeded medicines.

Assessment of data quality and reporting systems for underserved populations: the case of integrated community case management programs in Nigeria.

Decision makers are searching for reliable data and best practices to support the implementation and scale-up of the integrated community case management (iCCM) programs in underserved areas to reduce under-five mortality in low-income countries. This study assesses data quality and reporting systems of the World Health Organization supported Rapid Access Expansion program implementing iCCM in Abia and Niger States, Nigeria. This cross-sectional study used data from 16 primary health facilities in both states. Data were collected through review of registers and monthly summary reports of 140 community-oriented resource persons (CORPs), assessments of the five dimensions of the data reporting systems and 46 key informant interviews with stakeholders. Data quality was assessed by availability, completeness and consistency. Each component of the reporting system was assessed on a 3-point scale (weak, satisfactory and strong). Results show that both the structure, functions and capabilities, as well as data collection and reporting tools dimensions of the reporting system were strong, scoring (2.80, 2.73) for Abia and (2.88, 2.75) for Niger, respectively. Data management processes and links with national reporting system components scored low 2 s, indicating fair strength. Data availability, completeness and consistency were found to be good, an indication of adequate training and supervision of CORPs and community health extension workers. Indicator definitions and reporting guidelines were the weakest dimension of the system due to lack of data reporting guidelines in both states. In conclusion, the results indicate satisfactory data reporting systems and good quality data during early implementation of iCCM programs in the two states. Hence, countries planning to adopt and implement iCCM programs should first develop structures, establish national standardized tools for collecting and reporting data, provide for adequate training and supervision of community health workers and develop reporting guidelines for all reporting levels to ensure data quality.

Demand-related factors influencing caregivers' awareness of malaria tests and health workers' testing practices, in Makarfi, Nigeria.

BACKGROUND: Despite the World Health Organization's recommendation of malaria test-treat strategy, which is the treatment of parasitological confirmed malaria cases with anti-malarials, presumptive diagnosis of malaria remains fairly common in Nigeria. The reasons for this have not been established in Makarfi, Nigeria, despite the high burden of malaria in the area. A study was conducted among caregivers of febrile children less than 5 years presenting for treatment to understand their awareness of malaria diagnostic testing and being offered testing by clinicians, the determinants of these outcomes, and caregivers' perspectives of health workers' testing practices. METHODS: Using mixed-methods, data was combined from sub-analysis of cross-sectional survey data (n = 295) and focus group discussions (n = 4) with caregivers conducted in Makarfi General Hospital (Kaduna State, Nigeria) and surrounding communities in 2011. Bivariate and multivariate analysis of the quantitative survey data was conducted to examine associations of caregivers' sociodemographic characteristics with testing awareness and having ever been offered testing. Transcripts from focus group discussions (FGD) were analysed for emerging themes related to caregivers' perspectives on malaria testing. RESULTS: Among surveyed caregivers who were predominantly female (81.7%), not formally educated (72.5%), and were housewives (68.8%); only 5.3% were aware of any diagnostic testing for malaria, and only 4.3% had ever been offered a malaria test by a health worker. Having at least a primary level education (adjusted odds ratio [aOR] 20.3, 95% CI 4.5-92.1) and living within 5 km of the hospital (aOR 4.3, 95% CI 1.5-12.5) were determinants of awareness of malaria testing. Also, these were determinants of previously having been offered a test (aOR 9.9, 95% CI 2.1-48.7; and aOR 4.0, 95% CI 1.1-14.7). FGD showed many caregivers believed that malaria testing was for severe illness only, and that proximity to a health facility and cost of treatment influenced the seeking and receiving of care. CONCLUSIONS: Uptake of malaria testing prior to treatment can be improved by increasing its awareness and addressing misunderstandings among caregivers, promoting testing practices among health workers, and availing caregivers living farther from health centres alternative opportunities for community case management of febrile illnesses.

The role of drug vendors in improving basic health-care services in Nigeria.

OBJECTIVE: To characterize patent and proprietary medicine vendors and shops in Nigeria and to assess their ability to help improve access to high-quality, primary health-care services. METHODS: In 2013 and 2014, a census of patent and proprietary medicine shops in 16 states of Nigeria was carried out to determine: (i) the size and coverage of the sector; (ii) the basic characteristics of shops and their staff; and (iii) the range of products stocked for priority health services, particularly for malaria, diarrhoea and family planning. The influence of the medical training of people in charge of the shops on the health-care products stocked and registration with official bodies was assessed by regression analysis. FINDINGS: The number of shops per 100,000 population was higher in southern than in northern states, but the average percentage of people in charge with medical training across local government areas was higher in northern states: 52.6% versus 29.7% in southern states. Shops headed by a person with medical training were significantly more likely to stock artemisinin-based combination therapy, oral rehydration salts, zinc, injectable contraceptives and intrauterine contraceptive devices. However, these shops were less likely to be registered with the National Association of Patent and Proprietary Medicine Dealers and more likely to be registered with the regulatory body, the Pharmacist Council of Nigeria. CONCLUSION: Many patent and proprietary medicine vendors in Nigeria were medically trained. With additional training and oversight, they could help improve access to basic health-care services. Specifically, vendors with medical training could participate in task-shifting interventions.

Care-seeking at patent and proprietary medicine vendors in Nigeria.

BACKGROUND: To achieve health development goals, policymakers are increasingly focused on improving primary care in low- and middle-income countries, and private sector drug retailers offer one channel through which basic services may be delivered. In Nigeria, patent and proprietary medicine vendors (PPMVs) serve as a main source of medications, but little is known about their clientele or how care is sought at PPMVs for common illnesses. We explore differences in care-seeking at PPMV shops based on the most commonly reported symptoms. METHODS: In Kogi and Kwara states, Nigeria, 250 PPMV shop workers and 2,359 customers purchasing drugs were surveyed, and each worker-customer interaction was observed. Multivariate regression analysis was used to assess the association of commonly reported symptoms with care-seeking behavior prior to attending the shop and while interacting with the provider at the shop. RESULTS: Most customers sought care for headache (30.5 %), fever (22.9 %), cough/cold (18.1 %), or diarrhea (8.4 %). Customers with fever were more likely to report being diagnosed by a formally trained person, to have discussed the illness with and be examined by the shop worker, and have more difficulty paying. In contrast, customers with headache symptoms were less likely to experience these outcomes and spent less money purchasing drugs. Those reporting cough or cold symptoms were less likely to have been diagnosed by a formally trained person, waited longer before visiting the PPMV shop, and were more likely to discuss the illness with the shop worker, but were less likely to be examined or to recommend the purchased drug themselves. If a sick child was brought to the shop, a discussion of the illness and an exam were more likely and more money was spent on drugs. CONCLUSIONS: Because care-seeking behaviors vary by symptoms and the sick person's age, PPMVs should be trained to treat common illnesses for which customers are unlikely to seek a formal medical consultation. Interventions aimed at improving primary care need to target the places where most people access care, and equip PPMV workers with knowledge and tools to provide basic services.

Management of paediatric illnesses by patent and proprietary medicine vendors in Nigeria.

BACKGROUND: In Nigeria and elsewhere, informal drug sellers, or patent and proprietary medicine vendors (PPMVs), are a common source of care for children with malaria, diarrhoea, and pneumonia. However, their knowledge and stocking of recommended treatments for these common childhood illnesses are not well understood. METHODS: A census of PPMV shops was conducted in Kogi and Kwara states. A shop survey was conducted on a subset of 250 shops. Multivariate regression analysis was used to assess associations between shop worker characteristics and (1) knowledge of optimal treatments for malaria, diarrhoea, and pneumonia, and (2) stocking of essential medicines to treat these illnesses. RESULTS: From the census, 89.9% of shops stocked oral rehydration solution (ORS), while 61.1% of shops stocked artemisinin-based combination therapies and 72.2% of shops stocked amoxicillin. Stocking patterns varied by state, urban/rural location, and according to whether or not the shop was headed by someone with formal health training (e.g. having a professional health education degree). In multivariate analyses, selling drugs wholesale and participating in any training in the past year was associated with a higher likelihood of naming the correct treatment for malaria, and having formal health training was associated with stocking ORS. However, few other PPMV characteristics were predictive of correct knowledge of optimal treatments and stocking behaviour. CONCLUSION: Many PPMVs lack the knowledge and tools to properly treat common childhood illnesses. PPMV knowledge and selling of essential medicines for these illnesses should be strengthened to improve child health in Nigeria.

Differences in malaria care seeking and dispensing outcomes for adults and children attending drug vendors in Nasarawa, Nigeria.

OBJECTIVES: To characterise the differences in care seeking behaviour and dispensing outcomes between adults and children purchasing drugs for malaria at retail shops in Nigeria. METHODS: In Nasarawa State, retail drug shops were enumerated and a subset of those stocking antimalarials were selected as study sites and surveyed. Customers exiting shops after purchasing antimalarial drugs were surveyed and tested with a malaria rapid diagnostic test. Sick adults and caregivers accompanying sick children were eligible, but individuals purchasing drugs for a sick person that was not present were excluded. Multivariate regression analysis was used to identify the correlates of care seeking and the quality of interaction at the shop. RESULTS: Of 737 participants, 80% were adults and 20% were children (under age 18). Caregivers of sick children were more likely to obtain a prescription prior to attending a drug retailer than adults seeking care for themselves and waited a shorter time before seeking care. Caregivers of sick children were also more likely than sick adults to have been asked about symptoms by the retailer, to have been given an examination, and to have purchased an ACT. Fewer than half of respondents had purchased an ACT. Only 14% of adults, but 27% of children were RDT-positive; RDT-positive children were more likely to have had an ACT purchased for them than RDT-positive adults. CONCLUSIONS: Children with suspected malaria tend to receive better care at drug retailers than adults. The degree of overtreatment and prevalence of dispensing non-recommended antimalarials emphasise the need for routine diagnosis before treatment to properly treat both malaria and non-malaria illnesses.

Presumptive treatment of malaria from formal and informal drug vendors in Nigeria.

BACKGROUND: Despite policies that recommend parasitological testing before treatment for malaria, presumptive treatment remains widespread in Nigeria. The majority of Nigerians obtain antimalarial drugs from two types of for-profit drug vendors-formal and informal medicine shops-but little is known about the quality of malaria care services provided at these shops. AIMS: This study seeks to (1) describe the profile of patients who seek treatment at different types of drug outlets, (2) document the types of drugs purchased for treating malaria, (3) assess which patients are purchasing recommended drugs, and (4) estimate the extent of malaria over-treatment. METHODS: In urban, peri-urban, and rural areas in Oyo State, customers exiting proprietary and patent medicine vendor (PPMV) shops or pharmacies having purchased anti-malarial drugs were surveyed and tested with malaria rapid diagnostic test. A follow-up phone survey was conducted four days after to assess self-reported drug administration. Bivariate and multivariate regression analysis was conducted to determine the correlates of patronizing a PPMV versus pharmacy, and the likelihood of purchasing an artemisinin-combination therapy (ACT) drug. RESULTS: Of the 457 participants who sought malaria treatment in 49 enrolled outlets, nearly 92% had diagnosed their condition by themselves, a family member, or a friend. Nearly 60% pharmacy customers purchased an ACT compared to only 29% of PPMV customers, and pharmacy customers paid significantly more on average. Multivariate regression results show that patrons of PPMVs were younger, less wealthy, waited fewer days before seeking care, and were less likely to be diagnosed at a hospital, clinic, or laboratory. Only 3.9% of participants tested positive with a malaria rapid diagnostic test. CONCLUSIONS: Poorer individuals seeking care at PPMVs are more likely to receive inappropriate malaria treatment when compared to those who go to pharmacies. Increasing accessibility to reliable diagnosis should be explored to reduce malaria over-treatment.

How do risk preferences relate to malaria care-seeking behavior and the acceptability of a new health technology in Nigeria?

BACKGROUND: To reduce the burden of disease from malaria, innovative approaches are needed to engender behavior change. One unobservable, but fundamental trait-preferences for risk-may influence individuals' willingness to adopt new health technologies. We explore the association of risk preferences with malaria care-seeking behavior and the acceptability of malaria rapid diagnostic tests (RDTs) to inform RDT scale-up plans. METHODS: In Oyo State, Nigeria, adult customers purchasing anti-malarial medications at selected drug shops took surveys and received an RDT as they exited. After an initial risk preference assessment via a simple lottery game choice, individuals were given their RDT result and treatment advice, and called four days later to assess treatment adherence. We used bivariable and multivariable regression analysis to assess the association of risk game choices with malaria care-seeking behaviors and RDT acceptability. RESULTS: Of 448 respondents, 63.2% chose the lottery game with zero variance in expected payout, 27.9% chose the game with low variance, and 8.9% chose the game with high variance. Compared to participants who chose lower variance games, individuals choosing higher variance games were older, less educated, more likely to be male, and were more likely to patronize lower quality drug shops, seek care immediately, and report complete disability due to their illness. In contrast, individuals choosing lower variance games were more likely to follow the correct treatment directions and were more likely to report an increase in their willingness to pay for an RDT compared to other risk groups, our two measures of RDT acceptability. Differences in estimated associations between risk game choices and selected care-seeking behaviors remained after controlling sociodemographic confounders. CONCLUSIONS: The uptake of health diagnostic information in terms of translating the RDT experience into willingness to pay for an RDT and treatment adherence to test results may vary according to risk preferences. Hence, health promotion communications may want to be crafted bearing in mind differences in uptake among people of different risk preferences to encourage wider RDT adoption and more rational malaria treatment. Estimates will serve as the basis for power calculations for an expanded study.

SMS messages increase adherence to rapid diagnostic test results among malaria patients: results from a pilot study in Nigeria.

BACKGROUND: The World Health Organization now recommends parasitological confirmation for malaria case management. Rapid diagnostic tests (RDTs) for malaria are an accurate and simple diagnostic to confirm parasite presence in blood. However, where they have been deployed, adherence to RDT results has been poor, especially when the test result is negative. Few studies have examined adherence to RDTs distributed or purchased through the private sector. METHODS: The Rapid Examination of Malaria and Evaluation of Diagnostic Information (REMEDI) study assessed the acceptability of and adherence to RDT results for patients seeking care from private sector drug retailers in two cities in Oyo State in south-west Nigeria. In total, 465 adult participants were enrolled upon exit from a participating drug shop having purchased anti-malaria drugs for themselves. Participants were given a free RDT and the appropriate treatment advice based on their RDT result. Short Message Service (SMS) text messages reiterating the treatment advice were sent to a randomly selected half of the participants one day after being tested. Participants were contacted via phone four days after the RDT was conducted to assess adherence to the RDT information and treatment advice. RESULTS: Adherence to RDT results was 14.3 percentage points (P-val <0.001) higher in the treatment group who were sent the SMS. The higher adherence in the treatment group was robust to several specification tests and the estimated difference in adherence ranged from 9.7 to 16.1 percentage points. Further, the higher adherence to the treatment advice was specific to the treatment advice for anti-malarial drugs and not other drugs purchased to treat malaria symptoms in the RDT-negative participants who bought both anti-malarial and symptom drugs. There was no difference in adherence for the RDT-positive participants who were sent the SMS. CONCLUSIONS: SMS text messages substantially increased adherence to RDT results for patients seeking care for malaria from privately owned drug retailers in Nigeria and may be a simple and cost-effective means for boosting adherence to RDT results if and when RDTs are introduced as a commercial retail product.