Incentivizing appropriate malaria case management in the private sector: a study protocol for two linked cluster randomized controlled trials to evaluate provider- and client-focused interventions in western Kenya and Lagos, Nigeria.

BACKGROUND: A large proportion of artemisinin-combination therapy (ACT) anti-malarial medicines is consumed by individuals that do not have malaria. The over-consumption of ACTs is largely driven by retail sales in high malaria-endemic countries to clients who have not received a confirmatory diagnosis. This study aims to target ACT sales to clients receiving a confirmatory diagnosis using malaria rapid diagnostic tests (mRDTs) at retail outlets in Kenya and Nigeria. METHODS: This study comprises two linked four-arm 2 × 2 factorial cluster randomized controlled trials focused on malaria diagnostic testing and conditional ACT subsidies with the goal to evaluate provider-directed and client-directed interventions. The linked trials will be conducted at two contrasting study sites: a rural region around Webuye in western Kenya and the urban center of Lagos, Nigeria. Clusters are 41 and 48 participating retail outlets in Kenya and Nigeria, respectively. Clients seeking care at participating outlets across all arms will be given the option of paying for a mRDT-at a study-recommended price-to be conducted at the outlet. In the provider-directed intervention arm, the outlet owner receives a small monetary incentive to perform the mRDT. In the client-directed intervention arm, the client receives a free ACT if they purchase an mRDT and receive a positive test result. Finally, the fourth study arm combines both the provider- and client-directed interventions. The diagnosis and treatment choices made during each transaction will be captured using a mobile phone app. Study outcomes will be collected through exit interviews with clients, who sought care for febrile illness, at each of the enrolled retail outlets. RESULTS: The primary outcome measure is the proportion of all ACTs that are sold to malaria test-positive clients in each study arm. For all secondary outcomes, we will evaluate the degree to which the interventions affect purchasing behavior among people seeking care for a febrile illness at the retail outlet. CONCLUSIONS: If our study demonstrates that malaria case management can be improved in the retail sector, it could reduce overconsumption of ACTs and enhance targeting of publicly funded treatment reimbursements, lowering the economic barrier to appropriate diagnosis and treatment for patients with malaria. TRIAL REGISTRATION: ClinicalTrials.gov NCT04428307 , registered June 9, 2020, and NCT04428385 , registered June 9, 2020.

Social and cultural factors perpetuating early marriage in rural Gambia: an exploratory mixed methods study.

Background: Over the last two decades, early marriage in the Gambia declined significantly (from 58% to 30%). Yet evidence indicates that nearly 8.6% of marriages in the Gambia involved girls younger than 15, and 46.5% of marriages are with girls aged 18 or below. The reasons for the decline but continuing practice of early marriage, despite existing legislation prohibiting child marriage, are not very well understood. Very few studies have been conducted to find out what and how local factors influence decisions about early marriage in the Gambia. More information is therefore needed on underlying reasons for the persistence of early marriage in the Gambia so that program managers can use this information to design strategies towards accelerating the decline of early marriages.  Methods: The study was conducted in 24 rural settlements in Lower Baddibu District in the North Bank Region of the Gambia. It was based on a mixed-methods design including a cross-sectional household survey with a sample of 181 female adolescents and focus group discussions with 16 male and female parents. Focus group discussions were digitally-recorded, transcribed verbatim and analyzed using thematic content analysis, while survey data were analyzed using Stata. Results: Using multiple regression analysis, this study found that ethnicity more than other factors, exerts an independent effect on early marriage. Themes identified during focus group discussions also revealed that fear of premarital sex and loss of virginity outside marriage were major reasons for the perpetuation of early marriage. Conclusions: These findings suggest that the practice of early marriage in rural Gambia is associated with ethnicity and practices related to social and cultural norms. The findings also suggest that in order to decrease early marriages, future efforts should focus on allaying the fears around premarital sex and loss of virginity related to delay in marriage.

Choosing between nurse-led and medical doctor-led from private for-profit versus non-for-profit health facilities: A household survey in urban Burkina Faso.

BACKGROUND: Providers' qualification (Medical doctor [MD] or nurse); type of care facility ownership (for-profit [FP] or not-for-profit [NFP]) may all influence individuals' healthcare-seeking behavior and therefore merits empirical assessment to provide valuable evidence-informed policy orientation in the present context of private health system development. Previous studies have not examined these factors in combination, especially within the urban context of sub-Sahara Africa, where the private sector is rapidly growing. This study aims to explore factors associated with urban residents' preferences between private MD-led and private nurse-led outpatient care and how these factors vary by type of private health facility ownership (FP and NFP) and levels of disease severity (severe and non-severe cases). METHODS: A cross-sectional household survey was conducted in July-November 2011 on a random final sample of 2064 adults (646 households). We used a face-to-face interview to capture participants' choice of provider and their associated factors. A multivariable logistic regression was applied. RESULTS: For severe conditions, participants, almost equally sought FP and NFP facilities, only 36.4% preferred nurses compared to MDs, while for non-severe cases 53.2% preferred FP facilities and only 29.2% patronized nurses. For non-severe conditions, university educated were more likely to use MDs-led FP compared to nurse-led FP facilities (Odds Ratio [OR] = 4.66, 95% confidence interval [CI] = 2.62-8.30) and MD-led FP over MD-led NFP facilities (OR = 1.03, 95%CI = 1.01-1.04), for severe health conditions. Having insurance predicted MD-led FP preference over nurse-led FP. Furthermore, insurance predicted the preference for MD-led FP over MD-led NFP facilities. Employment did not distinguish participants' choice of provider. CONCLUSION: The findings suggest that, at different levels, MDs and nurses from FP and NFP facilities importantly contribute to health services delivery regardless of the severity of health conditions. The results offer some valuable evidence for policy orientation in the current rising tide of the private system, including workforce development, and practitioners' role definition. We suggested that health insurance mechanism would reinforce the private health services utilization and could enhance progress towards the attainment of Sustainable Development Goals.

Socioeconomic differential in self-assessment of health and happiness in 5 African countries: Finding from World Value Survey.

OBJECTIVE: Factors that contribute to wealth related inequalities in self-rated health (SRH) and happiness remains unclear most especially in sub-Saharan countries (SSA). This study aims to explore and compare socioeconomic differentials in SRH and happiness in five SSA countries. METHODS: Using the 2010/2014 World Values Survey (WVS), we obtained a sample of 9,869 participants of age 16 and above from five SSA countries (Nigeria, Ghana, South Africa, Rwanda and Zimbabwe). Socioeconomic inequalities were quantified using the concentration index. The contribution of each predictor to concentration index's magnitude was obtained by means of regression based decomposition analysis. RESULTS: Poor SRH ranges from approximately 9% in Nigeria to 20% in Zimbabwe, whereas unhappiness was lower in Rwanda (9.5%) and higher in South Africa (23.3%). Concentration index was negative for both outcomes in all countries, which implies that poor SRH and unhappiness are excessively concentrated among the poorest socioeconomic strata. Although magnitudes differ across countries, however, the major contributor to wealth-related inequality in poor SRH is satisfaction with financial situation whereas for unhappiness the major contributors are level of income and satisfaction with financial situation. CONCLUSIONS: This study underscores an association between wealth related inequalities and poor SRH and unhappiness in the context of SSA. Improving equity in health, as suggested by the commission of social determinants of health may be useful in fighting against the unfair distribution of resources. Thus, knowledge about the self-rating of health and happiness can serve as proxy estimates for understanding the distribution of health care access and economic resources needed for well-being in resident countries.

Psychometric evaluation of the French version of the Clinical Nursing Competence Questionnaire (CNCQ-22): A cross-sectional study in nursing education in Burkina Faso.

BACKGROUND: Clinical nursing competence (CNC) is the essence of the nursing profession. It has received attention as a central component of nursing education; however, most instruments of measure were developed in high income countries and essentially in English. To gauge the CNC of nursing students attending Bachelor of Science in Nursing programs, a specialized scale is needed. This study aimed to validate a French version of the 22-item Clinical Nursing Competence Questionnaire (CNCQ-22), designed and implemented in Taiwan. METHODS: A cross-sectional descriptive survey was carried out to assess the psychometric properties of the CNCQ-22. A total of 255 pre-graduate nursing students of three nursing campuses of Burkina Faso (École Nationale de Santé Publique) participated in the study from June to October 2009. In addition to descriptive analysis, the reliability of the instrument, test-retest, and convergent and discriminant validity were examined. RESULTS: Most participants were pre-registered nursing students (66.3%), predominantly male (68.2%), and their mean age was 30.54 (±5.66) (range 21-48). The original English version of the CNCQ-22 was translated into French and yielded an internal consistency coefficient of 0.89. The instrument revealed solid stability through a test-retest that yielded a Spearman's rho of 0.61 and supported good convergent and discriminant validity. Exploratory and confirmatory factor analyses resulted in a three-factor solution. CONCLUSION: The French version of the CNCQ-22 demonstrates promising psychometric integrity and can be considered as a reliable and valid instrument to evaluate CNC in a French nursing education context. An accurate assessment of CNC provided by an adapted, easy-to-use CNCQ-22 may help nursing educators and academics improve the quality of training.