Malaria SBC Evidence Discussion Series: Prescriber and Patient Interventions


Other than Money, Mike, how are you Good. Can you hear me OK. I can hear you loud and clear. Great. So I’m going to share my screen and advance the slides. Okay. It seemed to be easier that way, that way we don’t have to hand off back and forth. Thank you for making those last minute edits. Oh. My pleasure. We’ll make sure to get those two sooner. Oh, no worries. It slipped my mind as well, otherwise I would have Got some folks. Good morning everyone. This is Mike toe so I’m a Program Officer with Johns Hopkins Center for communication programs. This is the third in our series of malaria social behavior change communication evidence based discussions. Before we begin, I’d like to introduce our moderator. pick him up them. Thank you Mike. Good morning, good afternoon. Good evening, everyone. Can you hear me. Yep. Okay. Just as a word of quick introduction, Bridget is a malaria advisor for the US presidents malaria initiative. As a member of Social Change team, she provided support to PMI programs in the chair and getting we’re just going to start us off today with a few words about how this activity fits in with Within PM is global. Strategy welcome Bridget. Thank you Mike. And again, hello to everyone, as Mike said the US presidents malaria initiative is supporting this activity. So thank you for this opportunity to say a word or two about how it fits into our global strategy. So PMI prioritises activities that improve countries capacity to collect and use information and oftentimes this is in our own countries, but when appropriate, we can look at other countries data and studies to apply it to our own We’re also very interested in building the capacity of health systems of countries where we work. And so from our perspective regular discussion about rigorous malaria SPC evidence helps to build and maintain capacity among the malaria community. So we hope this activity meets your needs and thank you to break the reaction and to Dr. Chandler Thank you so much budget, just a few words about today, this discussion will be recorded, we will be sharing the slides and the webinar recording after the discussion. During the discussion, you’ll be on mute. But please keep your questions and add them in the chat box to the side. When it comes to the discussion time we will open up the floor. You will be able to either speak or type your question into the chat box if you’d like to speak. There’s a little button on the black bar of your computer you can raise your hand and we will call on you. As usual, these discussions are structured like a research paper if you are following along in the discussion guide the blue slides will indicate with section addresses specific questions in that guide. In addition to learning about Dr. Gentlemen, his findings we hope today’s discussion should lights on tips for reading and interpreting malaria SPC research for your own work. Today’s article comes from an online searchable database from malaria SPC evidence which includes both peer reviewed articles and grey literature, please take time to explore it when you have a chance I’d like to introduce our presenter Professor Claire Chandler Chandler is the director of interdisciplinary antimicrobial Antimicrobial Research Center at the London School of Hygiene and Tropical Medicine. She’s a professor in medical anthropology and currently heads the anthropology of antimicrobial resistance research group, the largest of its of its kind of globally. She’s a leading medical anthropologist on the topic of medicines and healthcare. Her research has produced rich and policy really relevant accounts of the roles of medicines and of diagnostic tests across settings with different resource availability. Hurt in depth ethnographic field sites have been in Uganda and Tanzania. She has also led research in Ghana, Nigeria Cameroon Sierra Leone allow ease and Bob why Ethiopia, South Africa. Afghanistan, India, Cambodia, Vietnam, the Philippines, Thailand and the Mr. As well as the United Kingdom. Her methodological expertise or and it’s not an ethnography mixed methods studies intervention design and the evaluation of complex health interventions. She also has a keen interest in capacity development and low resource settings, both in practice, and as a research topic. She has provided technical advice to the government of the United Kingdom, the World Health Organization and many LOWER MIDDLE INCOME lower and middle income governance. Welcome, Dr. Chandler Thank you very much. Before we get started. With the diving into the research today we’d like to frame our discussion around the social, ecological model which we find A helpful way to think about who and what influences important decision making about behaviors. Evidence base we have just mentioned describes growing body of research findings that tell us behavior isn’t the result of simply exchanging of information with an individual People make decisions based on a number of individual social and structural influences A reoccurring theme in this evidence discussion series will be a focus on interventions designed to influence multiple audiences instruction instructions within this model. When we say the social, ecological model influences our work we’re acknowledging that working on individual social and structural levels must be addressed to achieve positive behaviors and health outcomes. We’ve activated slide with a few examples of the factors at the individual interpersonal community and societal levels that the study we’re going to discuss today has taken into account. Hello pastor forward to our presenter for today Dr Kwame Chandler, who’s going to talk. Take us through her research for his Juris Doctor gentlemen. Thank you very much, Mike, and thank you for inviting me to talk about this. Research and hello to everybody. And let me begin with a brief description of what we set out to do with this project if you’re following the discussion guide. This is where we answer the first question in the discussion guide what evidence did authors collect and use to come to the conclusion that these approaches might be effective. So our objectives. So we, we had a set of objectives of what we wanted to achieve. Before we set out the intervention design. And the goal was to improve prescribers adherence to Malaria diagnostic tests and that means we wanted them to reduce the amount of anti malarial that will be prescribed, we already knew that there was a lot of non adherence to diagnostic testing, both in microscopy and rapid diagnostic tests. And baseline when we were started out these studies we had about 50% of people who had a negative test was still being given an anti malarial so we really wanted to reduce that and improve appropriate treatment. So that was the goal at the study So we carry this study out in Tanzania. We also at the same time we’re doing a number of studies in other countries through the AC T consortium that carried out with similar methods. This project in Tanzania was carried out in two different regions that have different levels of Malaria. So in marshy the level of malaria had actually decreased quite a lot in this in the previous few years and so it was actually quite a low level of malaria, whereas in Mesa district. We had a slightly higher level of malaria. So we were able To compare this this approach across the different areas. We know that prescribing behavior. May well we had from our descriptive work, we already knew that there was going to be a difference in how people would respond to diagnostic tests in lower low Transmission areas and the trust in the test might be different in those areas compared to settings where the test was positive more often. So to do the project. We wanted to include these two different sides, but because they have different baseline malaria and misty we wanted to make sure that we powered the study to be able to evaluate how interventions. In each of these sites. So we randomly selected health facilities in. So these were dispensary level, that means Its primary care. So, not in hospital settings primary healthcare facilities government facilities in each of the areas we picked 18 facilities in each area at random from those that were eligible and then we allocated three study arms to each of these to these 18 facilities that we randomly allocated them to either be in the control the health worker or or the health worker and patient on So, We have three different approaches we have 12 facilities overall six in each site that received a standard RDP training. So the government of Tanzania had introduced A standard training program of two days for health workers, which was actually quite good and comprehensive program. We then expanded upon that we delivered that training program and the controller in the second hour we expanded upon that to include some additional workshops and some additional materials And then in the third arm. In addition to that, we added a patient centered that section, which was actually the delivery of a leaflet and poster. So the timeline looks like this, and we Started with doing formative research and I had actually done two years of ethnographic fieldwork on this topic in these areas, prior to starting this project. So that was anthropological field work, working with healthcare providers and patients. And then we then did some formative research, specifically in the primary healthcare settings to try and understand current practices, now that are DTS have been started to be introduced. And we then we’re trying to identify areas in which we could Make some relatively low cost amendments that might change and the behavior of healthcare workers, remembering that from our baseline. People were completely ignoring the rapid diagnostic tests. By the time we did our baseline here on the formative research actually diagnostic testing had been introduced to a bit longer nationally and we had already seen some reduction. In or increase in adherence to diagnostic testing. So actually it wasn’t as bad as when we started off in our initial work about 2006 we had a 50% of people getting antimalarials when they had an egg to test it already reduced down quite a lot of our baseline. So that was already a good starting place but we then what we did to try and study was to review the evidence. Of other interventions that had worked in similar kinds of settings to reduce alter it to improve health worker prescribing and we looked at the various different theories About about theories of change for that might apply to health workers and we try to find some theories actually seem to fit best with our House work to a working within the communities of practice ideas from Etienne Banga seem to have the most salient. And we were, we kind of Built on that for these small scale workshops which combined with evidence from other settings typically high income settings were small peer groups into have been effective and changing behavior. And then we did a substantial set of pre testing and piloting and particularly the patient information recruitment spent a lot of time piloting that and also developing and piloting these training materials, which we did with Various professional organizations you helped us to develop those we then deliver the intervention and we had an end line survey where we compared prescribing practices across the different have Health care facilities. And so the things that we found in the form to preset Were really that health workers prescribe as exactly as Mark was saying in the introduction of that prescribing behavior is not just something that is in their head. What’s in their head is something that is informed by a wider set of communities of practice that they’re the reason that they’re prescribing in the way they do, is because other people do, because they fear doing the wrong thing a fear. The consequences of not giving an anti malarial in the case of visibility sick. Patient or potentially severely sick patient. He may not come back. They had really good reasons that they wanted to prescribe a mountain area, and also that That patients expected anti malaria. So we realized we were going to have to ship these expectations and shift what people thought was expected of them amongst their peers. So we did this through a series of steps. Our idea was that people would be taken through the health workers will be taken through These different steps of recognizing why we should be changing practice in terms of the changing epidemiology of Malaria. Malaria reducing in these particular areas. That actually not all fevers are due to malaria that we need to shift from what we used to say about treat everybody with an anti malaria. We needed to shift those narratives and then we wanted to give people the Opportunity to practice and come back. So they were given kind of homework go away and practice in in your clinic and come back with the actual challenges you have So that we can discuss them in these workshops. So our workshops operated over a period of time. Where people will be brought back together with other peers in a facilitated workshop where they could talk about What they’ve done in practice. So, then they’re incorporating the identity into their practice talking about the challenges they face and then trying out new ways of trying to Keep it into to incorporate it into what they were doing in everyday practice. And so we were trying to then help them to adhere to the results through through this kind of process of recognizing that their entire community of practice was changing And we tried to change the community of practice as well through the patients and this patient oriented leaflet. So methods. How did we evaluate what we did. And if you are following the discussion guide. This is an answer to questions, five and six where we explore the study design and analysis. And so in order to establish causality of the intervention, rather than just having a before and after study which can be subject to other Factors that may have changed over time, which we did see when you already there was an increasing adherence to to oddities Kind of going on in the background. Is it where we therefore did a randomized control trials studies and it was clustered so that we would Have everybody in a particular clinic will be clustered allocated to the same intervention, rather than having different individuals within the same clinic being Asked to do different things. The idea was that they would work as a group. So that’s different to some of the other studies that you might see around individual conditions individually randomized patients or individually randomized clinicians And so it was a class randomized trial and we administered Patient exit survey to establish our outcome. And we We attempted to control four variations between facilities, who of course you have some That are larger than others and some that have a different characteristics by stratify the facilities and ensuring that we had similar numbers across Each of the facilities at each of the owns and then we created a school, which is which is called a risk difference where we said, What’s the cluster level. What’s the average for each Each health facility. And then what’s the difference between the control and the average of the of the health facilities. The average between each of the help cities in each arm. And so for the results if you’re following the discussion guide the next few slides answer questions, two, three and four about behavior communication objectives, as well as how the impact was measured So here I’m going to take you through our findings to kind of in the chronological order. I think it makes most sense. So our primary outcome. I will show it kind of towards the end of the slides. So the first thing is, did people use the oddity at all. So amongst those who are eligible for testing. So that’s people who are presenting with a febrile illness. Did they did a clinician do an oddity and what we can see is in the control arm 55% of eligible patients were tested. And it was the same in the health worker, but it was highest physically significantly higher in the health work on patient on and that’s in the arm, where we had given The health worker leaflets to talk to the patient about. And we’ve done a lot of work on with community members in deciding what the messages should be we tested those messages we tested whether people could read If they were paired up with somebody who was more literate. What did they understand by the messages in this leaflet. And it’s quite interesting said just that leaflet on its own. Have can have such a big impact because relatively low cost intervention in the end. And so that really increased the number of patients a febrile patients who were tested. And then if you look at Adherence Amongst those who were Who were tested. You can see how many were are DT negative who didn’t receive an anti malarial and actually the majority across all of these did not did not receive an anti malaria, that’s much, much better than it was when we were working on this back in 2006 when our DTS with just being introduced. So we can see here that Across all accounts, it was, it was much better, but in it’s an incremental increase across all three study on say you’ve got 919 percent receiving an anti malarial when their guidelines would say they shouldn’t do in the control arm not being reduced quite dramatically down to 6% In the health worker arm and then reduce again to 4% in the health worker and patient arm so you can see the intervention, having a positive impact you know the starting point is is already quite a lot lower than it was when we initially started this work. And then if you combine those results together, we get this. This is our primary outcomes and treatment of eligible patients who had a non malaria illness. So amongst those patients who have had a fever, who were Tested. So first of all, how many of them were malaria negative. Most of them were negative, and then amongst those who are negative. You can see how many of them were prescribed incorrectly. So actually, it’s a very small number across all of them, but it is statistically significantly smaller in the intervention better the interventional you’ll notice that there are more malaria and negatives in health worker. And patient arm and I wonder if that’s because they tested more patients in the arm and maybe the patients that they were testing were actually negative. So maybe that clinical judgment was correct in terms of not testing some of the other patients don’t know We wouldn’t know that from the data that we have. But the aid can see that there’s a there is a statistically significant difference And I suppose 8% down to 2% when you scale that up is quite a large number of patients at least And then what are the consequences that we’ve been looking at. And we’ve found this from across Our studies we did a we published a paper across nine of our study sites and different nine of our study countries where we found the same thing that prescribing antimalarials went down with our DTS, but it went, but antibiotics went up and we can see the same here. So the prescribing antibiotics is Higher head and it was a baseline was between 55 and 60 I think a baseline. And so actually increased, and as a result of the Introduction and profit diagnostic tests. And so this this behavior, I think, you know, needing to prescribe some kind of medicine is is a really important phenomenon in the pharmaceutical ization of care that requires further work. And so here And the key results in terms of the quality of the oddity reporting that this, this was looking at the records that people that the physicians were or the clinical officers and only were writing in the in the notes. They write a record for every patient and actually we found those records were pretty good because we compare those with our patient exit. Interview, so the patient recall and the register were pretty much getting the same results. So that’s reassuring in terms of our sub sound for the patients that we interviewed on accent. So what are the programmatic implications. Now we’ve reviewed the results. What does it all mean and how does that help us and the next slides will explain discussion guide questions seven which asks about generalize ability So one of the questions is, does an eight to 2% change matter. And I think that’s something that we might want to consider. In terms of Cost effectiveness. Do you want to implement this intervention to reduce it down even further. I think one of the things that we often Failed. Think about when we’re considering cost effectiveness is that we think that we have to continue this intervention or other but my My suspicion, having worked on a number of these interventions in different settings is once you’ve done it. You don’t have to keep doing it. Some interventions on hand washing interventions, you have to keep doing but once you’ve changed this kind of expectation about the level of malaria, you’re likely to see in your clinical practice. I don’t think you will need to continue to do this kind of more expensive intervention. I think it’s more like a one off intervention that has to happen to train to kind of retrain the mindset that, then I think once you’ve got mentors continuing to To mental their Their clinical officers coming through and the nurses coming through. Then I think that you probably don’t have to continue to do that and kind of more intensive intervention. So I think this in this kind of scenario is probably a one off. And I think probably once you scale up then an 8% 30% change probably does matter. And actually if you look at The proportion of anti of anti malarial that were given to patients who had a malaria and active. I’d say 19% down to 674 percent is quite an important difference because presumably those patients should then be assessed for other courses of illness. And then one of the Points that I think is really important is that the patient intervention we that we implemented was really, really cheap, it was, it took quite a lot to make it was quite an intensive development process. But then in terms of scalable, I think it is very cheap to just print out these Pages, and I think it helps the communication between the health worker and patient will see these were setting specific drawings wouldn’t necessarily traveled to a different setting. We’d. I don’t know what it would do if you’ve just had that you didn’t have the housework training that will be an interesting question to answer, and probably worthwhile doing, given how cheap intervention was And so we, what’s the main implication that the prescribed interventions. According to study. Show that the combination of a simple and repeatable behavioral intervention comedies over diagnosing malaria to close to zero in an area where the majority of entrepreneurs have been described previously to those who didn’t have parasites. And because fever is still the most common diagnosis and clinics in Sub Saharan Africa even modest reductions and anti in overdiagnosis could have a significant impact and reducing anti malarial use But there is this big question of what to do with oddity negative patients, and the question of increasing antibiotic use. So this is by no means a EVERYTHING IS EVERYTHING IS OVER scenario. It kind of has raised a number of other issues that still need to be studied. And it’s possible that the additional benefit of the interventions can be attributed to the emphasis on changing practice to a shared experience of the process of change the strengths. This study And I think one of the strongest things about the design of the interventions was the extensive qualitative research that was conducted Before the study. And then we have done an interesting qualitative evaluation, which we haven’t talked about today about what the implications were following the study So how the health workers ended up changing. One of the things was that one of the unintended consequences of asking the health workers to change. Their practice in this way, was that they changed and became more aligned to the overall goals of the program and felt that they were less aligned to the patient. They were less able to provide Care to the specific patient because they were being told, and they felt that they had a kind of Somebody on their shoulder watching them because they were receiving text messages and so on. And so they felt that they had to align with the program and we’re saying things like, oh, this does this patient really deserve and anti malarial, which I think is the kind of language that gives away that people were starting to Line up as gatekeepers to medicines and I think that’s a question that needs to be taken forward and taken quite seriously. And they control and intervention group comparison. I think it’s really important. We always say that randomized control trials provides the best quality of evidence. But that it wasn’t a lot of blinded, randomized control trial. We don’t know that. And we don’t know that simply involve being involved in in in an intervention for stop. May have motivated people to change their practices in may not be the intentionally sound may just be the way that they were engaged with it that could have changed and change their practice that’s always a possibility. And limitations. So that’s what I’m saying about the incentive ization and then The post intervention survey so so we haven’t described the change between two points in time, although we do have this baseline survey. So we have an idea of what we’re doing a baseline. It wasn’t the study design didn’t incorporate change from baseline to end line. In addition to comparison between arms. As fairly standard in a in a randomized control trial and theory and that that’s that that is the best practice currently power to evaluate Causality And lessons learned. So changing prescribing practice is possible. And if we use peer groups physical activities we have people kind of walking around and doing songs and various different things as part of the workshop Self observation and feedback. Direct Commission text. We all of our materials are available on the AC T consulting website you can download our manuals that we used, everything is open access, and it’s free to use translate adapt adopt. But there are these questions about how clinician or authority. Chris clinician accountability might shift away from patients. And what does that mean And strict adherence to oddity results might lead to prescription other pharmaceuticals and actually one of the other unintended consequences. We have found the paper that’s just about to be published, is that We actually in many of our settings where we reduced Prescribing for with body T negatives with also reduce anti malarial prescribing an RDP positives. So we’re actually reducing appropriate use In positive Sarah oddities certainly are not A not sufficient on their own to improve clinical care. There are longer term things we need to do about improving health worker abilities to care and diagnose patients. So I think we’ve reached the end where we have a discussion. The Q AMP. A with participants is that, and who is in one says Thank you so much, Dr. Chandler, we appreciate your walking us through your research at this point if anyone has any questions you may either raise your hands in a participant box and will call on you. Otherwise, you can add them to the chat box. Maybe while we’re letting people think things over a little bit. Claire, I can start with one question. Hmm. You had said something about the cost of this intervention sort of almost being a sunk cost. It’s maybe a one and done. It’s the adoption of the behavior, whereas Later on, once they’ve learned it. Maybe they’ll, they’ll take them maintain that behavior seems like a really interesting thing I think for programs to think about, we’re often asked, What’s the cost of a behavior change intervention and I think It’s interesting to reflect on is the intervention that you’re introducing. Are you trying to get people to adopt a new behavior or are you trying to get them to maintain a behavior. If you were to go back and try to design an intervention. Not to introduce the not to have people adopt a new behavior, but maybe the same population of health workers if you wanted them to maintain the behavior. What, what sort of approach might you take I mean, I think one of the things here is talking about it as a behavior. And I wonder whether that’s slightly misleading because I don’t know that when we frame it as a behavior. It’s like we’re saying you know you’re doing is what is what you’re doing, but I think People are just prescribing, it’s just their practice and Then practice changes as long as change as the environment changes. And so what we used to do. We don’t do anymore, and that and that just changes and then something else will come in and so The effort that you have to go to to change what the norm is or what the expectations are of what you will do what patient expectations are and what your expectations are of your colleagues and of yourself and You know, within the medical profession or the clinical officer profession that what it takes to change that professional expectation, I think, is really What this project demonstrates, and so then you don’t then have to kind of be maintaining a behavior. In the same way as a behavior like handwashing requires continuous maintenance. I need to continue to watch my hand. But when it comes to something like prescribing you just change that you change. How many people you’re expecting to give an answer material to And then your expectations that are changed until we have more information or something that changes that again. Like you have an upgrade or something and then you will change what you’re doing. But I think. And so that’s where I think when we lump everything together under the umbrella of behavior. Then we are lumping together different questions at different types of things that we tried to change. I think when we change what professional norms. Oh, that’s one thing, changing something that you have to keep doing every day like washing your hands. It’s a completely different thing. Thank you think that’s very helpful. Um. We’ve got a question here from Bridget Bridget, you’re unmuted. Do you want to ask your question. Oh, sure. I was just curious, thank you for Saying, in particular the work that goes into creating these leaflets, that there was a lot of thought and study, but could you say more about when the patients received the leaflets. Was it when they came in with a fever or was it something that was shared in the community in advance. And so we gave the leaflets to the health centers and so they could do what they wanted with them mostly that just meant that they kept them in the connect in the office and they were giving them to the patient and the patient came in. And they needed to have an malaria test that we use it to explain why the patient should Have malaria test and they were also on the wall has posted versions in the clinics, we didn’t directly give them out to community members. So these were kind of users devices for the housework at to explain to try and get over any conflict with patients. Great, thank you. I can see some more questions. JESSICA What intensity of oversight or monitoring was needed during implementation to ensure participating health workers would hearing The patient interventions, like, like the patient. Even so, we didn’t do any oversight to ask what they were doing anything we did was Was we had people who were non conditions sitting outside two days a week on a random different days a week. To do patient exit interviews. We didn’t have any kind of oversight or ongoing intervention with the health workers in any of the arms. Beyond the intervention that was kind of the prescribed and described intervention. So we didn’t ask them, we didn’t sort of say, you have to, you know, we didn’t give them feedback on the prescribed or whatever they could do that themselves. They wanted to. We didn’t We didn’t kind of continue to enforce or supervise them in any way. Because we wanted to be slightly more programmatic Angela Acosta, what might be useful in considering how to approach the issue, reducing both anti malaria and advocating, how did you account stock outs and, you know, Your customer. So in terms of stock outs. We were fortunate we didn’t have stock outs. We supported the provision of oddities and 80s were in stopped throughout the study That is not always the case in other settings and then some of our other studies stock OUTS OF A CTS really were massive problem. And so, yeah, that is a really important thing To consider in some of the we were we were fortunate in this study that we didn’t have stock, what might be used when considering This issue of both gentlemen or an antibiotic movies, in my view, and you know a lot of my work at the moment is about antibiotic use as well. Fever case management in in these kinds of settings requires a different type of care at the moment, one can argue that and What we call pharmaceutical ization of a care has occurred, whereby the provision of care is the provision of medicines and actually Health care has been stripped down version of medicines and that is articulated throughout our development programs, whereby the count. Development in terms of how many antibiotics have been sent over somewhere or how many entrepreneurs have been center somewhere or how many benefits. And we count care in terms of how many things have been prescribed and actually a lot of our algorithms are centered around the provisional not of a medicine. And I think we need to consider whether we can reorient eight, the provision of care to Not just equate to the provision of medicine. And that requires a rethinking of how we train health workers and what we value and How we think about how much time should be spent with patients. And I don’t think that is specific to lemon and can continue to face exactly the same problem in the UK. Yeah. Bye to the questions here. We’ve got a question from precious and Nigeria about whether there’s been any such study there. And also at the at the bottom Susan’s asking if we would expect these results to be general generalizable to any other countries. So I guess I guess from our audiences point of view, what can they take home to their own countries. So we did do a study in Nigeria. With a research group or a new university. And so I think the lead author was OB on reject way and and that project went through a similar rigorous design of intervention and randomized control trial. We included there the drug shops as well in the analysis and in the intervention and analysis and there we didn’t do we didn’t use exactly the same intervention design was much more programmatic and that’s one of the scenarios in which massive issues of stocks massive issues of Yeah, the issue stock outs was so difficult that I think it made it quite difficult to really analyze the data, which I think was implications and the US was mentioning for and also the The drug shop vendors were really reluctant to use the diagnostic tests at all. So uptake in itself is very low. So we didn’t find a very Big difference in that study, I would have to check back on the exact figures to tell you, but I would look at that study in terms of what the content was in Nigeria. I do think that we find things quite differently in different study settings, even if they’re quite similar interventions. So I think, and I think it’s different. Whether you’re working in the government health workers more than mission house works or private sector in terms of whether people want to take up oddities and want to use in our dt as an arbiter of whether somebody deserves a medicine or not. And if your business orientated. You may want not want to do that. Versus when you’re being told, and you’re receptive to the authority of the biomedical profession, and then we see it’s quite different story. So we see that playing out different in different country context, according to the degree of authority which Of the of the bio mats and as a profession has. And I think that also goes to whether, for example. When you compare between countries who actually is, who actually is registering in and legitimising a particular healthcare practice in some countries, it’s the Ministry of minds of ministry of business in other countries Ministry of Health and these Are Ministry of Finance and that means that there is a very different expectation for what those people, you know, an accountability mechanism for those people who are describing. So do you think it’s different per country. Thanks, Claire i think i think it’s a good point that on one of the one of the goals of this activity is to make sure that there are taken lessons, but at the same time it’s, it can be very difficult to generalize across different countries. It’s got a really great question. We have done across country, we’ve done to cross country analyse so I’ll put them into the chat box and to show what we thought worked in terms of interventions that is generalizable across all countries. So we could do this in eight different countries. Excellent. Thank you. We’ve got a really great question here from for a she wanted to know if The patients in the health worker. At HTTP arm. Um, do you think that there was more people tested in that arm as as as sort of kind of big primes. As a result of the intervention. Seven again. Was just said, I think that’s an interesting that significantly more eligible patients were tested and the H WP arm so Could this be because patients were primed and could demand a test before treatments. depends. It depends, with those patients. So I don’t know if the if the patients were seeing the poster and asking for it. In those settings or whether the health worker just found more able to do the test because they have these leaflets and they will be there was kind of a queue for them. And yeah, that is, it’s possible that it’s the patient asking for it. I think it’s more likely it’s the clinician thinking Of being have been prompted by the fact that they have these leaflets that they would then do the test. I also think it’s interesting that they had feel positives. So yeah, it’s quite interesting. Further analysis that might need to be done. Is everything. Dr. Taylor in that you learned in this study that maybe wasn’t in the presentation today. But any any take homes that you really felt work. And yeah i think i think that i think the biggest take him was that designing designing these interventions is such an intensive process and takes so much longer than we think it’s going to if you want to do it. Well, I mean, even just thinking about the colors of the materials that you’re using. You don’t just make A Guide for the trainer, you have to make something for the trainee To sit and work through, you have to kind of think about what the train is going to say how to train the trainer and a particular ways that they’re not wagging their finger at people and telling them. That they should or shouldn’t be doing some things that there’s just so many things that you have to think about. And you have to prescribe in order to test it event to develop untested intervention like this. It’s just it was a lot more than we expected. Or. Thank you so much. Well, if there aren’t any more questions in the chat box. Maybe we’ll just wrap things up. Just as a reminder to everyone. This discussion came out of what has a an evidence database that has been created that a number of tools to help you and your program advocates for using research. To prove to donors and to your partners that social and behavior change communication R amp D effective and show them. The results of available research, a couple of our tools to do this, we’ve got a number of infographics. As you can see, both for it ends service providers as we’ve talked about today, as well as Maria case management. These are sort of the highest level simplest descriptions of different activities that have been successful. There are links and citations underneath each of them. These are available on the same website as the database itself. Number. Another way of looking at this research is fact sheets. We’ve taken a number of studies and evaluated them in two ways. One Based on the rigor of the study itself. The second way of looking at it would be to ask and analyze what sort of social behavior change best practices were used. So for each of these, you’ll find different colored dots that indicate both the rigor of the study and analysis as well as best practices. That were implemented. And with that, we’d like to thank you for participating today. If you have any questions, comments, if you want to follow up at all. You can see Claire’s contact as well as my own on the screen, please stick around. There’s about a 32nd survey, we’d love for you reply to before everything Thanks, everyone. Thank you very much. I’m putting a couple of links on the text box as well. I don’t know if they will stay up afterwards. Yes, thank you.

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