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Monitoring patient care through health facility exit interviews: an assessment of the Hawthorne effect in a trial of adherence to malaria treatment guidelines in Tanzania.

ABSTRACT: Survey of patients exiting health facilities is a common way to assess consultation practices. It is, however, unclear to what extent health professionals may change their practices when they are aware of such interviews taking place, possibly paying more attention to following recommended practices. This so-called Hawthorne effect could have important consequences for interpreting research and programme monitoring, but has rarely been assessed.A three-arm cluster-randomised trial of interventions to improve adherence to guidelines for the use of anti-malarial drugs was conducted in Tanzania. Patient interviews were conducted outside health facilities on two randomly-selected days per week. Health workers also routinely documented consultations in their ledgers. The Hawthorne effect was investigated by comparing routine data according to whether exit interviews had been conducted on three key indicators of malaria care. Adjusted logistic mixed-effects models were used, taking into account the dependencies within health facilities and calendar days.Routine data were collected on 19,579 consultations in 18 facilities. The odds of having a malaria rapid diagnostic test (RDT) result reported were 11 % higher on days when exit surveys were conducted (adjusted odds ratio 95 % CI: 0.98-1.26, p = 0.097), 17 % lower for prescribing an anti-malarial drug to patients with a negative RDT result (0.56-1.23, p = 0.343), and 27 % lower for prescribing an anti-malarial when no RDT result was reported (0.53-1.00, p = 0.052). The effect varied with time, with a U-shaped association over the study period (p < 0.001). We also observed a higher number of consultations recorded on days when exit-interviews were conducted (adjusted mean difference = 2.03, p < 0.001).Although modest, there was some suggestion of better practice by health professionals on days when exit interviews were conducted. Researchers should be aware of the potential Hawthorne effect, and take into account assessment methods when generalising findings to the 'real word' setting. This effect is, however, likely to be context dependent, and further controlled evaluation across different settings should be conducted.ClinicalTrials.gov: NCT01292707 . Registered on 29th January 2011.

SUBMITTER: Leurent B

PROVIDER: S-EPMC4739341 | biostudies-literature | 2016 Feb

REPOSITORIES: biostudies-literature

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Monitoring patient care through health facility exit interviews: an assessment of the Hawthorne effect in a trial of adherence to malaria treatment guidelines in Tanzania.

Leurent Baptiste B Reyburn Hugh H Muro Florida F Mbakilwa Hilda H Schellenberg David D

BMC infectious diseases 20160203

<h4>Background</h4>Survey of patients exiting health facilities is a common way to assess consultation practices. It is, however, unclear to what extent health professionals may change their practices when they are aware of such interviews taking place, possibly paying more attention to following recommended practices. This so-called Hawthorne effect could have important consequences for interpreting research and programme monitoring, but has rarely been assessed.<h4>Methods</h4>A three-arm clus ...[more]

PMID: 26842751

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Project description:BackgroundSurvey of patients exiting health facilities is a common way to assess consultation practices. It is, however, unclear to what extent health professionals may change their practices when they are aware of such interviews taking place, possibly paying more attention to following recommended practices. This so-called Hawthorne effect could have important consequences for interpreting research and programme monitoring, but has rarely been assessed.MethodsA three-arm cluster-randomised trial of interventions to improve adherence to guidelines for the use of anti-malarial drugs was conducted in Tanzania. Patient interviews were conducted outside health facilities on two randomly-selected days per week. Health workers also routinely documented consultations in their ledgers. The Hawthorne effect was investigated by comparing routine data according to whether exit interviews had been conducted on three key indicators of malaria care. Adjusted logistic mixed-effects models were used, taking into account the dependencies within health facilities and calendar days.ResultsRoutine data were collected on 19,579 consultations in 18 facilities. The odds of having a malaria rapid diagnostic test (RDT) result reported were 11 % higher on days when exit surveys were conducted (adjusted odds ratio 95 % CI: 0.98-1.26, p = 0.097), 17 % lower for prescribing an anti-malarial drug to patients with a negative RDT result (0.56-1.23, p = 0.343), and 27 % lower for prescribing an anti-malarial when no RDT result was reported (0.53-1.00, p = 0.052). The effect varied with time, with a U-shaped association over the study period (p < 0.001). We also observed a higher number of consultations recorded on days when exit-interviews were conducted (adjusted mean difference = 2.03, p < 0.001).ConclusionsAlthough modest, there was some suggestion of better practice by health professionals on days when exit interviews were conducted. Researchers should be aware of the potential Hawthorne effect, and take into account assessment methods when generalising findings to the ‘real word’ setting. This effect is, however, likely to be context dependent, and further controlled evaluation across different settings should be conducted.Trial registrationClinicalTrials.gov: NCT01292707. Registered on 29th January 2011.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1362-0) contains supplementary material, which is available to authorized users.

Project description:BackgroundAvailable evidence suggests that provision of quality of care in family planning services is crucial to increasing uptake and continuation of use of contraception. Kenya achieved a modern contraceptive prevalence rate of 60% in 2018, surpassing its 2020 target of 58%. With the high prevalence, focus is geared towards improved quality of family planning services. The objective of this study is to examine the quality of family planning counseling and its associated factors in health facilities in Kenya.MethodsWe conducted a secondary analysis of the 2019 Kenya Performance Monitoring and Action, client exit data of women who had received family planning services. Quality of counseling was assessed using the Method Information Index Plus. We conducted a multivariable ordinal logistic regression analysis of data from 3,731 women to establish determinants of receiving quality family planning services.ResultsThe Method Information Index Plus score for higher-quality counseling was 56.7%, lower-quality counseling 32.4%, and no counseling 10.9%. Women aged 15-24 years (aOR = 0.69, 95% CI = 0.56-0.86, p = 0.001) had lower odds of receiving better counseling compared to women aged 35 years and above. Those with no education (aOR = 0.52, 95% CI = 0.33-0.82, p = 0.005), primary (aOR = 0.56, 95% CI = 0.44-0.71, p<0.001) and secondary (aOR = 0.79, 95% CI = 0.65-0.98, p = 0.028) were less likely to receive better counseling compared to those with tertiary education. Women who received long acting and reversible contraception methods (aOR = 1.75, 95% CI = 1.42-2.17, p<0.001), and those who were method switchers (aOR = 1.24, 95% CI = 1.03-1.50, p = 0.027), had a higher likelihood of receiving better quality of counseling as compared to those on short-term methods and those who were continuers, respectively.ConclusionThe quality of family planning counseling in Kenya is still sub-optimal considering that some women receive no form of counseling at service delivery point. There is need to review the existing FP guidelines and training packages to increase focus on the quality of counseling services offered by health providers. Social accountability strategies that empower women to demand quality services should be included in community-level family planning interventions.

Project description:The increasing investment in malaria rapid diagnostic tests (RDTs) to differentiate malarial and non-malarial fevers, and an awareness of the need to improve case management of non-malarial fever, indicates an urgent need for high quality evidence on how best to improve prescribers' practices.A three-arm stratified cluster-randomised trial was conducted in 36 primary healthcare facilities from September 2010 to March 2012 within two rural districts in northeast Tanzania where malaria transmission has been declining. Interventions were guided by formative mixed-methods research and were introduced in phases. Prescribing staff from all facilities received standard Ministry of Health RDT training. Prescribers from facilities in the health worker (HW) and health worker-patient (HWP) arms further participated in small interactive peer-group training sessions with the HWP additionally receiving clinic posters and patient leaflets. Performance feedback and motivational mobile-phone text messaging (SMS) were added to the HW and HWP arms in later phases. The primary outcome was the proportion of patients with a non-severe, non-malarial illness incorrectly prescribed a (recommended) antimalarial. Secondary outcomes investigated RDT uptake, adherence to results, and antibiotic prescribing.Standard RDT training reduced pre-trial levels of antimalarial prescribing, which was sustained throughout the trial. Both interventions significantly lowered incorrect prescribing of recommended antimalarials from 8% (749/8,942) in the standard training arm to 2% (250/10,118) in the HW arm (adjusted RD (aRD) 4%; 95% confidence interval (CI) 1% to 6%; P?=?0.008) and 2% (184/10,163) in the HWP arm (aRD 4%; 95% CI 1% to 6%; P?=?0.005). Small group training and SMS were incrementally effective. There was also a significant reduction in the prescribing of antimalarials to RDT-negatives but no effect on RDT-positives receiving an ACT. Antibiotic prescribing was significantly lower in the HWP arm but had increased in all arms compared with pre-trial levels.Small group training with SMS was associated with an incremental and sustained improvement in prescriber adherence to RDT results and reducing over-prescribing of antimalarials to close to zero. These interventions may become increasingly important to cope with the wider range of diagnostic and treatment options for patients with acute febrile illness in Africa.

Project description:Aims of the studyDespite the widespread existence of guidelines regarding undernutrition monitoring and reporting, there is scarce information whether they are followed. We aimed to evaluate the adherence to guidelines regarding undernutrition monitoring and reporting as well as their determinants in a university hospital.MethodsRetrospective analysis of discharged patients with data on Nutritional Risk Screening score (NRS-2002) from the department of internal medicine of the Lausanne University Hospital for years 2013-14. Adherence to the hospital monitoring guidelines, i.e.: 1) discharged patients with NRS-2002 score≥3 should have prealbumin levels measured, and 2) discharged patients with prealbumin levels<0.20 g/l should be rechecked 7 days afterwards, was assessed. Reporting of nutritionally 'at-risk' status in the discharge letter was also assessed. Multivariable logistic regression was used to examine potential determinants of adherence to guidelines.ResultsOf the 2,539 discharged patients with NRS-2002 data, 1,605 (63.0%) were nutritionally 'at-risk'. Complete adherence to the monitoring guideline was observed in 238 (14.8%) of 'at-risk' patients. After multivariable analysis, adherence to the first step of monitoring guideline was associated with older age (≥ 80 years) [OR (95% CI): 2.03 (1.29-3.18)], high comorbidity index [1.36 (1.05-1.77)], and nutritional management [5.57 (4.38-7.07)]. Nutritional management was also associated with adherence to the second step of monitoring [3.98 (2.33-6.78)]. Adherence to the reporting guideline was observed in 343 (21.4%) of 'at-risk' patients. Multivariable analysis showed that adherence to the reporting guideline was associated with NRS-2002 score>4 [1.97 (1.47-2.64)], nutritional management [3.80 (2.85-5.07)], and adherence to the monitoring guideline [3.33 (2.35-4.71)].ConclusionsOur results show a poor adherence to guidelines regarding undernutrition monitoring and reporting, possibly due to lack of training, staff, and time.

Project description:BackgroundCurrent efforts to estimate the spatially diverse malaria burden in malaria-endemic countries largely involve the use of epidemiological modelling methods for describing temporal and spatial heterogeneity using sparse interpolated prevalence data from periodic cross-sectional surveys. However, more malaria-endemic countries are beginning to consider local routine data for this purpose. Nevertheless, routine information from health facilities (HFs) remains widely under-utilized despite improved data quality, including increased access to diagnostic testing and the adoption of the electronic District Health Information System (DHIS2). This paper describes the process undertaken in mainland Tanzania using routine data to develop a high-resolution, micro-stratification risk map to guide future malaria control efforts.MethodsCombinations of various routine malariometric indicators collected from 7098 HFs were assembled across 3065 wards of mainland Tanzania for the period 2017-2019. The reported council-level prevalence classification in school children aged 5-16 years (PfPR5-16) was used as a benchmark to define four malaria risk groups. These groups were subsequently used to derive cut-offs for the routine indicators by minimizing misclassifications and maximizing overall agreement. The derived-cutoffs were converted into numbered scores and summed across the three indicators to allocate wards into their overall risk stratum.ResultsOf 3065 wards, 353 were assigned to the very low strata (10.5% of the total ward population), 717 to the low strata (28.6% of the population), 525 to the moderate strata (16.2% of the population), and 1470 to the high strata (39.8% of the population). The resulting micro-stratification revealed malaria risk heterogeneity within 80 councils and identified wards that would benefit from community-level focal interventions, such as community-case management, indoor residual spraying and larviciding.ConclusionThe micro-stratification approach employed is simple and pragmatic, with potential to be easily adopted by the malaria programme in Tanzania. It makes use of available routine data that are rich in spatial resolution and that can be readily accessed allowing for a stratification of malaria risk below the council level. Such a framework is optimal for supporting evidence-based, decentralized malaria control planning, thereby improving the effectiveness and allocation efficiency of malaria control interventions.

Project description:IntroductionQualitative exit interviews can supplement clinical trial results by providing a rich and detailed picture of the patient's experience, while highlighting the treatment benefits that are meaningful to patients. Exit interviews can be particularly useful for providing insight into newer medications when less is known about the patient's subjective experience of treatment. Tirzepatide is a novel dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist for type 2 diabetes mellitus. The purpose of this study was to conduct exit interviews with patients following participation in two trials to better understand the impact of tirzepatide from the patients' point of view.MethodsTelephone interviews were conducted with patients with type 2 diabetes treated with tirzepatide soon after completing one of two trials (SURPASS-2, SURPASS-3). Interviews, conducted according to a semi-structured interview guide, were recorded, transcribed, and analyzed following a content analysis approach using ATLAS.ti.ResultsA total of 28 patients (64% female; mean age 57.6 years) completed interviews. All participants (100%) reported at least one treatment benefit. Patients provided descriptions of treatment benefits, including improved glycemic control (reported by 96% of the sample), weight loss (93%), decreased appetite (79%), and increased energy (79%), as indicated by qualitative coding. All participants said these treatment-related changes mattered to them. Patients described improvements in quality of life and daily activities associated with these treatment benefits. Despite adverse events reported by some patients (most commonly nausea, reported by 13 patients), all 28 said they would recommend tirzepatide to others, and 27 said they would be willing to continue treatment. Examples of representative quotations are presented for descriptions of treatment benefits, quality-of-life impact, and adverse events.DiscussionThe current results indicate that treatment benefits observed in clinical trials of tirzepatide are important to patients. As demonstrated in quotations from patients, the most enthusiastic descriptions of treatment outcomes focused on the weight loss associated with tirzepatide. The study also highlights the usefulness of exit interviews, which can supplement quantitative trial data by showing how these benefits have a meaningful impact on patients' quality of life.

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Monitoring patient care through health facility exit interviews: an assessment of the Hawthorne effect in a trial of adherence to malaria treatment guidelines in Tanzania.

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Monitoring patient care through health facility exit interviews: an assessment of the Hawthorne effect in a trial of adherence to malaria treatment guidelines in Tanzania.

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