Improving Patient Adherence with Job Aids, Niger · PDF fileImproving Patient Adherence with...

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Improving Patient AdherenceImproving Patient Adherencewith Job Aids, Nigerwith Job Aids, Niger

Wendy Edson, Maina Boucar,Peggy Koniz-Booher,

Sabou Djbrina, IbrahimaMahamane

Study PurposeStudy Purpose

To develop and evaluate the effectiveness of job aids to improve caretaker compliance

with antibiotic regimens for thetreatment of pneumonia inchildren.

RationaleRationale

Improving patient counselingand improving adherence to theantibiotic regimen will curb thedevelopment of antimicrobialresistance.

Target Study PopulationTarget Study Population

Mostly illiterate caretakers ofchildren with pneumonia andtreated as outpatients in BoboyeDistrict, NigerHealth care workers at clinics

Step 1: Formative ResearchStep 1: Formative ResearchHealth center– What information is currently given to the

caretaker?– What are the reasons for not counseling?

Caretaker– What are the cultural beliefs?– How is information disseminated traditionally?– How are antibiotics used in the home?

Step 1: Formative ResearchStep 1: Formative ResearchMethods of data collection– Health worker observations– Focus groups caretakers– Key informant interviews

Results: Care-seekingResults: Care-seekingbehaviorbehavior

Pneumonia is considered a serious illnessConstraints to seeking care:– Cost of the visit, usually borne by the

father– Availability of cotrimoxazole in the

market at the same cost as a health visitCotrimoxazole is considered effective byparents, well tolerated and easy to use

Results: Patient CounselingResults: Patient CounselingIn Niger only 2 or 3 days of the 5-daycourse is given (Caretaker must return forthe rest)Healthcare workers offered littlecounseling on administration of antibioticAntibiotic given in paper cone sometimeswith marks to indicate dosage

Results: AntibioticResults: AntibioticAdministrationAdministration

Crushed tablet with finger and mixed withavailable waterMedication was not stored properly athome

Results: CommunicationResults: Communication

Most respected information sources werehealth workers and regional radioMost could not read or write, some coulddistinguish letters and numbers.Were familiar with pictures of diarrhea,polio, HIV, etc.

Step 2: Development of theStep 2: Development of thejob aidsjob aids

Held workshop to present results tonational, regional and district levelparticipantsFormed technical committee tooversee development of materials

Workshop participants

Birni, Niger, September 2000

Image for Job AidImage for Job Aid

Prepare tablet by crushing with a spoon andmixing with clean water

Father is involved in care of childGive medication with a spoon

Store medication in a safe placeOut of the reach of children

Finish entire package of medicine

Technical CommitteeTechnical Committee

Counseling CardCounseling Card

Counseling Card - TextCounseling Card - Text

Medication EnvelopeMedication Envelope

PosterPoster

InterpersonalCommunicationand Job AidsTraining Manual

Step 3: Test the effectivenessStep 3: Test the effectivenessof the job aidsof the job aids

Experimental Study Design– 4 control sites, 4 experimental sites

Intervention– Interpersonal communication training– Use of job aids (poster, counseling

card, envelopes)

Step 3: Test the effectivenessStep 3: Test the effectivenessof the job aidsof the job aids

Data Collection methodology– Caretakers interviewed after clinic visit– Caretakers visited in their homes 4-5

days after clinic visit– Healthcare workers observed at 2

points in study– Nov. 2000 to April 2001

Child CharacteristicsChild Characteristics

Control N = 327

Experimental N = 348

Child Age (mean)

18.3 mos 18.2 mos

% Male 49% 54%

Birth Order (mean)

3.5 3.7

Maternal CharacteristicsMaternal Characteristics

ControlN = 327

ExperimentalN = 348

Age(Mean)

27.2 yrs 27.9 yrs

% noschooling 57% 49%

% Married 97% 96%

Household CharacteristicsHousehold CharacteristicsControlN = 327

ExperimentalN = 348

Size of HH* 7.4 persons 9.3 persons

Ethnic Grp*% Peul% Djerma% Haoussa

18%74%7%

6%89%1%

% with radio* 44% 68%

* p < .001

Results: Use of Clean WaterResults: Use of Clean Water

Use of CleanWater

Control Experimental

*P< .001

Results: Antibiotic StorageResults: Antibiotic Storage

Stored AntibioticCorrectly*

*P = .04

Results: Patient AdherenceResults: Patient Adherence

CorrectAdherence

*P< .001

Results: Follow-upResults: Follow-upAppointmentAppointment

Kept Follow-upAppt

*P< .001

Results: Maternal KnowledgeResults: Maternal Knowledge

99 99 97 93 98 99

Correct number ofpills

Correct timeduring day*

Correct number ofdays

*P = .01

Results: Perceived Child’sResults: Perceived Child’sHealthHealth

Health ImprovedCompletely

*P< .001

ConclusionsConclusions

Preliminary ResultsFurther analyses– effect of health worker and clinicRecommendations– Change national policy so that a

full dose is given at first visit

DevelopmentDevelopment of a Case of a CaseManagementManagement Map Map in in Uganda Uganda

Barbara Kerstiëns, MD, MPHQuality Assurance Project

Johns Hopkins University

Presented byPresented by

Wendy Edson, PhD, RN, MPHQuality Assurance Project

Case Management MapCase Management Map(CMM)(CMM)

Job aid and medical recordBased on critical pathway approach “optimal sequencing and timing of

interventions by medical staff for aparticular condition...”

(Coffey 1992)

CMM FormatCMM Format

Rows: Activities(Monitoring,Treatment,Medication, Diet,Patient counseling)Columns: Time(Day, Hour, Month)

Steps in CMM DevelopmentSteps in CMM Development

Selection of the conditionSelection of the teamDefinition of scope of theprotocolDescription of currentprocess of management

Definition of format of CMMDevelopment of prototypeDevelopment of monitoringplanDevelopment ofimplementation plan

ImplementationMonitoring and problemsolving

Challenges During DevelopmentChallenges During Development

Team membership keptchangingNot enough intern physiciansNo familiarity with criticalpathwayUnavailability of needed supplies(MgSO4, reflex hammers)

Results - Improved patientResults - Improved patientoutcomesoutcomes

Before After(06/98- 06/99) (09/99-09/00)

n=36 n=50Progress to eclampsia 17% 6%# of maternal deaths 5.5% 3.1%Live delivery 56% 83%

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